No requirement of perioperative glucocorticoid replacement in patients with endogenous Cushing's syndrome - a pilot study

Abstract

Purpose: Surgical therapy represents the first-line treatment for endogenous Cushing's syndrome (CS). While postoperative glucocorticoid replacement is mandatory after surgical remission, the role of perioperative glucocorticoid therapy is unclear.

Methods: We recruited patients with central or adrenal CS in whom curative surgery was planned and patients who underwent pituitary surgery for other reasons than CS as a control group. Patients did not receive any perioperative glucocorticoids until the morning of the first postoperative day. We performed blood samplings in the morning of surgery, immediately after surgery, in the evening of the day of surgery, and in the morning of the first and third postoperative day before any morning glucocorticoid intake. We continued clinical and biochemical monitoring during the following outpatient care.

Results: We recruited 12 patients with CS (seven with central CS, five with adrenal CS) and six patients without CS. In patients with CS, serum cortisol concentrations <5.0 µg/dL (<138 nmol/L) were detected in the morning of the first and third postoperative day in four (33%) and six (50%) patients, respectively. Morning serum cortisol concentrations on the third postoperative day were significantly lower when compared to preoperative measurements (8.5 ± 7.6 µg/dL vs. 19.9 ± 8.9 µg/dL [235 ± 210 nmol/L vs. 549 ± 246 nmol/L], p = 0.023). No patient developed clinical or biochemical signs associated with hypocortisolism. During follow-up, we first observed serum cortisol concentrations >5.0 µg/dL (>138 nmol/L) after 129 ± 97 days and glucocorticoids were discontinued after 402 ± 243 days. Patients without CS did not require glucocorticoid replacement at any time.

Conclusion: Perioperative glucocorticoid replacement may be unnecessary in patients with central or adrenal CS undergoing curative surgery as first-line treatment.

Keywords: Adrenal; Cushing’s disease; Cushing’s syndrome; Hypercortisolism; Perioperative glucocorticoid replacement; Pituitary.

Fig. 1

Flow-chart of inpatient blood samplings (BS1–5) and summary of timeframes of outpatient blood samplings (BS6–26). BS blood sampling

Fig. 2

Serum cortisol concentration of patients with CS during inpatient treatment. C1–12 represents patients with CS. Blood sampling 1 took place on the morning of surgery, blood sampling 2 immediately after surgery, blood sampling 3 on the evening of the day of surgery, and blood sampling 4 and 5 on the morning of postoperative days 1 and 3, respectively. CS Cushing’s syndrome

Fig. 3

Serum cortisol concentrations of patients with CS during follow-up visits after discharge from inpatient treatment. C1–12 represents patients with CS. Blood samplings 6–26 took place during routine outpatient visits after surgery, please refer to Fig. 1 for target time frame of blood samplings. CS Cushing’s syndrome

Fig. 4

Serum ACTH concentrations in patients with central (A) and adrenal (B) CS during inpatient and outpatient treatment. C1–12 represents patients with CS. Blood sampling 1 took place on the morning of surgery, blood sampling 2 immediately after surgery, blood sampling 3 on the evening of the day of surgery, and blood sampling 4 and 5 on the morning of postoperative days 1 and 3, respectively. Blood samplings 6–26 took place during routine outpatient visits after surgery, please refer to Fig. 1 for target time frame of blood samplings. ACTH adrenocorticotrophic hormone, CS Cushing’s syndrome