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Al-Shamkhi N, Berinder K, Borg H, Burman P, Dahlqvist P, Höybye C, Olsson DS, Ragnarsson O, Ekman B, Edén Engström B. Pituitary function before and after surgery for nonfunctioning pituitary adenomas-data from the Swedish Pituitary Register. Eur J Endocrinol 2023; 189:217-224. [PMID: 37551511 DOI: 10.1093/ejendo/lvad104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE Data on pre- and postoperative pituitary function in nonfunctioning pituitary adenomas (NFPA) are not consistent. We aimed to investigate pituitary function before and up to 5 years after transsphenoidal surgery with emphasis on the hypothalamic-pituitary-adrenal axis (HPA). DESIGN AND METHODS Data from the Swedish Pituitary Register was used to analyze anterior pituitary function in 838 patients with NFPA diagnosed between 1991 and 2014. Patients who were reoperated or had received radiotherapy were excluded. RESULTS Preoperative ACTH, TSH, LH/FSH, and GH deficiencies were reported in 31% (236/755), 39% (300/769), 51% (378/742), and 28% (170/604) of the patients, respectively. Preoperative median tumor volume was 5.0 (2.4-9.0) cm3. Among patients with preoperative, 1 year and 5 years postoperative data on the HPA axis (n = 428), 125 (29%) were ACTH-deficient preoperatively. One year postoperatively, 26% (32/125) of them had recovered ACTH function while 23% (70/303) patients had developed new ACTH deficiency. Thus, 1 year postoperatively, 163 (38%) patients were ACTH-deficient (P < .001 vs. preoperatively). No further increase was seen 5 years postoperatively (36%, P = .096). At 1 year postoperatively, recoveries in the TSH and LH/FSH axes were reported in 14% (33/241) and 15% (46/310), respectively, and new deficiencies in 22% (88/403) and 29% (83/288), respectively. CONCLUSIONS Adrenocorticotrophic hormone deficiency increased significantly at 1 year postoperatively. Even though not significant, some patients recovered from or developed new deficiency between 1 and 5 years postoperatively. This pattern was seen in all axes. Our study emphasizes that continuous individual evaluations are needed during longer follow-up of patients operated for NFPA.
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Affiliation(s)
- Nasrin Al-Shamkhi
- Department of Internal Medicine, Örebro University Hospital and School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Endocrinology and Diabetology, Uppsala University Hospital, Uppsala, Sweden
| | - Katarina Berinder
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Borg
- Department of Endocrinology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Charlotte Höybye
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Daniel S Olsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Göteborg, Sweden
| | - Bertil Ekman
- Departments of Endocrinology in Linköping and Norrköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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De Alcubierre D, Puliani G, Cozzolino A, Hasenmajer V, Minnetti M, Sada V, Martines V, Zaccagnino A, Ruggeri AG, Pofi R, Sbardella E, Venneri MA. Pituitary adenoma consistency affects postoperative hormone function: a retrospective study. BMC Endocr Disord 2023; 23:92. [PMID: 37101307 PMCID: PMC10131333 DOI: 10.1186/s12902-023-01334-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/05/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Tumor consistency recently emerged as a key factor in surgical planning for pituitary adenomas, but its impact on postoperative endocrine function is still unclear. Our study aimed to evaluate the impact of tumor consistency on the development of postoperative pituitary deficiencies. METHODS Single-center, retrospective analysis of consecutive pituitary surgeries performed between January 2017 and January 2021 at Policlinico Umberto I in Rome. All patients underwent radiological and biochemical evaluations at baseline, and hormone assessments 3 and 6 months after pituitary surgery. Postoperative MRI studies were used to determine resection rates following surgery. Data on tumor consistency, macroscopic appearance, neurosurgical approach, and intraoperative complications were collected. RESULTS Fifty patients [24 women, mean age 57 ± 13 years, median tumor volume 4800 mm3 [95% CI 620-8828], were included. Greater tumor volume (χ2 = 14.621, p = 0.006) and male sex (χ2 = 12.178, p < 0.001) were associated with worse preoperative endocrine function. All patients underwent transsphenoidal adenomectomy. Fibrous consistency was observed in 10% of patients and was associated with a Ki-67 greater than 3% (χ2 = 8.154, p = 0.04), greater risk of developing postoperative hormone deficiencies (χ2 = 4.485, p = 0.05, OR = 8.571; 95% CI: 0.876-83.908), and lower resection rates (χ2 = 8.148, p = 0.004; OR 1.385, 95% CI; 1.040-1.844). Similarly, worse resection rates were observed in tumors with suprasellar extension (χ2 = 5.048, p = 0.02; OR = 6.000, 95% CI; 1.129-31.880) and CSI (χ2 = 4.000, p = 0.04; OR = 3.857, 95% CI; 0.997-14.916). CONCLUSIONS Tumor consistency might provide useful information about postoperative pituitary function, likely due to its impact on surgical procedures. Further prospective studies with larger cohorts are needed to confirm our preliminary findings.
