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Lee A, Jang S, Lee S, Park HK, Kim IY, Ahn R, Seok JH, Lee KR. Comparative analysis of salivary cortisol measurements using different assay methods in relation to serum-free cortisol measurement. Pract Lab Med 2024; 40:e00393. [PMID: 38645932 PMCID: PMC11026831 DOI: 10.1016/j.plabm.2024.e00393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/26/2024] [Accepted: 04/08/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives Salivary cortisol reflects the biologically active form of serum cortisol, offering a noninvasive evaluation method for the diurnal rhythm of the hypothalamic-pituitary-adrenal (HPA) axis. While liquid chromatography-tandem mass spectrometry (LC-MS/MS) is known for its specificity, immunoassays (IA) are commonly used because of their simplicity. This study aimed to assess the performance of salivary cortisol measurement using both IA and LC-MS/MS in comparison to serum-free cortisol measurement. Methods Assay results for 188 saliva and 94 serum samples from 47 participants were analyzed. Salivary samples collected at different time points were analyzed using IA and LC-MS/MS. Serum samples were analyzed for cortisol, cortisol-binding globulin, and free cortisol. The statistical analyses included correlations and method comparisons. Results The diurnal salivary cortisol profiles exhibited a comparable circadian rhythm pattern; however, the concentrations measured using IA were consistently higher than those measured using LC-MS/MS. The correlation analysis revealed robust associations among salivary cortisol (IA), salivary cortisol (LC-MS/MS), and serum-free cortisol levels (LC-MS/MS). However, the method comparison revealed a systematic bias between IA and LC-MS/MS in salivary cortisol measurement. Conclusions This study contributes to the ongoing debate on assay techniques by affirming the suitability of IA and LC-MS/MS for salivary cortisol measurement to assess dynamic changes in HPA axis activity. The identified systematic bias emphasizes the importance of selecting methods based on specific research or clinical requirements.
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Affiliation(s)
- Anna Lee
- Department of Laboratory Medicine, Seoul Clinical Laboratories, Yong-In, Republic of Korea
| | - Sooah Jang
- Research Institute of Minds.AI, Co. Ltd., Seoul, Republic of Korea
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sanghoo Lee
- Center for Companion Biomarker, Seoul Clinical Laboratories Healthcare Inc., Yong-In, Republic of Korea
| | - Hyun-Kyung Park
- Department of Laboratory Medicine, Seoul Clinical Laboratories, Yong-In, Republic of Korea
| | - In-Young Kim
- Research Institute of Minds.AI, Co. Ltd., Seoul, Republic of Korea
| | - Ryunsup Ahn
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Hormone Analysis Center, Minds.AI, Co. Ltd., Seoul, Republic of Korea
| | - Jeong-Ho Seok
- Research Institute of Minds.AI, Co. Ltd., Seoul, Republic of Korea
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Ryul Lee
- Department of Laboratory Medicine, Seoul Clinical Laboratories, Yong-In, Republic of Korea
- Center for Companion Biomarker, Seoul Clinical Laboratories Healthcare Inc., Yong-In, Republic of Korea
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2
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Lightman SL. Clinical Endocrinology-Time for a Reset? J Endocr Soc 2024; 8:bvae024. [PMID: 38440109 PMCID: PMC10910589 DOI: 10.1210/jendso/bvae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 03/06/2024] Open
Abstract
Measurement of blood levels of circulating hormones has always been the cornerstone of the biochemical diagnosis of endocrine diseases, with the objective of detecting hormone excess or insufficiency. Unfortunately, the dynamic nature of hormone secretion means single-point measurements of many hormones often lack diagnostic validity. Endocrinologists have devised complex dynamic tests as indirect assessments of the functioning of the hormone system under investigation. Recent advances in the measurement of dynamic hormone changes across the day now offer an opportunity to reconsider whether there might be better ways both to diagnose and to monitor the therapy of endocrine conditions.
