PMC:4143611 / 3945-7422 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/4143611","sourcedb":"PMC","sourceid":"4143611","source_url":"https://www.ncbi.nlm.nih.gov/pmc/4143611","text":"Defining surgical success\nThe criteria for determining immediate remission following surgery are not standardized and vary widely across centers. Variability occurs in the types of biochemical parameters used to evaluate success, the assays used, limitations of the assays, and the timing of measurements [8]. Furthermore, results can be confounded by other factors, such as peri-operative administration of glucocorticoids and pre-operative treatment with steroidogenesis inhibitors [4, 5].\n\nBiochemical indication of remission\nEarly morning serum cortisol measured between 8 and 10 a.m. is the most commonly utilized measure of immediate remission following surgery. Cortisol secretion normally follows a diurnal pattern with highest levels between 7–9 a.m. that decline to lowest levels around 10–11 p.m. [9]. In patients with CD, the circadian rhythm is aberrant and cortisol levels remain consistently elevated [9, 10]. The goals of pituitary surgery are to extract the ACTH-secreting adenoma and subsequently reduce cortisol levels, leading to improvements in the signs and symptoms of CD.\nSurgical success is confirmed by subnormal levels of early morning serum cortisol measured within a few days of surgery. Typically, early morning serum cortisol levels of either \u003c2 µg/dL (~50 nmol/L) or \u003c5 µg/dL within a few days after surgery are considered to be indicative of remission [3]. However, reported results are mixed and difficult to interpret since some studies measure basal serum cortisol levels while others use serum cortisol following dexamethasone suppression, or some combination of these measures [5, 11–13]. While clinical practice guidelines provide recommendations for testing in the context of initial diagnosis of CD [10], there is no expert consensus with regard to post-operative testing for surgical success.\nThe timing of biochemical measurements differs among treatment centers and can vary considerably within the same center. Intervals between surgery and biochemical measurement range from 1 to 2 days [14, 15], up to several weeks [16, 17], and even months [14]. As a result, the definition of post-surgical remission is unclear.\n\nOther confounding factors\nThis is further complicated by the fact that several circumstances can influence serum cortisol levels. Prophylactic medical treatments are often used prior to or during surgery to control cortisol levels in patients with CD. Since successful pituitary adenomectomy typically results in adrenal insufficiency, glucocorticoids are commonly administered peri- and/or pre-operatively [5]. On the other hand, because invasive surgery is a stressful procedure that elevates cortisol levels [18, 19], some centers attempt to mitigate such elevations in patients with CD, who are already hypercortisolemic as a result of the disease, prior to TSS [3, 20]. Steroidogenesis inhibitors, such as ketoconazole and metyrapone, may be administered for several weeks preceding adenomectomy [12, 21]. While the practice considers the patient’s best interest, pre-operative administration of these drugs often delays surgery and can pose challenges to the evaluation of remission status immediately following surgery. It is possible that adrenal insufficiency might be exaggerated by the action of these drugs and potentially falsely identifies some cases as surgical successes. It is therefore important for clinicians to time preoperative treatment discontinuation in order to avoid mistaking