Postoperative Management of the Hypothalamic-Pituitary-Adrenal Axis in Patients Undergoing Resection of Sellar-Suprasellar Tumors

Introduction: Management of the hypothalamic-pituitary-adrenal (HPA) axis in patients undergoing surgical resection of sellar/suprasellar tumors is controversial and often challenging. The routine use of perioperative glucocorticoids is intended to provide a “stress dose” to patients to avoid a potentially life-threatening adrenal crisis. Although postoperative ACTH deficiency is critical to recognize and treat in a timely fashion, a consensus regarding maintenance steroid dosing and timing of discontinuation remains inconclusive. The goal of this study was to minimize steroid use while avoiding the risk of postoperative Addisonian crisis.

Methods: A retrospective review of a prospectively maintained database was performed to identify patients with surgically resected sellar/suprasellar tumors, >12 months follow-up, and an AM cortisol level on postoperative day (POD) #2. A total of 108 patients were identified who fulfilled these criteria over an 81-month period. The average duration of follow-up was 43.7 months ± 18.9 months. Perioperatively, all patients received hydrocortisone 100 mg IV q 8 hours on POD #0, hydrocortisone 50 mg IV q 12 hours on POD #1, and had an AM cortisol drawn on POD #2. If cortisol was >12 mcg/dL, then replacement steroids were discontinued. If cortisol was <12 mcg/dL, then patients were continued on dexamethasone 0.5 mg po daily.

Results: At last follow-up, 29 of 108 patients (27%) remained on steroid replacement. Of the 63 patients (58%) with POD #2 AM cortisol >12 mcg/dL, only 11 of the 63 (17%) required steroids. Conversely, 45 patients (42%) had AM cortisol <12 on POD #2, and 18 of those (40%) had persistently insufficient HPA axis function at last follow-up. Only one patient required readmission for acute management of ACTH deficiency. All other patients were able to manage as outpatients.

Conclusion: The practice of prolonged postoperative glucocorticoid replacement in patients undergoing sellar/suprasellar tumor resection has recently been challenged, citing the dangers of even short-term glucocorticoid excess. Using a threshold of 12 mcg/dL, we were able to utilize the POD #2 AM cortisol level to limit the use of postoperative glucocorticoid replacement. Overall, 27% of patients required long-term steroids, but only 17% of those with a POD #2 AM cortisol >12 mcg/dL. No patients in this study experienced an Addisonian crisis, and all but one were able to be managed in the outpatient setting. Additional future areas of study include attempting to determine the optimal postoperative day to check the AM cortisol and to delineate the role of Cortrosyn stimulation tests in evaluation of the HPA axis.