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Affiliation(s)
- Dario De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Puliani
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Valentina Sada
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Antonella Zaccagnino
- Department of Neurology and Psychiatry-Neurosurgery Unit, Sapienza University of Rome, Rome, Italy
| | - Andrea Gennaro Ruggeri
- Department of Neurology and Psychiatry-Neurosurgery Unit, Sapienza University of Rome, Rome, Italy
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Mary Anna Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
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Gruber LM, Bancos I. Secondary Adrenal Insufficiency: Recent Updates and New Directions for Diagnosis and Management. Endocr Pract 2022; 28:110-117. [PMID: 34610473 DOI: 10.1016/j.eprac.2021.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
Secondary adrenal insufficiency is the most common subtype of adrenal insufficiency; it is caused by certain medications and pituitary destruction (pituitary masses, inflammation, or infiltration) and is rarely associated with certain germline variants. In this review, we discuss the etiology, epidemiology, and clinical presentation of secondary adrenal insufficiency and focus on the diagnostic and management challenges. We also review the management of selected special populations of patients and discuss patient-important outcomes associated with secondary adrenal insufficiency.
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Affiliation(s)
- Lucinda M Gruber
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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Alexander TD, Collopy S, Yu S, Karsy M, Chitguppi C, Farrell CJ, Evans JJ. Perioperative Outcomes of a Hydrocortisone Protocol after Endonasal Surgery for Pituitary Adenoma Resection. Skull Base Surg 2021; 83:383-389. [DOI: 10.1055/s-0041-1735588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
Abstract
Introduction In pituitary adenomas (PAs), the use of postoperative steroid supplementation remains controversial, as it reduces peritumoral edema and sinonasal complaints but disrupts the detection of adrenal insufficiency (AI). It is unclear whether postoperative cortisol supplementation has a measurable effect on improving outcomes in patients with pituitary adenoma undergoing endoscopic transsphenoidal surgery (ETS). The objective of the study was to evaluate a postoperative steroid treatment protocol on various surgical outcomes in patients with PA undergoing ETS.
Methods A retrospective cohort study was performed for patients undergoing ETS from 2005 to 2020 for PA at a single tertiary academic center. Patients were divided into two groups: those managed by a routine postoperative glucocorticoid supplementation protocol (steroid protocol) and those who received supplementation based on postoperative cortisol laboratory assessment (steroid sparing protocol). Management was otherwise the same between groups. Evaluation of length of stay (LOS), sinonasal outcomes, 30-day readmission, and perioperative complications, including AI, were performed.
Results Among 535 patients, 21% (n = 111) received postoperative steroids, while the remainder (n = 424) did not. There were no differences in mean LOS (3 vs. 3 days, p = 0.72), sinonasal complaints (27 vs. 19%, p = 0.12), 30-day readmission (5% vs. 5%, p = 0.44), and perioperative complications (5 vs. 5%, p = 0.79) between both the groups. A multivariate model supported that both groups were comparable in predicting LOS, 30-day readmission, and complications. No reduction in readmission for AI was seen.
Conclusion Routine administration of postoperative glucocorticoids did not significantly improve patient outcomes in patients with PA who underwent ETS.
