Abstract
Background
Late-night salivary cortisol level is one of the first-line tests recommended by the Endocrine Society for the diagnosis of endogenous hypercortisolism. Most routine laboratories measure cortisol levels using immunoassay tests which fail to determine low cortisol levels accurately due to the numerous interfering substances. A liquid chromatography–tandem mass spectrometry (LC–MS/MS) method with simple and rapid sample preparation was developed for the simultaneous measurement of cortisol and cortisone and its performance in the diagnosis of endogenous hypercortisolism was evaluated.
Methods
324 late-night saliva samples were analyzed from which 272 samples were derived from patients with a suspected diagnosis of endogenous hypercortisolism. Salivary cortisol levels were assayed using an electrochemiluminescent immunoassay (ECLIA, Cortisol II, Roche), and simultaneous measurement of cortisol and cortisone was performed using an LC–MS/MS method.
Results
A strong correlation between cortisol results measured using ECLIA and LC–MS/MS (r 2 = 0.892) was demonstrated. Receiver operating characteristics (ROC) analysis showed good diagnostic performance of cortisol and cortisone levels assayed using LC–MS/MS method and for cortisol measured using ECLIA.
Conclusions
Late-night salivary cortisol and cortisone are useful parameters for the diagnosis of hypercortisolism. Using samples obtained from patients where the diagnosis of hypercortisolism is extremely challenging cut-off values for midnight salivary cortisol and cortisone measured by LC–MS/MS method were established.
Similar content being viewed by others
Abbreviations
- CS:
-
Cushing’s syndrome
- LC–MS/MS:
-
Liquid chromatography–tandem mass spectrometry
- ECLIA:
-
Electrochemiluminescent immunoassay
- ROC:
-
Receiver operating characteristics
- HPA:
-
Hypothalamic–pituitary–adrenal
- LNSC:
-
Late-night salivary cortisol
- UFC:
-
Urine free cortisol
- CBG:
-
Cortisol binding globulin
- ESI:
-
Electrospray ionization
- SPE:
-
Solid-phase extraction
- MRM:
-
Multiple reaction monitoring
- DP:
-
Declustering potential
- CE:
-
Collision energy
- CXP:
-
Cell exit potential
- AUC:
-
Areas under curve
- HSD11β:
-
11-Beta-hydroxysteroid dehydrogenase
References
Guaraldi F, Salvatori R (2012) Cushing Syndrome: maybe not so uncommon of an endocrine disease. J Am Board Fam Med 25:199–208
Catargi B, Rigalleau V, Poussin A et al (2003) Occult Cushing’s syndrome in type-2 diabetes. J Clin Endocrinol Metab 88:5808–5813
Tiryakioglu O, Ugurlu S, Yalin S et al (2010) Screening for Cushing’s syndrome in obese patients. Clinics 65:9–13
Chiodini I, Mascia M, Muscarella S et al (2007) Subclinical hypercortisolism among outpatients referred for osteoporosis. Ann Intern Med 147:541–548
Omura M, Saito J, Yamaguchi K, Kakuta Y, Nishikawa T (2004) Prospective study on the prevalence of secondary hypertension among hypertensive patients visiting a general outpatient clinic in Japan. Hypertens Res 27:193–202
Nieman L, Biller B, Findling J et al (2008) The diagnosis of Cushing’s Syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 3:1526–1540
Elias P, Martinez E, Barone B, Mermejo L, Castro M, Moreira A (2014) Late-night salivary cortisol has a better performance than urinary free cortisol in the diagnosis of Cushing’s syndrome. J Clin Endocrinol Metab 9:2045–2051
Ceccato F, Barbot M, Zilio M et al (2015) Screening tests for Cushing’s Syndrome: urinary free cortisol role measured by LC-MS/MS. J Clin Endocrinol Metab 100:3856–3861
Bou Khalil R, Baudry C, Guignat L et al (2011) Sequential hormonal changes in 21 patients with recurrent Cushing’s disease after successful pituitary surgery. Eur J Endocrinol 165:729–737
Beko G, Varga I, Glaz E et al (2010) Cutoff values of midnight salivary cortisol for the diagnosis of overt hypercortisolism are highly influenced by methods. Clin Chim Acta 11:364–367
Perogramvos I, Keevil B, Ray D, Trainer P (2010) Salivary cortisone is a potential biomarker for serum free cortisol. J Clin Endocrinol Metab 95:4951–4958
Raff H, Singh R (2012) Measurement of late-night salivary cortisol and cortisone by LC-MS/MS to assess preanalytical sample contamination with topical hydrocortisone. Clin Chem 58:947–948
Del Corral P, Schurman RC, Kinza MJ, Kordick CA, Rusch JL, Nadolski JB (2016) Salivary but not plasma cortisone tracks the plasma cortisol response to exercise: effect of time of day. J Endocrinol Invest 39:315–322
Handelsman D, Wartofsky L (2013) Requirement for mass spectrometry sex steroid assays in the Journal of Clinical Endocrinology and Metabolism. J Clin Endocrinol Metab 98:3971–3973
Cuzzola A, Petri A, Mazzini F, Salvadori S (2009) Application of hyphenated mass spectrometry techniques for the analysis of urinary free glucocorticoids. Rapid Commun Mass Spectrom 23:2975–2982
