Predicting Recurrence

[mertie]

<H2 class=title_document>Role for postoperative cortisol response to desmopressin in predicting the risk for recurrent Cushing's disease</H2>

• Daniella Jesus Patrick Carminatti Romanholi*^,?,
  
• Marcio Carlos Machado*^,?^,?,
  
• Camila Canteiro Pereira??Division of Endocrinology and Metabolism and ,
  
• Debora Seguro Danilovic??Division of Endocrinology and Metabolism and ,
  
• Maria Adelaide Albergaria Pereira??Division of Endocrinology and Metabolism and ,
  
• Valter Angelo S. Cescato??Neuroendocrine Unit, Division of Neurosurgery, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil,
  
• Malebranche Berardo C. Cunha Neto??Neuroendocrine Unit, Division of Neurosurgery, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil,
  
• Nina Rosa Castro Musolino??Neuroendocrine Unit, Division of Neurosurgery, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil,
  
• Berenice Bilharinho de Mendon?a??Division of Endocrinology and Metabolism and and
  
• Luiz Roberto Salgado??Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil,
  

• ?Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil, ?Neuroendocrine Unit, Service of Endocrinology and Metabolism, Hospital de Clinicas, Federal University of Parana (SEMPR), Curitiba, PR, Brazil, ?Division of Endocrinology and Metabolism and ?Neuroendocrine Unit, Division of Neurosurgery, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
  

Correspondence: Luiz Roberto Salgado, Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo School of Medicine, Av. Dr Eneas de Carvalho Aguiar #155, 8th floor, Cerqueira Cesar, Sao Paulo, SP 05403?060, Brazil. Tel./Fax: +55 11 3069 7694; E-mail: salga@uol.com.br*Daniella J.P.C. Romanholi and Marcio C. Machado contributed equally to this work.

 

<H3 id=h1>Summary</H3> In the early postoperative period of Cushing's disease patients, desmopressin may stimulate ACTH secretion in the remnant corticotrophic tumour, but not in nontumour suppressed cells.

 

Objective The aim of this study is to evaluate the serum cortisol responses to desmopressin after pituitary surgery, establishing an optimal cut-off for absolute increment (Δ) of serum cortisol (F) suitable to predict recurrence risk.

 

Design Retrospective case record study.

 

Patients Fifty-seven Cushing's disease patients submitted to pituitary surgery and desmopressin stimulation in the early postoperative with a long-term follow-up (20?161 months) were studied.

 

Methods and measurements Serum cortisol levels after desmopressin test (10 ?g IV) 15?30 days after adenomectomy were used to determine ΔF (absolute increment of F: F peak − F baseline). Sensitivity and specificity of ΔF were calculated and a ROC curve was performed to establish an optimal cut-off for ΔF to predict recurrence risk.

 

Results Fifteen patients had immediate postoperative failure (basal F > 165 nmol/l; 6 ?g/dl) and one patient was lost during the follow-up. Forty-one patients achieved initial remission and were followed-up. Five of 11 patients who recurred had ΔF > 193 nmol/l (7 ?g/dl), but none of 30 patients who remained in prolonged remission showed ΔF > 193 nmol/l after postoperative desmopressin stimulation.

 

Conclusions Persistence of cortisol response (ΔF > 193 nmol/l) to desmopressin in the early postoperative period can help to identify Cushing's disease patients with initial remission who present risk for later recurrence.

[judycolby]

I hate to sound dumb, but can you put that in plain language. I almost understand it but get muddled at the end.

But it sounds like a good thing. Does this mean they could predict whether a patient was cured before their eymptoms recurred?

Judy

[mertie]

Yes. I thought this was relevant since so many people (most) worry about not being cured immediately after surgery. Unfortunately we've been told to take a "wait and see" attitude. This test just might alleviate some of our worries.

[copacabana]

Anyone want a trip to Brazil?!

 

Thanks for the info Mary, it's very interesting!