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Affiliation(s)
- Tyler D. Alexander
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Sarah Collopy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Siyuan Yu
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Chandala Chitguppi
- Department of Otolaryngology and Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Christopher J. Farrell
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - James J. Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
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Abstract
The hypothalamo-pituitary-adrenal (HPA) axis is one of the main components of the stress system. Maintenance of normal physiological events, which include stress responses to internal or external stimuli in the body, depends on appropriate HPA axis function. In the case of severe cortisol deficiency, especially when there is a triggering factor, the patient may develop a life-threatening adrenal crisis which may result in death unless early diagnosis and adequate treatment are carried out. The maintenance of normal physiology and survival depend upon a sufficient level of cortisol in the circulation. Life-long glucocorticoid replacement therapy, in most cases meeting but not exceeding the need of the patient, is essential for normal life expectancy and maintenance of the quality of life. To enable this, the initial step should be the correct diagnosis of adrenal insufficiency (AI) which requires careful evaluation of the HPA axis, a highly dynamic endocrine system. The diagnosis of AI in patients with frank manifestations is not challenging. These patients do not need dynamic tests, and basal cortisol is usually enough to give a correct diagnosis. However, most cases of secondary adrenal insufficiency (SAI) take place in a gray zone when clinical manifestations are mild. In this situation, more complicated methods that can simulate the response of the HPA axis to a major stress are required. Numerous studies in the assessment of HPA axis have been published in the world literature. In this review, the tests used in the diagnosis of secondary AI or in the investigation of suspected HPA axis insufficiency are discussed in detail, and in the light of this, various recommendations are made.
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Affiliation(s)
- Zuleyha Karaca
- Department of Endocrinology, Erciyes University, Medical School, Kayseri, Turkey
| | - Ashley Grossman
- Centre for Endocrinology, Barts and London School of Medicine, London, UK
- OCDEM, University of Oxford, Oxford, UK
| | - Fahrettin Kelestimur
- Department of Endocrinology, Yeditepe University, Medical School, Istanbul, Turkey.
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Clarke DB, Hebb ALO, Massoud E, Imran SA. In-Hospital Endocrinology Consultation After Transsphenoidal Surgery: Is It Always Necessary? Can J Neurol Sci 2021; 48:534-9. [PMID: 33059786 DOI: 10.1017/cjn.2020.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with sellar masses undergoing transsphenoidal surgery (TSS) frequently develop endocrine dysfunction; therefore, in-hospital endocrinology consultation (IHEC) is recommended. However, we wondered whether routine endocrinology assessment of all TSS patients is always necessary. METHODS We developed an IHEC Physician's Guide to identify patients who would require peri-operative IHEC. An analysis of all patients undergoing TSS for a sellar mass over a 4-year period was conducted to assess the predictive value of the IHEC Physician's Guide in identifying patients who required IHEC. RESULTS A total of 116 patients underwent TSS; 24 required IHEC. As expected, the risk of endocrine complications requiring peri-operative endocrine management was significantly higher in the IHEC group versus no-IHEC group (96% vs. 1%; p < 0.001). The negative predictive value of the IHEC Physician's Guide in identifying patients who did not require IHEC was 0.99 (95% CI 0.9409-0.9997); Fisher's exact test, p < 0.001), meaning that the IHEC Physician's Guide successfully identified all but one patient who truly required IHEC. CONCLUSION Results from our study show that most patients do not need IHEC after TSS and that those patients requiring IHEC can be reliably predicted at surgery by using a simple IHEC Physician's Guide.
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Pofi R, Gunatilake S, Macgregor V, Shine B, Joseph R, Grossman AB, Isidori AM, Cudlip S, Jafar-Mohammadi B, Tomlinson JW, Pal A. Recovery of the Hypothalamo-Pituitary-Adrenal Axis After Transsphenoidal Adenomectomy for Non-ACTH-Secreting Macroadenomas. J Clin Endocrinol Metab 2019; 104:5316-5324. [PMID: 31225871 DOI: 10.1210/jc.2019-00406] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 06/17/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Secondary adrenal insufficiency is a potential complication of transsphenoidal adenomectomy (TSA). Most centers test recovery of the hypothalamo-pituitary-adrenal (HPA) axis after TSA, but, to our knowledge, there are no data predicting likelihood of recovery or the frequency of later recovery of HPA function. OBJECTIVE To assess timing and predictors of HPA axis recovery after TSA. DESIGN Single-center, retrospective analysis of consecutive pituitary surgeries performed between February 2015 and September 2018. PATIENTS Patients (N = 109) with short Synacthen test (SST) data before and at sequential time points after TSA. MAIN OUTCOME MEASURES Recovery of HPA axis function at 6 weeks, and 3, 6, and 9 to12 months after TSA. RESULTS Preoperative SST indicated adrenal insufficiency in 21.1% Among these patients, 34.8% recovered by 6 weeks after TSA. Among the 65.2% (n = 15) remaining, 13.3% and 20% recovered at 3 months and 9 to 12 months, respectively. Of the 29% of patients with adrenal insufficiency at the 6-week SST, 16%, 12%, and 6% subsequently recovered at 3, 6, and 9 to 12 months, respectively. Preoperative SST 30-minute cortisol, postoperative day 8 cortisol, and 6-week postoperative SST baseline cortisol levels above or below 430 nmol/L [15.5 μg/dL; AUC ROC, 0.86]; 160 nmol/L (5.8 μg/dL; AUC ROC, 0.75); and 180 nmol/L (6.5 μg/dL; AUC ROC, 0.88), were identified as cutoffs for predicting 6-week HPA recovery. No patients with all three cutoffs below the threshold recovered within 12 months after TSA, whereas 92% with all cutoffs above the threshold recovered HPA function within 6 weeks (OR, 12.200; 95% CI, 5.268 to 28.255). CONCLUSION HPA axis recovery can occur as late as 9 to 12 months after TSA, demonstrating the need for periodic reassessment of patients who initially have SST-determined adrenal insufficiency after TSA. Pre- and postoperative SST values can guide which patients are likely to recover function and potentially avoid unnecessary lifelong glucocorticoid replacement.