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Affiliation(s)
- Stafford L Lightman
- Translational Health Sciences, The Medical School, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol BS1 3NY, UK
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3
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Ceccato F, Fleseriu M. Commentary: Cortisone or Cortisol, "the E" or "the F," That Is the Question! J Clin Endocrinol Metab 2023; 109:e428-e429. [PMID: 37290037 DOI: 10.1210/clinem/dgad348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Filippo Ceccato
- Department of Medicine (DIMED), University of Padova, 35128 Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, 35128 Padova, Italy
| | - Maria Fleseriu
- Pituitary Center, Oregon Health & Science University, Portland, OR 97239, USA
- Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, USA
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4
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Bäcklund N, Brattsand G, Lundstedt S, Aardal E, Bartuseviciene I, Berinder K, Höybye C, Burman P, Edén Engström B, Isaksson A, Blomgren A, Ragnarsson O, Rüetschi U, Wahlberg J, Olsson T, Dahlqvist P. Salivary cortisol and cortisone in diagnosis of Cushing's syndrome - a comparison of six different analytical methods. Clin Chem Lab Med 2023; 61:1780-1791. [PMID: 37013440 DOI: 10.1515/cclm-2023-0141] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVES Salivary cortisol and cortisone at late night and after dexamethasone suppression test (DST) are increasingly used for screening of Cushing's syndrome (CS). We aimed to establish reference intervals for salivary cortisol and cortisone with three liquid chromatography-tandem mass spectrometry (LC-MS/MS) techniques and for salivary cortisol with three immunoassays (IAs), and evaluate their diagnostic accuracy for CS. METHODS Salivary samples at 08:00 h, 23:00 h and 08:00 h after a 1-mg DST were collected from a reference population (n=155) and patients with CS (n=22). Sample aliquots were analyzed by three LC-MS/MS and three IA methods. After establishing reference intervals, the upper reference limit (URL) for each method was used to calculate sensitivity and specificity for CS. Diagnostic accuracy was evaluated by comparing ROC curves. RESULTS URLs for salivary cortisol at 23:00 h were similar for the LC-MS/MS methods (3.4-3.9 nmol/L), but varied between IAs: Roche (5.8 nmol/L), Salimetrics (4.3 nmol/L), Cisbio (21.6 nmol/L). Corresponding URLs after DST were 0.7-1.0, and 2.4, 4.0 and 5.4 nmol/L, respectively. Salivary cortisone URLs were 13.5-16.6 nmol/L at 23:00 h and 3.0-3.5 nmol/L at 08:00 h after DST. All methods had ROC AUCs ≥0.96. CONCLUSIONS We present robust reference intervals for salivary cortisol and cortisone at 08:00 h, 23:00 h and 08:00 h after DST for several clinically used methods. The similarities between LC-MS/MS methods allows for direct comparison of absolute values. Diagnostic accuracy for CS was high for all salivary cortisol and cortisone LC-MS/MS methods and salivary cortisol IAs evaluated.
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Affiliation(s)
- Nils Bäcklund
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Göran Brattsand
- Department of Medical Biosciences, Umeå University, Umeå, Sweden
| | | | - Elisabeth Aardal
- Department of Clinical Chemistry, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Inga Bartuseviciene
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Berinder
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University, Uppsala, Sweden
- Department of Endocrinology and Diabetes, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Isaksson
- Department of Clinical Chemistry and Pharmacology, Lund University, Lund, Sweden
| | - Anders Blomgren
- Department of Clinical Chemistry and Pharmacology, Lund University, Lund, Sweden
| | - Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Ulrika Rüetschi
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jeanette Wahlberg
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Medicine, Örebro University Hospital, Örebro, Sweden