remission.","divisions":[{"label":"title","span":{"begin":0,"end":25}},{"label":"p","span":{"begin":26,"end":491}},{"label":"sec","span":{"begin":493,"end":2161}},{"label":"title","span":{"begin":493,"end":528}},{"label":"p","span":{"begin":529,"end":1095}},{"label":"p","span":{"begin":1096,"end":1834}},{"label":"p","span":{"begin":1835,"end":2161}},{"label":"title","span":{"begin":2163,"end":2188}}],"tracks":[{"project":"2_test","denotations":[{"id":"24980037-21301487-63233402","span":{"begin":306,"end":307},"obj":"21301487"},{"id":"24980037-23450054-63233403","span":{"begin":485,"end":486},"obj":"23450054"},{"id":"24980037-20556520-63233404","span":{"begin":488,"end":489},"obj":"20556520"},{"id":"24980037-9793762-63233405","span":{"begin":809,"end":810},"obj":"9793762"},{"id":"24980037-9793762-63233406","span":{"begin":917,"end":918},"obj":"9793762"},{"id":"24980037-18334580-63233407","span":{"begin":920,"end":922},"obj":"18334580"},{"id":"24980037-18413427-63233408","span":{"begin":1386,"end":1387},"obj":"18413427"},{"id":"24980037-20556520-63233409","span":{"begin":1616,"end":1617},"obj":"20556520"},{"id":"24980037-15579802-63233410","span":{"begin":1619,"end":1621},"obj":"15579802"},{"id":"24980037-16474220-63233410","span":{"begin":1619,"end":1621},"obj":"16474220"},{"id":"24980037-22120352-63233410","span":{"begin":1619,"end":1621},"obj":"22120352"},{"id":"24980037-18334580-63233411","span":{"begin":1741,"end":1743},"obj":"18334580"},{"id":"24980037-23393167-63233412","span":{"begin":2034,"end":2036},"obj":"23393167"},{"id":"24980037-23242860-63233413","span":{"begin":2038,"end":2040},"obj":"23242860"},{"id":"24980037-11380492-63233414","span":{"begin":2064,"end":2066},"obj":"11380492"},{"id":"24980037-22278423-63233415","span":{"begin":2068,"end":2070},"obj":"22278423"},{"id":"24980037-23393167-63233416","span":{"begin":2090,"end":2092},"obj":"23393167"},{"id":"24980037-20556520-63233417","span":{"begin":2571,"end":2572},"obj":"20556520"},{"id":"24980037-5427262-63233418","span":{"begin":2675,"end":2677},"obj":"5427262"},{"id":"24980037-15951937-63233419","span":{"begin":2679,"end":2681},"obj":"15951937"},{"id":"24980037-18413427-63233420","span":{"begin":2830,"end":2831},"obj":"18413427"},{"id":"24980037-16698415-63233421","span":{"begin":2833,"end":2835},"obj":"16698415"},{"id":"24980037-16474220-63233422","span":{"begin":2965,"end":2967},"obj":"16474220"},{"id":"24980037-22533782-63233423","span":{"begin":2969,"end":2971},"obj":"22533782"}],"attributes":[{"subj":"24980037-21301487-63233402","pred":"source","obj":"2_test"},{"subj":"24980037-23450054-63233403","pred":"source","obj":"2_test"},{"subj":"24980037-20556520-63233404","pred":"source","obj":"2_test"},{"subj":"24980037-9793762-63233405","pred":"source","obj":"2_test"},{"subj":"24980037-9793762-63233406","pred":"source","obj":"2_test"},{"subj":"24980037-18334580-63233407","pred":"source","obj":"2_test"},{"subj":"24980037-18413427-63233408","pred":"source","obj":"2_test"},{"subj":"24980037-20556520-63233409","pred":"source","obj":"2_test"},{"subj":"24980037-15579802-63233410","pred":"source","obj":"2_test"},{"subj":"24980037-16474220-63233410","pred":"source","obj":"2_test"},{"subj":"24980037-22120352-63233410","pred":"source","obj":"2_test"},{"subj":"24980037-18334580-63233411","pred":"source","obj":"2_test"},{"subj":"24980037-23393167-63233412","pred":"source","obj":"2_test"},{"subj":"24980037-23242860-63233413","pred":"source","obj":"2_test"},{"subj":"24980037-11380492-63233414","pred":"source","obj":"2_test"},{"subj":"24980037-22278423-63233415","pred":"source","obj":"2_test"},{"subj":"24980037-23393167-63233416","pred":"source","obj":"2_test"},{"subj":"24980037-20556520-63233417","pred":"source","obj":"2_test"},{"subj":"24980037-5427262-63233418","pred":"source","obj":"2_test"},{"subj":"24980037-15951937-63233419","pred":"source","obj":"2_test"},{"subj":"24980037-18413427-63233420","pred":"source","obj":"2_test"},{"subj":"24980037-16698415-63233421","pred":"source","obj":"2_test"},{"subj":"24980037-16474220-63233422","pred":"source","obj":"2_test"},{"subj":"24980037-22533782-63233423","pred":"source","obj":"2_test"}]}],"config":{"attribute types":[{"pred":"source","value type":"selection","values":[{"id":"2_test","color":"#93ecaf","default":true}]}]}}