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Affiliation(s)
- Riccardo Pofi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals National Health Servce Foundation Trust, Oxford, United Kingdom
| | - Sonali Gunatilake
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Victoria Macgregor
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Brian Shine
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Robin Joseph
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals National Health Servce Foundation Trust, Oxford, United Kingdom
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Simon Cudlip
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Jeremy W Tomlinson
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Aparna Pal
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
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Vulto A, Bergthorsdottir R, van Faassen M, Kema IP, Johannsson G, van Beek AP. Residual endogenous corticosteroid production in patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2019; 91:383-390. [PMID: 31059146 PMCID: PMC6851705 DOI: 10.1111/cen.14006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed at comparing precursors of endogenous corticosteroid production in patients with primary adrenal insufficiency and in secondary adrenal insufficiency. DESIGN Twenty patients with primary adrenal insufficiency and matched controls and 19 patients with secondary adrenal insufficiency participated in this ancillary analysis of two different studies. PATIENTS AND MEASUREMENTS Patients with primary adrenal insufficiency were on stable hydrocortisone and fludrocortisone therapy. Patients with secondary adrenal insufficiency received two different doses of hydrocortisone in a randomized crossover study. Main outcome measures were concentrations of precursors of cortisol and aldosterone measured by LC-MS/MS RESULTS: Compared to controls, progressively lower concentrations of the glucocorticoid precursors 11-deoxycortisol, 11-deoxycorticosterone and corticosterone concentrations were found in patients with secondary adrenal insufficiency on lower hydrocortisone dose, secondary adrenal insufficiency on higher hydrocortisone dose and primary adrenal insufficiency, respectively. Half of the primary adrenal insufficient patients showed evidence of residual endogenous cortisol or aldosterone synthesis, as determined by quantifiable 11-deoxycortisol, 11-deoxycorticosterone and corticosterone conce ntrations. In secondary adrenal insufficient patients with higher endogenous cortisol production, as indicated by 11-deoxycortisol concentrations above the median, no increased cortisol exposure was observed both by plasma pharmacokinetic parameters and 24-hour free cortisol excretion in urine. CONCLUSIONS Adrenal corticosteroid production is likely to continue during treatment in a considerable percentage of patients with both primary and secondary adrenal insufficiency. In patients with secondary adrenal insufficiency, this synthesis appears to be sensitive to the dose of hydrocortisone. However, the residual corticosteroid concentrations were quantitatively low and its clinical significance remains therefore to be determined.
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Affiliation(s)
- Annet Vulto
- Department of EndocrinologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Ragnhildur Bergthorsdottir
- Department of EndocrinologySahlgrenska University HospitalGothenburgSweden
- Department of Internal Medicine and Clinical Nutrition, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Martijn van Faassen
- Department of Laboratory MedicineUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Ido P. Kema
- Department of Laboratory MedicineUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Gudmundur Johannsson
- Department of EndocrinologySahlgrenska University HospitalGothenburgSweden
- Department of Internal Medicine and Clinical Nutrition, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
| | - André P. van Beek
- Department of EndocrinologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
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Abstract
PURPOSE Non-functioning pituitary adenomas (NFPAs) are associated with impaired well-being, increased comorbidities, and reduced long-term survival. Data on optimal management of NFPAs around surgical treatment are scarce, and postoperative treatment and follow-up strategies have not been evaluated in prospective trials. Here, we review the preoperative, perioperative, and early postoperative management of patients with NFPAs. METHODS We searched Medline and the Cochrane Library for articles published in English with the following items "Pituitary neoplasms AND Surgery" and "Surgery AND Hypopituitarism". Studies containing detailed analyses of the management of NFPAs in adult patients, including pituitary surgery, endocrine care, imaging, ophthalmologic assessment and long-term outcome were reviewed. RESULTS Treatment options for NFPAs include active surveillance, surgical resection, and radiotherapy. Pituitary surgery is currently recommended as first-line treatment in patients with visual impairment due to adenomas compressing the optic nerves or chiasma. Radiotherapy is reserved for large tumor remnants or tumor recurrence following one or more surgical attempts. There is no consensus of optimal pre-, peri-, and postoperative management such as timing, frequency, and duration of endocrine, radiologic, and ophthalmologic assessments as well as management of smaller tumor remnants or tumor recurrence. CONCLUSIONS In clinical practice, there is a great variation in the treatment and follow-up of patients with NFPAs. We have, based on available data, suggested an optimal management strategy for patients with NFPAs in relation to pituitary surgery. Prospective trials oriented at drawing up strategies for the management of NFPAs are needed.