| | - Tommy Olsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Musacchio S, Kallenbach MD, Huber DL, Raff H, Johnson BD, Leddy J, McCrea MA, Meier TB, Nelson LD. Salivary Cortisol Dynamics After Mild Traumatic Brain Injury. J Head Trauma Rehabil 2023; 38:E318-E327. [PMID: 36696236 PMCID: PMC10329977 DOI: 10.1097/htr.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To assess mild traumatic brain injury (mTBI)-related alterations in baseline (resting) salivary cortisol and cortisol reactivity to cognitive and exercise stressors, which are frequently encountered during mTBI rehabilitation and recovery. SETTING Persons with mTBI were recruited from a level 1 trauma center emergency department. Uninjured controls (UCs) were recruited from the community. PARTICIPANTS Participants were 37 individuals with mTBI and 24 UCs. All patients with mTBI were enrolled at 7 ± 3 days post-injury, met the American Congress of Rehabilitation Medicine definition of mTBI, and had no acute intracranial findings on clinical neuroimaging (if performed). DESIGN A prospective cohort study design was used. All participants provided saliva samples 10 times during each of 2 visits spaced 3 weeks apart (1 week and 1 month post-injury for the mTBI group). Each visit included baseline saliva sampling and sampling to evaluate reactivity to a cognitive stressor (Paced Auditory Serial Addition Test) and physical stressor (Buffalo Concussion Treadmill Test [BCTT]). MAIN OUTCOME MEASURE Natural log-transformed salivary cortisol was measured by enzyme immunoassay. Cortisol was predicted using a linear mixed-effects model by group (mTBI and UC), visit (1 week and 1 month), and saliva sample. RESULTS Mean salivary cortisol was higher in the mTBI group (1.67 nmol/L [95% CI 1.42-1.72]) than in controls (1.30 nmol/L [1.12-1.47]), without an mTBI × time interaction. At 1 week, the mTBI group had greater cortisol reactivity in response to the BCTT. CONCLUSIONS Higher cortisol in individuals with mTBI at 1 week and 1 month post-injury extends previous findings into the subacute recovery period. Furthermore, the mTBI group demonstrated a greater cortisol response to mild-to-moderate aerobic exercise (BCTT) at 1 week post-injury. Given the increasing role of exercise in mTBI rehabilitation, further research is warranted to replicate these findings and identify the clinical implications, if any, of enhanced hypothalamic-pituitary-adrenal axis responses to exercise in civilians with recent mTBI.
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Affiliation(s)
- Sophia Musacchio
- Departments of Neurosurgery (Ms Musacchio, Mx Kallenbach, Mr Huber, and Drs McCrea, Meier, and Nelson) and Medicine, Surgery, and Physiology (Dr Raff), Medical College of Wisconsin, Milwaukee; Endocrine Research Laboratory, Aurora St Luke's Medical Center, Advocate Aurora Research Institute, Milwaukee, Wisconsin (Dr Raff); Department of Kinesiology, Indiana University, Bloomington (Dr Johnson); and UBMD Orthopaedics and Sports Medicine, and SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (Dr Leddy)
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6
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Flowers KC, Shipman KE. Pitfalls in the Diagnosis and Management of Hypercortisolism (Cushing Syndrome) in Humans; A Review of the Laboratory Medicine Perspective. Diagnostics (Basel) 2023; 13:diagnostics13081415. [PMID: 37189516 DOI: 10.3390/diagnostics13081415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Biochemical confirmation of a diagnosis of hypercortisolism (Cushing syndrome) is vital to direct further investigations, especially given the overlap with non-autonomous conditions, such as pseudo-Cushing, and the morbidity associated with missed diagnoses. A limited narrative review was performed focusing on the laboratory perspective of the pitfalls of making a biochemical diagnosis of hypercortisolism in those presenting with presumed Cushing syndrome. Although analytically less specific, immunoassays remain cheap, quick, and reliable in most situations. Understanding cortisol metabolism can help with patient preparation, specimen selection (e.g., consideration of urine or saliva for those with possible elevations of cortisol binding globulin concentration), and method selection (e.g., mass spectrometry if there is a high risk of abnormal metabolites). Although more specific methods may be less sensitive, this can be managed. The reduction in cost and increasing ease of use makes techniques such as urine steroid profiles and salivary cortisone of interest in future pathway development. In conclusion, the limitations of current assays, particularly if well understood, do not impede diagnosis in most cases. However, in complex or borderline cases, there are other techniques to consider to aid in the confirmation of hypercortisolism.
