Background. Multiple studies tried to identify cortisol cut-offs after pituitary surgery able to assess accurately hypothalamic-pituitary-adrenal axis function, however there is no consensus nowadays. This study aimed to evaluate the accuracy of morning cortisol after transsphenoidal surgery in predicting long term secondary adrenal insufficiency. Methods. In our tertiary Center, we prospectively determined first and second day cortisol after transsphenoidal surgery in 92 patients without preoperative adrenal insufficiency and not treated with glucocorticoids perioperative. Definitive diagnosis of secondary adrenal insufficiency was obtained with re-evaluation three months after transsphenoidal surgery and clinical follow-up of at least one year. Results. 10 patients (10.8%) developed long-term postoperative secondary adrenal insufficiency. The ROC curves demonstrated that first day cortisol had a moderate diagnostic accuracy, while a second day cortisol ≤9.3 µg/dL (257 nmol/L) showed the best performance in predicting adrenal insufficiency (Se 88.9%, Sp 86.9%, AUC 0.921). Moreover, a second day cortisol ≤3.2 µg/dL (89 nmol/L) was able to diagnose adrenal insufficiency in 100% of cases (Se 22.2%, Sp 100%) and >14 µg/dL (386 nmol/L) was able to exclude ACTH deficiency (Se 100%, Sp 57.4%). Conclusions. Adrenal function can be carefully studied in the second day after pituitary surgery, using cut-off values that international guidelines suggested for non-stressed conditions. In fact, second day cortisol levels ≤3.2 μg/dL (89 nmol/L) and >14 μg/dL (386 nmol/L) are diagnostic of secondary adrenal insufficiency and normal function, respectively. We also suggest performing a definitive re-evaluation with an HPA-axis stimulation test when second day cortisol values are between 3.3 and 14 μg/dL (90-386 nmol/L).


中文翻译：

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经蝶手术后第二天早上的皮质醇水平是继发性肾上腺皮质功能不全的准确预测指标，其诊断截止值与非压力情况相似。

背景。多项研究试图确定垂体手术后皮质醇临界值能够准确评估下丘脑-垂体-肾上腺轴功能，但目前尚未达成共识。本研究旨在评估经蝶手术后早晨皮质醇预测长期继发性肾上腺皮质功能不全的准确性。方法。在我们的三级中心，我们前瞻性地确定了 92 名无术前肾上腺功能不全且围手术期未使用糖皮质激素治疗的患者在经蝶手术后第一天和第二天的皮质醇。继发性肾上腺皮质功能不全的明确诊断是在经蝶手术后三个月重新评估和至少一年的临床随访获得的。结果。10 名患者（10.8%）出现长期术后继发性肾上腺皮质功能不全。ROC 曲线表明，第一天皮质醇的诊断准确性适中，而第二天皮质醇≤9.3 µg/dL (257 nmol/L) 在预测肾上腺功能不全方面表现出最佳性能（Se 88.9%，Sp 86.9%，AUC 0.921） . 此外，第二天皮质醇≤3.2 µg/dL (89 nmol/L) 能够在 100% 的病例（Se 22.2%，Sp 100%）和 >14 µg/dL（386 nmol/L）中诊断肾上腺功能不全。能够排除 ACTH 缺乏症（Se 100%，Sp 57.4%）。结论。肾上腺功能可以在垂体手术后的第二天仔细研究，使用国际指南建议的非压力条件的临界值。事实上，第二天皮质醇水平≤3.2 μg/dL (89 nmol/L) 和 >14 μg/dL (386 nmol/L) 分别可诊断继发性肾上腺皮质功能不全和正常功能。