Accuracy of repeated measurements of late-night salivary cortisol to screen for early-stage recurrence of Cushing's disease following pituitary surgery.

OBJECTIVE: The performance of late-night salivary cortisol (LNSC) to accurately screen for postoperative recurrence of Cushing's disease (CD) at an early stage is unknown. The aim of this study was to compare the accuracy of multiple sampling strategies to suggest the optimal number of LNSC samples needed for diagnosing post-surgical recurrences of CD at an early stage. DESIGN: Retrospective analysis in a single centre. PATIENTS AND MEASUREMENTS: Thirty-six patients in surgical remission of CD had successive measurements of LNSC, defined as 'sequences', using a locally modified RIA assay as part of long-term follow-up (69·2 ± 10·6 months). Patients underwent an extensive biochemical evaluation within 3 months before or after a sequence of saliva sampling and were classified as being in remission or in early-stage recurrence. The accuracy of three diagnostic strategies combining two, three or four LNSC results from a sequence was estimated using areas under the ROC curves (AUC), sensitivity, specificity and predictive values. RESULTS: Forty-four sequences of LNSC measurements were available. Fifty-two percent of sequences were performed during early-stage recurrence. The intrasequence variability of LNSC was higher during recurrence than during remission (medians of SDs: 2·1 vs 0·5 nm; P < 0·0001). AUCs from ROC curves ranged from 0·93 to 0·96 depending on the strategy. For 90% sensitivities, the best specificities (92·9% and 90·9%) were achieved by strategies taking into account three or four measurements summarized either by their mean or their maximum value. CONCLUSIONS: Increase in LNSC concentration is an early abnormality during post-surgical recurrence of CD. However, due to a major within-patient variability of LNSC from 1 day to another, a screening strategy using three or four samples collected on successive days may be recommended to detect early-stage recurrence of CD with a high accuracy.

[Adrenal incidentalomas]. / Incidentalomes et tumeurs de la loge de la surrénale.

The adrenal incidentaloma is an adrenal mass, generally more than 1 cm in diameter, that is discovered serendipitously during a radiologic examination performed for indications other than an evaluation of adrenal disease. The prevalence of adrenal incidentalomas is at least 1% in patients who underwent abdominal CT examination. The main therapeutic issues are to select which patient should undergo surgical excision, and the optimal procedure and duration of follow-up for patients in whom surgery is not indicated. Surgery is mandatory in patients with secretory tumours (pheochromocytoma, secreting cortical adenomas) and with adrenal cancer. However, the vast majority of adrenal incidentalomas are benign cortical adenomas and surgery is mandatory only in a minority of patients. Systematic aetiological investigation of adrenal incidentalomas should therefore be performed in order to guide the decision on surgical or non surgical management. This investigation includes, at least, clinical assessment, biological endocrine evaluation and appropriate standardized CT scan examination of the mass. The optimal duration and modalities of follow-up for patients with adrenal incidentalomas are uncertain.