Methlie P, Hustad S, Kellman R et al (2013) Multisteroid LC–MS/MS assay for glucocorticoids and androgens and its application in Addison’s disease. Endocr Connect 2:125–136
Nieman L, Biller B, Findling J et al (2008) The diagnosis of Cushing’s Syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 93:1526–1540
Szappanos Á, Tőke J, Lippai D et al (2010) Bone turnover in patients with endogenous Cushing’s syndrome before and after successful treatment. Osteoporos Int 21:637–645
Szappanos Á, Patócs A, Tőke J et al (2009) BclI polymorphism of the glucocorticoid receptor gene is associated with decreased bone mineral density in patients with endogenous hypercortisolism. Clin Endocrinol 71:636–643
Elecsys Cortisol II (2017) Roche Diagnostics. https://dialog1.roche.com/hu/hu/elabdoc. Accessed 11 Jan 2017
Guidance for industry—bioanalytical method validation. Food and Drug Administration. http://www.fda.gov/downloads/Drugs/Guidance/ucm070107.pdf. Accessed 11 Jan 2017
Magnisali P, Chalioti M-B, Livadaraa T et al (2011) Simultaneous quantification of 17-OH progesterone, 11-deoxycortisol, 4-androstenedione, cortisol and cortisone in newborn blood spots using liquid chromatography–tandem mass spectrometry. J Chromatogr B 879:1565–1572
AbuRuz S, Millership J, Heaney L, McElnay J (2003) Simple liquid chromatography method for the rapid simultaneous determination of prednisolone and cortisol in plasma and urine using hydrophilic lipophilic balanced solid phase extraction cartridges. J Chromatogr B 798:193–201
Newell-Price J, Trainer P, Besser M, Grossman A (1998) The diagnosis and differential diagnosis of Cushing’s syndrome and pseudo-Cushing’s states. Endocr Rev 19:647–672
Meinardi J, Wolffenbuttel B, Dullaart R (2007) Cyclic Cushing’s syndrome: a clinical challenge. Eur J Endocrinol 157:245–254
Androulakis I, Kaltsas G, Chrousos MD (2017) Pseudo-Cushing’s states. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK279081/. Accessed 11 Jan 2017
Antonelli G, Ceccato F, Artusi C, Marinova M, Plebani M (2015) Salivary cortisol and cortisone by LC-MS/MS: validation, reference intervals and diagnostic accuracy in Cushing’s syndrome. Clin Chim Acta 451:247–251
Ceccato F, Barbot M, Zilio M et al (2013) Performance of salivary cortisol in the diagnosis of Cushing’s syndrome, adrenal incidentaloma, and adrenal insufficiency. Eur J Endocrinol 169:31–36
Løvås K, Thorsen TE, Husebye ES (2006) Saliva cortisol measurement: simple and reliable assessment of the glucocorticoid replacement therapy in Addison’s disease. J Endocrinol Invest 29:727–731
Friso S, Pizzolo F, Choi SW et al (2008) Epigenetic control of 11 beta-hydroxysteroid dehydrogenase 2 gene promoter is related to human hypertension. Atherosclerosis 199:323–327
Mongia A, Vecker R, George M et al (2012) Role of 11βHSD type 2 enzyme activity in essential hypertension and children with chronic kidney disease (CKD). J Clin Endocrinol Metab 97:3622–3629
Ferrari P, Krozowski Z (2000) Role of the 11b-hydroxysteroid dehydrogenase type 2 in blood pressure regulation. Kidney Int 57:1374–1381
Lutz SZ, Peter A, Machicao F et al (2016) Genetic variation in the 11β-hydroxysteroid-dehydrogenase 1 gene determines NAFLD and visceral obesity. J Clin Endocrinol Metab 101:4743–4751
Stimson R, Walker B (2013) The role and regulation of 11β-hydroxysteroid dehydrogenase type 1 in obesity and the metabolic syndrome. Horm Mol Biol Clin Invest 15:37–48
Acknowledgements
The authors receive financial support from Hungarian Academy of Sciences “Lendulet 2013” Grant (AP) and Bionics Innovation Center (AP, KR, GK). The authors are grateful to Professor Barna Vasarhelyi (Department of Laboratory Medicine, Semmelweis University) for useful comments and critical review of the manuscript.
Author information
Authors and Affiliations
Contributions
Study design: AP, KM, MT, KR; performing LC–MS/MS measurements: KM, GK, ZM, BM; evaluation of results: AP, KM, GK; clinical evaluation of patients: MT, KR, NS, JT; writing the manuscript: KM, AP; all authors reviewed and agreed with the submission of manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no conflicts of interest to declare.
Ethical approval
The study protocol was approved by the National Scientific and Ethical Committee, Medical Research Council of Hungary (TUKEB, ETT), and was executed according to the Declaration of Helsinki principles.
Informed consent
Informed consent was obtained from all patients involved in the study.
Rights and permissions
About this article
Cite this article
Mészáros, K., Karvaly, G., Márta, Z. et al. Diagnostic performance of a newly developed salivary cortisol and cortisone measurement using an LC–MS/MS method with simple and rapid sample preparation. J Endocrinol Invest 41, 315–323 (2018). https://doi.org/10.1007/s40618-017-0743-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40618-017-0743-6