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Affiliation(s)
- Daniela Esposito
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden.
| | - Daniel S Olsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlange, Germany
| | - Thomas Skoglund
- Department of Neurosurgery, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
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10
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Abstract
Although removal of pituitary tumors yields excellent surgical outcomes, perturbations in the hypothalamic-pituitary axis are not uncommon. Careful assessment of postoperative hormone status with supplementation or further medical therapy is critical to successful outcomes. Although many centers routinely use perioperative steroids, they can be associated with worse outcomes in the absence of intact preoperative adrenal function or damage to the pituitary gland or stalk during surgery. Postoperative assessment of prolactin, cortisol, and growth hormone can be prognostic of surgical cure. Hormonal axes should be reevaluated routinely several weeks after surgery, because longitudinal monitoring is important for surgical and medical outcomes.
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Affiliation(s)
- Anshu Buttan
- Department of Medicine, Division of Endocrinology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker B-131, Los Angeles, CA 90048, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, 127 S San Vicente Boulevard, A6600, Los Angeles, CA 90048, USA.
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Sherlock M, Stewart PM. The Short Synacthen Test and Its Utility in Assessing Recovery of Adrenal Function in Patients With Central Adrenal Insufficiency. J Clin Endocrinol Metab 2019; 104:17-20. [PMID: 30085278 PMCID: PMC6260064 DOI: 10.1210/jc.2018-01317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 07/30/2018] [Indexed: 01/18/2023]
Abstract
The short synacthen test is useful in assessing recovery of adrenal function in patients with central adrenal insufficiency.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Beaumont, Dublin 9, Ireland
- Department of Endocrinology, Royal College of Surgeons in Ireland Medical School, Beaumont, Dublin 9, Ireland
| | - Paul M Stewart
- Medical School, University of Leeds, Leeds, United Kingdom
- Correspondence and Reprint Requests: Paul M. Stewart, MD, Medical School, University of Leeds, Room 7.08, Worsley Building, Clarendon Way, Leeds LS2 9NL, United Kingdom. E-mail:
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Pofi R, Feliciano C, Sbardella E, Argese N, Woods CP, Grossman AB, Jafar-Mohammadi B, Gleeson H, Lenzi A, Isidori AM, Tomlinson JW. The Short Synacthen (Corticotropin) Test Can Be Used to Predict Recovery of Hypothalamo-Pituitary-Adrenal Axis Function. J Clin Endocrinol Metab 2018; 103:3050-3059. [PMID: 29846658 DOI: 10.1210/jc.2018-00529] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/22/2018] [Indexed: 12/11/2022]
Abstract
CONTEXT The 250-μg short Synacthen (corticotropin) test (SST) is the most commonly used tool to assess hypothalamo-pituitary-adrenal (HPA) axis function. There are many potentially reversible causes of adrenal insufficiency (AI), but no data to guide clinicians as to the frequency of repeat testing or likelihood of HPA axis recovery. OBJECTIVE To use the SST results to predict adrenal recovery. DESIGN A retrospective analysis of 1912 SSTs data. PATIENTS Seven hundred seventy-six patients with reversible causes of AI were identified who had at least two SSTs performed. A subgroup analysis was performed on individuals previously treated with suppressive doses of glucocorticoids (n = 110). MAIN OUTCOME MEASURES Recovery of HPA axis function. RESULTS SST 30-minute cortisol levels above or below 350 nmol/L (12.7 μg/dL) best predicted HPA axis recovery [area under the curve (AUC) receiver operating curve (ROC) = 0.85; median recovery time: 334 vs 1368 days, P = 8.5 × 10-13]: 99% of patients with a 30-minute cortisol >350 nmol/L recovered adrenal function within 4 years, compared with 49% in those with cortisol levels <350 nmol/L. In the subgroup analysis, delta cortisol (30-minute-basal) best predicted the recovery (AUC ROC = 0.77; median recovery time: 262 vs 974 days, P = 7.0 × 10-6). No patient with a delta cortisol <100 nmol (3.6 μg/dL) and a subsequent 1-year random cortisol <200 nmol/L (7.3 μg/dL) recovered HPA axis function. CONCLUSIONS Cortisol levels across an SST can be used to predict recovery of AI and may guide the frequency of repeat testing and inform both clinicians and patients as to the likelihood of restoration of HPA axis function.