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Affiliation(s)
- Kade C Flowers
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
| | - Kate E Shipman
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
- Department of Medical Education, Brighton and Sussex Medical School, University of Sussex, Falmer Campus, Brighton BN1 9PX, UK
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7
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Karachaliou CE, Koukouvinos G, Goustouridis D, Raptis I, Kakabakos S, Petrou P, Livaniou E. Cortisol Immunosensors: A Literature Review. BIOSENSORS 2023; 13:bios13020285. [PMID: 36832050 PMCID: PMC9954523 DOI: 10.3390/bios13020285] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/02/2023] [Accepted: 02/13/2023] [Indexed: 05/26/2023]
Abstract
Cortisol is a steroid hormone that is involved in a broad range of physiological processes in human/animal organisms. Cortisol levels in biological samples are a valuable biomarker, e.g., of stress and stress-related diseases; thus, cortisol determination in biological fluids, such as serum, saliva and urine, is of great clinical value. Although cortisol analysis can be performed with chromatography-based analytical techniques, such as liquid chromatography-tandem mass spectrometry (LC-MS/MS), conventional immunoassays (radioimmunoassays (RIAs), enzyme-linked immunosorbent assays (ELISAs), etc.) are considered the "gold standard" analytical methodology for cortisol, due to their high sensitivity along with a series of practical advantages, such as low-cost instrumentation, an assay protocol that is fast and easy to perform, and high sample throughput. Especially in recent decades, research efforts have focused on the replacement of conventional immunoassays by cortisol immunosensors, which may offer further improvements in the field, such as real-time analysis at the point of care (e.g., continuous cortisol monitoring in sweat through wearable electrochemical sensors). In this review, most of the reported cortisol immunosensors, mainly electrochemical and also optical ones, are presented, focusing on their immunosensing/detection principles. Future prospects are also briefly discussed.
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Affiliation(s)
- Chrysoula-Evangelia Karachaliou
- Immunopeptide Chemistry Lab., Institute of Nuclear & Radiological Sciences & Technology, Energy & Safety, National Centre for Scientific Research ‘‘Demokritos”, P.O. Box 60037, 153 10 Agia Paraskevi, Greece
| | - Georgios Koukouvinos
- Immunoassay/Immunosensors Lab., Institute of Nuclear & Radiological Sciences & Technology, Energy & Safety, National Centre for Scientific Research ‘‘Demokritos”, P.O. Box 60037, 153 10 Agia Paraskevi, Greece
| | - Dimitrios Goustouridis
- ThetaMetrisis S.A., Christou Lada 40, 121 32 Athens, Greece
- Department of Electrical & Electronics Engineering, University of West Attica, 122 44 Athens, Greece
| | - Ioannis Raptis
- ThetaMetrisis S.A., Christou Lada 40, 121 32 Athens, Greece
- Institute of Nanoscience and Nanotechnology, National Centre for Scientific Research ‘‘Demokritos”, P.O. Box 60037, 153 10 Agia Paraskevi, Greece
| | - Sotirios Kakabakos
- Immunoassay/Immunosensors Lab., Institute of Nuclear & Radiological Sciences & Technology, Energy & Safety, National Centre for Scientific Research ‘‘Demokritos”, P.O. Box 60037, 153 10 Agia Paraskevi, Greece
| | - Panagiota Petrou
- Immunoassay/Immunosensors Lab., Institute of Nuclear & Radiological Sciences & Technology, Energy & Safety, National Centre for Scientific Research ‘‘Demokritos”, P.O. Box 60037, 153 10 Agia Paraskevi, Greece
| | - Evangelia Livaniou
- Immunopeptide Chemistry Lab., Institute of Nuclear & Radiological Sciences & Technology, Energy & Safety, National Centre for Scientific Research ‘‘Demokritos”, P.O. Box 60037, 153 10 Agia Paraskevi, Greece
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8
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Raff H, Zhang CD. A New Approach - Home Waking Salivary Cortisone to Screen for Adrenal Insufficiency. NEJM EVIDENCE 2023; 2:EVIDe2200306. [PMID: 38320042 DOI: 10.1056/evide2200306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Adrenal insufficiency is a common and potentially life-threatening endocrine disorder that can be drug induced or endogenous and of adrenal (primary) or pituitary/hypothalamic (secondary/tertiary) origin.1,2 Of particular concern in drug-induced disease is the patient with glucocorticoid- or opioid-induced adrenal insufficiency. Adrenal insufficiency of any cause is typically diagnosed biochemically with a subnormal morning serum cortisol (the circadian, awakening peak) and serum dehydroepiandrosterone sulfate, followed by or simultaneously with an assessment of the acute (30 and 60 minutes) serum cortisol response to injected synthetic corticotropin (ACTH[1-24]), if clinically indicated.