[twinkie]

Thanks so much Mary! Does anyone know what desmopressin is? Is it a drug? In any case, it looks like only 15 had a reaccurance....at least that's how I understand it.

love,

melly in nv

[Jo MacRaild]

Desmopressins, a medical made up vasopressin, ...theres a lot of stuff out there on Vasopressin, thats your own natural posterior pit hormone for holding in water, & how it can stimulate release of tumor & hyperplasic ACTH..& I think vice versa in cushies...

 

 

 

 

http://jcem.endojournals.org/cgi/content/full/84/6/2195

 

 

Great article Mary, thanks.

[copacabana]

Does anyone know if they could do that test here?!

[Jo MacRaild]

Nicole, there is a standard, but probably not oft done, pre surgery desmo /ACTH pituitary stim test, anyhow, so cant see it would be a problem..

 

NIH were fascinated with Corries ACTH & sodiums..& tracked them, but in her water load tracks ACTH, but the sodiums go up, when the adrenals switch on, which is ACTH independent..

 

 

Have a look at this.............

http://www.google.com/search?q=Desmopressi...GL_enGB236GB236

[Kathryn G]

Thanks for sharing that article, Mary.

Kate G

[casag]

The way I read this, 30 out of the 57 had prolonged remissions.

 

Interesting article, Mary!

[ADDflower]

This is interesting... especially since this is an epub ahead of publication (date for this article is July 2008) Let me see if I can parse this out...

 

In the early postoperative period of Cushing s disease (CD) patients, desmopressin may stimulate ACTH secretion in the remnant corticotrophic tumour, but not in non-tumour suppressed cells. okay, this makes sense

 

Objective: The aim of this study is to evaluate the serum cortisol responses to desmopressin after pituitary surgery, establishing an optimal cut off for absolute increment (delta) of serum cortisol (F) suitable to predict recurrence risk. this describes what they want to find out, they're going to give patients desmopressin after surgery, see what their response is, and then follow them to try to find out what level of serum cortisol in response to desmopression correlates to risk of reoccurence

 

Design: Retrospective case record study. this means that they looked back at charts to see what happened AFTER

 

Patients: Fifty-seven CD patients submitted to pituitary surgery and desmopressin stimulation in the early postoperative with a long-term follow-up (20-161 months) were studied. they started with 57 patients who had pituitary surgery and not too long after surgery had desmopressin stimulation test. The follow up period for patients was from 20 to 161 months after surgery

 

Methods and Measurements: Serum cortisol levels after desmopressin test (10 g IV) 15-30 days after adenomectomy were used to determine delta F (absolute increment of F: F peak - F baseline). here they describe how they did the test and what they used to determine what values they were going to use to determine their values range

 

Sensitivity and specificity of delta F were calculated and a ROC curve was performed to establish an optimal cut off for delta F to predict recurrence risk. someone who actually took statistics could better explain this, but they're talking about math used to determine how accurate their results might be

 

Results: Fifteen patients had immediate postoperative failure (basal F > 165 nmol/L; 6 mug/dL) and one patient was lost during the follow-up. 16 patients total had to be excluded from their final results because they clearly did not get remission from the surgery and one never came back for followup

 

Forty-one patients achieved initial remission and were followed-up. this is pretty clear

 

Five of 11 patients who recurred had delta F > 193 nmol/L (7 mug/dL), but none of 30 patients who remained in prolonged remission showed delta F > 193 nmol/L after postoperative desmopressin stimulation. 11 people of the remaining 41 had reoccurence. Only 5 of those 11 had values on the desmopressin greater then the baseline they set. The 30 that stayed in remission for the length of the study had values lower than the baseline they set

 

Conclusions: Persistence of cortisol response (delta F > 193 nmol/L) to desmopressin in the early postoperative period can help to identify CD patients with initial remission who present risk for later recurrence. their conclusion...

 

*******************

 

This is a fairly small study, but it certainly sounds interesting. I'm not sure what the practical use of this would be... other than to predict who might have a reoccurence after pituitary surgery, but IMHO I think it more predicts the opposite, who will stay in remission. I think that the study isn't long enough for all the patients... I mean, how many were in the 20 month follow up group? That's hardly long enough. But interesting none the less.