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Affiliation(s)
- Riccardo Pofi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chona Feliciano
- Centre for Endocrinology, Diabetes, and Metabolism, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Nicola Argese
- Department of Endocrinology, S.S. Annunziata Hospital, Taranto, Italy
| | - Conor P Woods
- Department of Endocrinology, Naas General Hospital, Kildare and Tallaght Hospital, Dublin, Ireland
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes, and Metabolism, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Jeremy W Tomlinson
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
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Abstract
Carbon monoxide (CO) is a colorless, odorless gas that is found in the environment, in the home, and in the human body as a normal part of mammalian metabolism. Poisoning from CO, a common exposure, is associated with significant morbidity and mortality if not recognized and treated in a timely manner. This review evaluates the signs and symptoms of CO poisoning, conditions that present similar to CO poisoning, and an approach to the recognition and management for CO poisoning. CO poisoning accounts for thousands of emergency department visits annually. If not promptly recognized and treated, it leads to significant morbidity and mortality. CO poisoning poses a challenge to the emergency physician because it classically presents with non-specific symptoms such as headache, dizziness, nausea, and vomiting. Due to nonspecific presentations, it is easily mistaken for other, more benign diagnoses such as viral infection. The use of specific historical clues such as exposure to non-conventional heat sources or suicide attempts in garages, as well as the use of targeted diagnostic testing with CO-oximetry, can confirm the diagnosis of CO poisoning. Once diagnosed, treatment options range from observation to the use of hyperbaric oxygen. CO poisoning is an elusive diagnosis. This review evaluates the signs and symptoms CO poisoning, common chameleons or mimics, and an approach to management of CO poisoning.
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Affiliation(s)
- Patrick Chow Ng
- Medical Toxicology, Rocky Mountain Poison and Drug Center, Denver Health and Hospital, 1391 Speer Blvd, Denver, CO, 80204, USA.
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
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Munro V, Elnenaei M, Doucette S, Clarke DB, Imran SA. The effect of time of day testing and utility of 30 and 60 minute cortisol values in the 250 mcg ACTH stimulation test. Clin Biochem 2018; 54:37-41. [PMID: 29458002 DOI: 10.1016/j.clinbiochem.2018.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite widespread use of the 250-mcg Cosyntropin test (ACTH test) for the diagnosis of adrenal insufficiency (AI), the effect of time of day and the utility of performing both 30- and 60-min serum cortisol values remains unclear. METHODS We conducted a retrospective cohort study of all ACTH testing at the Halifax Neuropituitary Program, Nova Scotia, Canada between January 2006 and April 2016. Data were collected on age, gender, medication history, serum cortisol levels at 0, 30 and 60 min after ACTH administration, as well as time of and indication for testing. RESULTS There were 336 tests performed, divided by time of day (0800-1000 h, 1001-1200 h, and after 1200 h). There were no differences in mean cortisol levels at 30 (574.5, 559, 534 nmol/L, respectively; p = 0.25) and 60 min (642, 623, 619 nmol/L, respectively; p = 0.63) between groups. When comparing 30- vs. 60-min values using a cut-off of ≥500 nmol/L, 45 patients (13.4%) failed to reach the cut-off at 30 min but met the cut-off at 60 min. Conversely, only 2 patients (0.6%) who met the cut-off at 30 min failed to reach it at 60 min. CONCLUSION We found that outcomes from ACTH testing are not affected by time of day. Furthermore, using a 30-min cortisol level in isolation results in more than one in seven patients having a false positive diagnosis of AI; a 60-min value of ≥500 nmol/L alone may be sufficient to diagnose AI in >99% of cases.
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