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Submitted on May 31, 2005
Accepted on October 6, 2005
Division of Neurosurgery, University of California at Los Angeles School of Medicine, and UCLA Pituitary Tumor and Neuroendocrine Program, Los Angeles, California, and Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy; Division of Neurosurgery, University of California at Los Angeles School of Medicine, Los Angeles, California; Division and Endocrinology, University of California at Los Angeles School of Medicine, and UCLA Pituitary Tumor and Neuroendocrine Program, and UCLA Gonda Diabetes Center, Los Angeles, California; Division of Neurosurgery, University of California at Los Angeles School of Medicine, Los Angeles, California; Division of Neurosurgery, University of California at Los Angeles School of Medicine, Los Angeles, California; Division of Endocrinology, Metabolism and Nutrition, Harbor-UCLA Medical Center, Torrance, California; Division of Endocrinology, Metabolism and Nutrition, Harbor-UCLA Medical Center, Torrance, California; Division of Neurosurgery, University of California at Los Angeles School of Medicine, and UCLA Pituitary Tumor and Neuroendocrine Program, Los Angeles, California
* To whom correspondence should be addressed. E-mail: dkelly{at}mednet.ucla.edu.
Introduction: We describe use of serum cortisol and ACTH levels on post-operative day one and two as remission predictors after transsphenoidal surgery for Cushing's disease (CD).
Methods: Morning cortisol and ACTH levels were drawn daily after operation; glucocorticoids were withheld until evidence of hypocortisolemia. Early remission was defined retrospectively as a subnormal A.M. cortisol level (
140nmol/L [5mcg/dL]) on post-operative day one or two and sustained remission as subsequent eucortisolemia.
Results: Of 40 consecutive adults with CD (mean age 39 yr), 80% achieved early remission. Of 39 patients with a minimum follow-up of 14 months (mean 33 months), 31 (79.5%) achieved sustained remission at a mean follow-up of 32 months, including 30/31 (97%) with early remission and 1/8 (12%) without early remission (P < 0.0001). Sustained remission was achieved in 26/28 (93%) patients having their first operation compared with 5/11 (45%) with a prior unsuccessful operation (P < 0.001). For the 32 patients in early remission vs. the 8 in non-remission, mean nadir cortisol levels were 57.6 ± 33.0 [2.05 ± 1.2 mcg/dL] vs. 631.1 ± 352.2 nmol/L [22.9 ± 12.8 mcg/dL] (P < 0.0001), and nadir ACTH levels were 11.9 ± 6.5 vs. 64.1 ± 54.6 ng/L (P < 0.001). Of 31 patients with sustained remission, 100% had subnormal A.M. cortisol levels, while 31% had subnormal ACTH levels (P < 0.0001).
Conclusion: Serum morning cortisol levels on post-operative day one and two without glucocorticoid replacement provide a safe, simple and reliable measure of early remission for CD and are predictive of sustained remission. This method allows for consideration of a repeat operation during the same hospitalization in patients with persistent hypercortisolemia.
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