Case for the wider adoption of mass spectrometry-based adrenal steroid testing, and beyond
Abstract
The move by the JCEM to mandate measurement of sex steroids by mass spectrometry (MS) in manuscripts to be published from the beginning of 2015 (1) sparked vigorous debate among clinicians and scientists working within the diverse subspecialties of endocrinology. In response, The Endocrine Society Council assembled a Sex Steroid Assays Reporting Task Force (SSARTF) to review current reporting polices laid out by the Journal (and sister journals) and to recommend through the Publications Core Committee a clear policy on the future reporting of sex steroid hormone measurements. We commend the SSARTF in broadening the scope of their new guideline not only to encompass sex steroid hormone measurement but also to address the measurement of all steroid hormones more generally. Such an inclusive policy will undoubtedly propel the field toward optimized measurement procedures. With this goal in mind, we wish to make the case that the limitations inherent in immunoassay (IA) and the opportunities afforded by MS are not confined to the measurement of sex steroids, but rather the argument for measurement of cortisol and related metabolites is equally as compelling. Here, we present the case for cortisol measurement as an exemplar for the wider adoption of MS. IAs for serum steroid measurement are afflicted with cross-reactivity, to varying and often clinically significant degrees, with both endogenous and exogenous steroid hormones and their metabolites (2). Examples of analytical interference in commercial IAs include cross-reactivity in T assay by the structurally similar oral contraceptive pill component norethisterone (3) and the impact of both sample matrix and gender on the measurement of cortisol, likely attributable to variations in both cortisol-binding globulin concentration, and the accumulation of structurally related steroids in various physiological and pathophysiological conditions (4) acts to illustrate the inherent and persistent obstacles encountered by IA-based methodologies regardless of measurand, be it androgen or glucocorticoid. Similarly, indirect interference in many cortisol IAs has been demonstrated in patients receiving the 11β-hydroxylase inhibitor metyrapone for the medical management of Cushing's syndrome (5, 6). Metyrapone therapy blocks the conversion of 11-deoxycortisol to cortisol, causing a >10-fold increase in circulating concentration of this precursor (7, 8), which cross-reacts significantly in cortisol IA. The consequent positive interference carries the very real risk of inappropriate dose escalation and unrecognized hypoadrenalism. Salivary cortisol measurement used routinely in the investigation of Cushing's syndrome, and as a measure of “stress” in psychological research, is often measured by IA. However, there is a failure to recognize that, because of the abundance in parotid tissue of the enzyme 11β-hydroxysteroid dehydrogenase type II, which converts cortisol to cortisone, the latter is the predominate glucocorticoid in saliva at levels between 4- and 9-fold greater than cortisol. Cortisone cross-reactivity may therefore confound the accurate measurement of salivary cortisol in many IAs. Some of these problems inherent in IAs may be resolved by extracting samples to remove cross-reacting compounds and alleviate matrix effects before measurement, but importantly, such preanalytical extraction adds additional costs and complexity. In recent decades, the great advantage with IA has been speed and simplicity; sample prepurification seriously derogates from this and would therefore need to be evaluated in view of potential gains in diagnostic efficiency (9). These common and clinically important interferences in IA can be surmounted by the use of MS, and at present there are no feasible methodological alternatives that provide equivalent analytical robustness for steroid assay. As well as eliminating cross-reactivity, a further crucial practical advantage of MS is the dynamic range of measurement that can be achieved, comfortably exceeding that possible by conventional competitive IA methodology for the quantification of small molecules such as steroid hormones. For competitive IA, the typical dynamic range of the sigmoidal dose-response curve is no more than two orders of magnitude in measurand concentration. Assay manufacturers must therefore consider the clinical requirement for analytical sensitivity and also the expected (patho)physiological concentrations of measurand when designing these assays. Further methodological advantages of MS include the lack of susceptibility to interference from antireagent antibodies and the capacity to multiplex measurements for steroid profiling. In other words, a female androgen profile consisting of T, androstenedione, and dehydroepiandrosterone sulfate may be simultaneously measured in a single assay at negligible extra cost compared to measuring any of the steroids individually. From a practical standpoint, rapid MS assays for the rou
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The Endocrine Society has set minimum performance criteria for steroid assays, acknowledging that metrological traceability is not yet available for all assays but remains an important goal.
“The Endocrine Society has now established minimum performance criteria for steroid assays, which recognize that metrological traceability is not currently available for all assays, yet remains an important goal (12)(13)(14).”
From Serum cortisol: an up-to-date assessment of routine assay performance (2016) · cites this paper as [14]
Salivary cortisol assay was linear up to 2293 nmol/L and salivary cortisone was linear up to 3676 nmol/L.
“Salivary cortisol assay was linear up to a concentration of 2293 nmol/L and salivary cortisone was linear up to 3676 nmol/L.”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [11]
Jones et al. showed the LC-MS/MS method demonstrated excellent imprecision and accuracy for salivary cortisol and salivary cortisone.
“Jones et al. showed LC-MS/MS method demonstrated excellent imprecision and accuracy for salivary cortisol and salivary cortisone.”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [11]
The lower limit of quantification was 0.75 nmol/L for cortisol and 0.5 nmol/L for cortisone.
“The lower limit of quantification was found to be 0.75 nmol/L for cortisol and 0.5 nmol/L for cortisone (11).”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [11]
LNSC detects recurrent Cushing's disease earlier than UFC.
“It also appears that LNSC detects recurrent CD earlier than UFC thus making it the ideal test to follow up patients after successful pituitary surgery for CD (6, 11, 13).”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [11]
The assay was shown to be very specific for both cortisol and cortisone following the analysis of 29 structurally related steroids at supraphysiologic doses.
“The assay was shown to be very specific for both cortisol and cortisone following the analysis of 29 structurally related steroids at supraphysiologic doses.”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [11]
Only 0.3% interference from prednisolone was observed for the salivary cortisol assay and 1% interference from prednisone for salivary cortisone.
“Only 0.3% interference from prednisolone was observed for salivary cortisol assay and 1% interference from prednisone for salivary cortisone.”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [11]
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- Authors
- Monaghan, P. J., Keevil, B. G., Stewart, P. M., & Trainer, P. J.
- Affiliations
- The Christie Pathology Partnership (P.J.M.), Manchester, M20 4BX, UK
- Department of Clinical Biochemistry (B.G.K.), University Hospital of South Manchester, Manchester M23 9LT, United Kingdom
- University of Leeds (GB)
- Manchester Academic Health Science Centre (GB)
- Corresponding author
- Trainer, Peter J.
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2014-12-01
- Volume
- 99
- Issue
- 12
- Pages
- 4434-4437
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- OpenAlex
- W2047246870
- Cited by
- 41
- References
- 15
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 2 · 2023: 6 · 2022: 5 · 2021: 2 · 2020: 1 · 2019: 5 · 2018: 2 · 2017: 4 · 2016: 5 · 2015: 6
- FWCI
- 4.02
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Physical Sciences › Chemistry › Spectroscopy › Mass Spectrometry Techniques and Applications
- Keywords
- mass spectrometry, cortisol measurement, immunoassay limitations, cross-reactivity, analytical interference, 11-deoxycortisol, metyrapone, Cushing's syndrome, adrenal insufficiency, salivary cortisol, corticosteroid-binding globulin, reporting guidelines, 11β-hydroxylase
- MeSH terms
- Adrenal Cortex Hormones, Adrenal Gland Diseases, Female, Humans, Immunoassay, Male, Gonadal Steroid Hormones, Mass Spectrometry, Reproducibility of Results
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