PMC:4143611 / 20438-23351
Annnotations
{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/4143611","sourcedb":"PMC","sourceid":"4143611","source_url":"https://www.ncbi.nlm.nih.gov/pmc/4143611","text":"Discussion\nCD is most commonly treated by surgical removal of the transgressing pituitary adenoma. Reported success rates vary widely and could be a result of surgeon expertise, reliability or timing of assays, or cut-off levels used to define remission. Furthermore, prophylactic measures, such as the use of pre- and/or peri-operative glucocorticoids or steroidogenesis inhibitors may confound results from biochemical assays performed soon after surgery [5]. It has recently been suggested that peri-operative use of glucocorticoids may be unnecessary and that they should be administered only if a biochemical or clinical need is confirmed [5]. Consideration of these variables is important because recurrence of CD following TSS is not uncommon and the current common perception is that post-surgical cortisol levels may predict a patient’s predisposition to relapse.\nDespite the large number of long-term follow-up studies published, no single positive predictive factor of recurrence has emerged. Although subnormal levels of early morning serum cortisol levels measured within a few days following surgery suggest a lower risk of recurrence, relapse does occur in approximately 9 % of patients in this population [40]. Patients who achieve normal, but not subnormal post-surgical levels of cortisol are at a higher risk for recurrence (~24 %), although many of these patients may experience long-term remission [40]. Evaluation of the HPA axis in addition to cortisol levels may provide an advantage, but results to date are contradictory and further studies are needed. Since there is no fail-safe predictor of recurrence, standardized lifelong monitoring of post-surgical patients with CD is recommended for timely detection and optimal treatment of disease recurrence.\nWe propose the application of rigorous post-surgical monitoring to patients with CD who have been treated with TSS. Education of endocrinologists on this matter has begun with Bertagna and Guignat’s recent publication on the approach to the diagnosis and treatment of persistence and recurrent CD [48]. The authors highlight the available tests and therapeutic avenues, including combination therapies that can be used to treat a patient not cured by primary TSS. Based on our own clinical experiences and understanding of the literature, we have proposed what we believe is a feasible algorithm for post-surgical follow-up monitoring. The algorithm represents our recommendations for post-surgical monitoring of patients with CD and is presented with the caveat that it is designed to be a general guide rather than a simple protocol. Treatment decisions can be complex and must be made on a case-by-case basis using all available information, including levels of biochemical markers, severity of disease, the evolving availability of medical therapies, and patient concerns and preferences in cases of persistent hypercortisolemia.","divisions":[{"label":"title","span":{"begin":0,"end":10}},{"label":"p","span":{"begin":11,"end":872}},{"label":"p","span":{"begin":873,"end":1779}}],"tracks":[{"project":"2_test","denotations":[{"id":"24980037-20556520-63233451","span":{"begin":458,"end":459},"obj":"20556520"},{"id":"24980037-20556520-63233452","span":{"begin":645,"end":646},"obj":"20556520"},{"id":"24980037-20651632-63233453","span":{"begin":1222,"end":1224},"obj":"20651632"},{"id":"24980037-20651632-63233454","span":{"begin":1420,"end":1422},"obj":"20651632"},{"id":"24980037-23564942-63233455","span":{"begin":2078,"end":2080},"obj":"23564942"}],"attributes":[{"subj":"24980037-20556520-63233451","pred":"source","obj":"2_test"},{"subj":"24980037-20556520-63233452","pred":"source","obj":"2_test"},{"subj":"24980037-20651632-63233453","pred":"source","obj":"2_test"},{"subj":"24980037-20651632-63233454","pred":"source","obj":"2_test"},{"subj":"24980037-23564942-63233455","pred":"source","obj":"2_test"}]}],"config":{"attribute types":[{"pred":"source","value type":"selection","values":[{"id":"2_test","color":"#ec93ad","default":true}]}]}}