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Affiliation(s)
- Hershel Raff
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Milwaukee
| | - Catherine D Zhang
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
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9
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Raff H. Late Night Salivary Cortisol in the diagnosis of neoplastic hypercortisolism (including cyclic Cushing's syndrome). Pituitary 2022; 25:698-700. [PMID: 35334030 DOI: 10.1007/s11102-022-01214-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 10/18/2022]
Abstract
Late night salivary cortisol (LNSC) is a mainstay in the diagnosis of neoplastic hypercortisolism (Cushing's syndrome) with a sensitivity and specificity of > 90% in patients with syndromic signs and symptoms. Intermittent hormonogenesis (day to day variation) is common in milder Cushing's disease whereas true cyclic Cushing's syndrome (weeks to months of tumor quiescence) is unusual. In both cases, LNSC is useful as a sensitive evaluative diagnostic tool, although its lower specificity may lead to false positive results in patients without Cushing's disease. Furthermore, intermittent hormonogenesis may lead to false negative LNSC results in patients with mild Cushing's disease. Finally, LNSC is useful as an approach to follow patients after pituitary surgery to detect a recurrence even many years after a full remission.
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Affiliation(s)
- Hershel Raff
- Departments of Medicine (Endocrinology and Molecular Medicine), Surgery, and Physiology, Medical College of Wisconsin, 53226, Milwaukee, WI, USA.
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Advocate Aurora Research Institute, 53215, Milwaukee, WI, USA.
- Endocrinology Aurora St. Luke's Medical Center, 2801 W KK River Pky MOB260, 53215, Milwaukee, WI, USA.
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Abstract
Endogenous Cushing's syndrome (CS) is associated with morbidities (diabetes, hypertension, clotting disorders) and shortens life because of infections, pulmonary thromboembolism, and cardiovascular disease. Its clinical presentation is immensely variable, and diagnosis and treatment are often delayed. Thus, there are many opportunities for basic and clinical research leading to better tests, faster diagnosis, and optimized medical treatments. This review focuses on CS caused by excessive adrenocorticotropin (ACTH) production. It describes current concepts of the regulation of ACTH synthesis and secretion by normal corticotropes and mechanisms by which dysregulation occurs in corticotrope (termed "Cushing's disease") and noncorticotrope (so-called ectopic) ACTH-producing tumors. ACTH causes adrenal gland synthesis and pulsatile release of cortisol; the excess ACTH in these forms of CS leads to the hypercortisolism of endogenous CS. Again, the differences between healthy individuals and those with CS are highlighted. The clinical presentations and their use in the interpretation of CS screening tests are described. The tests used for screening and differential diagnosis of CS are presented, along with their relationship to cortisol dynamics, pathophysiology, and negative glucocorticoid feedback regulation in the two forms of ACTH-dependent CS. Finally, several gaps in current understanding are highlighted in the hope of stimulating additional research into this challenging disorder.
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Affiliation(s)
- Lynnette K Nieman
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
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11
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Balomenaki M, Margaritopoulos D, Vassiliadi DA, Tsagarakis S. Diagnostic workup of Cushing's syndrome. J Neuroendocrinol 2022; 34:e13111. [PMID: 35979805 DOI: 10.1111/jne.13111] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Abstract
Cushing's syndrome (CS) is a rare but detrimental endocrine disorder. Early diagnosis and prompt treatment are essential since the duration of hypercortisolism has an adverse impact on the extent of comorbidities and overall survival. The diagnostic approach involves a stepwise process that includes (1) screening and confirming the diagnosis and (2) establishing the aetiology of CS. The tests currently used to confirm the diagnosis of CS include urinary free cortisol measurements, the dexamethasone suppression test and late- night salivary cortisol or midnight serum cortisol measurements. None of these tests are ideal; all have pitfalls and require careful interpretation. Following confirmation of CS, measurement of ACTH discriminates between ACTH-dependent and non-ACTH dependent causes of CS. Adrenal imaging provides clues for the aetiology of non-ACTH dependent forms. Differentiation between the ACTH-dependent forms that involve pituitary corticotroph adenomas and ectopic ACTH sources is more complex and include pituitary MRI imaging, the high dose dexamethasone suppression test, the CRH test, bilateral inferior petrosal sinus sampling and, when required imaging modalities to detect ectopic ACTH secreting lesions. This review, which is part of a special issue on "Update of Cushing's syndrome: 100 years after Minnie G" will provide an update on our current diagnostic workup for the confirmation and differential diagnosis of CS.
