The Value of Perioperative Levels of ACTH, DHEA, and DHEA-S and Tumor Size in Predicting Recurrence of Cushing Disease

• Published in: The journal of clinical endocrinology and metabolism 2018-02, Vol.103 (2), p.477-485
• Main Authors: El Asmar, Nadine, Rajpal, Aman, Selman, Warren R, Arafah, Baha M
• Format: Article
• Language: English
• Subjects: ACTH-Secreting Pituitary Adenoma - complications; ACTH-Secreting Pituitary Adenoma - diagnosis; ACTH-Secreting Pituitary Adenoma - pathology; ACTH-Secreting Pituitary Adenoma - surgery; Adenoma - complications; Adenoma - diagnosis; Adenoma - pathology; Adenoma - surgery; Adrenal glands; Adrenocorticotropic hormone; Adrenocorticotropic Hormone - blood; Adult; Cortisol; Cushing syndrome; Cushing Syndrome - blood; Cushing Syndrome - diagnosis; Cushing Syndrome - etiology; Cushing Syndrome - surgery; Cushing's disease; Dehydroepiandrosterone; Dehydroepiandrosterone - blood; Dehydroepiandrosterone Sulfate - blood; Female; Follow-Up Studies; Glucocorticoids; Hormones; Humans; Male; Middle Aged; Nervous system diseases; Perioperative Period; Pituitary; Predictive Value of Tests; Prognosis; Recurrence; Secretion; Surgery; Tumor Burden; Tumors
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/jc.2017-01797

Despite the development of hypocortisolemia after corticotroph surgical adenomectomy, 15% to 20% patients have recurrence of Cushing disease (CD). In this study, we investigated the effect of tumor size and the value of perioperative assessment of corticotropin (ACTH) and adrenal steroid levels in predicting recurrence. Perioperatively, no glucocorticoids were administered until the serum cortisol was ≤3 μg/dL. Blood samples were obtained before and repeatedly after adenomectomy in 79 patients with CD. Of these, 66 had a nadir serum cortisol of ≤3.0 μg/dL and clinical and biochemical remissions. During a median follow-up of 131 months, 11 of 66 had disease recurrence (REC), whereas 55 of 66 did not (NO-REC). Preoperative hormone levels in the REC and NO-REC groups were similar. After adenomectomy, a brief and similar increase in ACTH, cortisol, and dehydroepiandrosterone (DHEA) levels was observed in both groups followed by gradual decline in those levels. Although REC and NO-REC patients had similar cortisol levels (3.4 ± 1.7 μg/dL vs 2.9 ± 2.2 μg/dL) at the 36th postoperative hour, their respective ACTH (33 ± 7.1 ng/L vs 12.1 ± 5.4 ng/L; P < 0.0001), DHEA (3.8 ± 1.7 ng/mL vs 1.2 ± 1.1 ng/mL; P = 0.005), and dehydroepiandrosterone sulphate (DHEA-S) (143.9 ± 45.2 μg/dL vs 48.9 ± 38.2 μg/dL; P < 0.0001) were higher. At nadir hypocortisolemia, perioperative ACTH levels were >20 in all REC patients and