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A combined dexamethasone desmopressin test as an early (...)

J Clin Endocrinol Metab. 2009 Jun ;94(6):1897-903
A combined dexamethasone desmopressin test as an early marker of postsurgical recurrence in Cushing’s disease.
Castinetti F, Martinie M, Morange I, Dufour H, Sturm N, Passagia JG, Conte-Devolx B, Chabre O, Brue T.

CONTEXT : Recurrence of Cushing’s disease (CD) after transsphenoidal surgery (TSS) occurs in about 25% of cases. Twenty percent of patients with immediate postsurgical corticotroph deficiency will present late recurrence. OBJECTIVE : The aim of the study was to evaluate a coupled dexamethasone desmopressin test (CDDT) as a predictor of recurrence of CD. DESIGN : We conducted a prospective bicenter study (Marseille and Grenoble, France). PATIENTS : We studied 38 patients treated by TSS for CD with a mean follow-up of 60 months. INTERVENTION(S) : We evaluated 24-h urinary free cortisol, ACTH, and cortisol plasmatic levels and performed low-dose dexamethasone suppression test and CDDT 3 to 6 months after surgery and then yearly. MAIN OUTCOME MEASURES : After CDDT, ACTH ratio (ACTHr) was defined as (PeakACTH - BaseACTH)/BaseACTH. Cortisol ratio (Cortisolr) was defined as (PeakCortisol - BaseCortisol)/BaseCortisol. Basal values were observed after low-dose dexamethasone suppression test. Receiver operator characteristics curve defined ACTHr and Cortisolr giving the best sensitivity and specificity associated with recurrence. RESULTS : Ten patients presented recurrence. ACTHr and Cortisolr were superior or equal to 0.5 in all patients with recurrence and in three of 28 patients in remission (100% sensitivity, 89% specificity). The test became positive in eight of 10 patients with recurrence 6-60 months before classical markers of hypercortisolism. Six patients with immediate postsurgical corticotroph deficiency presented recurrence. All of them presented CDDT positivity during the 3 yr after surgery, and recurrence 6 to 60 months after CDDT positivity. CONCLUSIONS : CDDT is an early predictor of recurrence of CD and could be of particular interest in the first 3 yr after surgery, by selecting patients at high risk of recurrence despite falsely reassuring classical hormonal markers.

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