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Affiliation(s)
- Maria Balomenaki
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
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12
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Mohamed RS, Abuelgasim B, Barker S, Prabhudev H, Martin NM, Meeran K, Williams EL, Darch S, Matthew W, Tan T, Wernig F. Late-night salivary cortisol and cortisone should be the initial screening test for Cushing's syndrome. Endocr Connect 2022; 11:EC-22-0050. [PMID: 35671282 PMCID: PMC9254321 DOI: 10.1530/ec-22-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 11/08/2022]
Abstract
Endogenous Cushing's syndrome (CS) poses considerable diagnostic challenges. Although late-night salivary cortisol (LNSC) is recommended as a first-line screening investigation, it remains the least widely used test in many countries. The combined measurement of LNSC and late-night salivary cortisone (LNS cortisone) has shown to further improve diagnostic accuracy. We present a retrospective study in a tertiary referral centre comparing LNSC, LNS cortisone, overnight dexamethasone suppression test, low-dose dexamethasone suppression test and 24-h urinary free cortisol results of patients investigated for CS. Patients were categorised into those who had CS (21 patients) and those who did not (33 patients). LNSC had a sensitivity of 95% and a specificity of 91%. LNS cortisone had a specificity of 100% and a sensitivity of 86%. With an optimal cut-off for LNS cortisone of >14.5 nmol/L the sensitivity was 95.2%, and the specificity was 100% with an area under the curve of 0.997, for diagnosing CS. Saliva collection is non-invasive and can be carried out at home. We therefore advocate simultaneous measurement of LNSC and LNS cortisone as the first-line screening test to evaluate patients with suspected CS.
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Affiliation(s)
| | - Biyaser Abuelgasim
- Imperial College School of Medicine, Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Sally Barker
- Imperial College School of Medicine, Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Hemanth Prabhudev
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Niamh M Martin
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Emma L Williams
- Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Darch
- Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Whitlock Matthew
- Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Tricia Tan
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Florian Wernig
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Correspondence should be addressed to F Wernig:
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13
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DeLozier OM, Dream SY, Findling JW, Carroll TB, Evans DB, Wang TS. Selective Glucocorticoid Replacement Following Unilateral Adrenalectomy for Hypercortisolism and Primary Aldosteronism. J Clin Endocrinol Metab 2022; 107:e538-e547. [PMID: 34558612 DOI: 10.1210/clinem/dgab698] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Indexed: 01/06/2023]
Abstract
CONTEXT An institutional study previously demonstrated that cosyntropin stimulation testing on postoperative day 1 (POD1-CST) identified patients at risk for adrenal insufficiency (AI) following unilateral adrenalectomy (UA) for adrenal-dependent hypercortisolism (HC) and primary aldosteronism (PA), allowing for selective glucocorticoid replacement (GR). OBJECTIVE This study re-evaluates the need for GR following UA for patients with HC and PA in a larger cohort. METHODS A prospective database identified 108 patients who underwent UA for mild autonomous cortisol excess (MACE) (n = 47), overt hypercortisolism (OH) (n = 27), PA (n = 22), and concurrent PA/HC (n = 12) from September 2014 to October 2020; all underwent preoperative evaluation for HC. MACE was defined by the 1 mg dexamethasone suppression test (cortisol >1.8 μg/dL), with ≥5 defined as OH. GR was initiated for basal cortisol ≤5 or stimulated cortisol ≤14 (≤18 prior to April 2017) on POD1-CST. RESULTS Fifty-one (47%) patients had an abnormal POD1-CST; 54 (50%) were discharged on GR (27 MACE, 20 OH, 1 PA, 6 PA/HC). Median duration of GR was OH: 6.0 months, MACE: 2.1 months, PA: 1 month, PA/HC: 0.8 months. Overall, 26% (n = 7) of patients with OH and 43% (n = 20) of patients with MACE did not require GR. Two (2%) patients with OH had normal POD1-CST but developed AI several weeks postoperatively requiring GR. None experienced life-threatening AI. CONCLUSION POD1-CST identifies patients with HC at risk for AI after UA, allowing for selective GR. One-quarter of patients with OH and nearly half of patients with MACE can forgo GR after UA. Patients with PA do not require evaluation for AI if concurrent HC has been excluded preoperatively.
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Affiliation(s)
- Olivia M DeLozier
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Sophie Y Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - James W Findling
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ty B Carroll
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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14
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Berndt V, Dahlqvist P, de Verdier J, Ryberg H, Ragnarsson O. The diagnostic value of salivary cortisol and salivary cortisone in patients with suspected hypercortisolism. Front Endocrinol (Lausanne) 2022; 13:1028804. [PMID: 36506050 PMCID: PMC9728582 DOI: 10.3389/fendo.2022.1028804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Diagnosing endogenous hypercortisolism remains a challenge, partly due to a lack of biochemical tests with good diagnostic accuracy. OBJECTIVES To evaluate the diagnostic value of salivary cortisol and cortisone in patients with suspected hypercortisolism. METHODS Retrospective study including 155 patients with adrenal incidentaloma, and 54 patients with suspected Cushing´s syndrome (CS). Salivary samples were collected at home, at 11 p.m., and at 8 a.m. following an over-night dexamethasone suppression test (DST). Salivary cortisol and cortisone were measured with liquid chromatography-tandem mass spectrometry. RESULTS Ten of 155 patients with adrenal incidentaloma were considered to have autonomous cortisol secretion (ACS). Using previously established cut-offs, all patients with ACS had elevated plasma-cortisol (>50 nmol/L) following DST, 9/10 had elevated late-night salivary cortisone (>15 nmol/L) whereas only 4/10 had elevated late-night salivary cortisol (LNSC; >3 nmol/L) compared to 35%, 9% and 8%, respectively, of the 145 patients with non-functioning adrenal incidentaloma. Six (60%) patents with ACS had elevated salivary cortisol and cortisone at 8 a.m. following DST compared to 9% and 8%, respectively, of patients with non-functioning adrenal incidentaloma. One of 6 patients with overt CS had a normal LNSC and one had normal late-night salivary cortisone, while all had increased salivary cortisol and cortisone following DST. CONCLUSION LNSC is not sufficiently sensitive or specific to be used for screening patients with suspected hypercortisolism. Instead, late-night salivary cortisone seems to be a promising alternative in patients with adrenal incidentaloma and salivary cortisone at 8 a.m. following DST in patients with suspected CS. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Vendela Berndt
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jennie de Verdier
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Henrik Ryberg
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- *Correspondence: Oskar Ragnarsson,
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15
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Abstract
Cushing's disease (CD) is the most prevalent cause of endogenous hypercortisolism. CD is responsible for multiple co-morbidities and increased mortality. Accurate and prompt diagnosis and optimal treatment are essential to improve the prognosis of CD. However, the diagnosis of CD is probably one of the most difficult in endocrinology and, therefore, diagnostic workup should be performed in an experienced center. Transsphenoidal surgery performed by an expert surgeon is the only therapeutic option that can offer definitive cure and remains the first-line treatment in most patients. Second-line treatments include pharmacotherapy, pituitary radiotherapy and bilateral adrenalectomy. The second-line therapeutic strategy is complex, must be individualized and performed in a multidisciplinary expert center. Symptomatic treatments of persisting co-morbidities after remission, which are responsible for increased mortality and impaired quality of life is an important part of medical management.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France; INSERM U1215, NeuroCentre Magendie, University of Bordeaux, France.
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16
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Keevil BG. LC-MS/MS the First 20 years: A Personal View. Ann Clin Biochem 2021; 59:3-6. [PMID: 34459220 DOI: 10.1177/00045632211040059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Brian G Keevil
- Clinical Biochemistry, Wythenshawe Hospital, 5293Manchester University NHS Foundation Trust, Manchester, UK.,University of Manchester, 158986Manchester Academic Health Science Centre, Manchester, UK
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Abellán Galiana P. Recent developments in the management of Cushing's syndrome. ENDOCRINOL DIAB NUTR 2021; 68:141-143. [PMID: 34167692 DOI: 10.1016/j.endien.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/24/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Pablo Abellán Galiana
- Sección de Endocrinología y Nutrición, Hospital General Universitari de Castelló, Castellón, Spain; Departamento de Medicina, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón, Spain.
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