Inferior petrosal sinus sampling in Cushing’s syndrome: usefulness and pitfalls

Vassiliadi, Dimitra Argyro; Mourelatos, Panagiotis; Kratimenos, Theodoros; Tsagarakis, Stylianos

doi:10.1007/s12020-021-02764-4

Cited by 21 publications

(18 citation statements)

References 79 publications

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“…62 The diagnostic accuracy of BIPSS is hampered by the occurrence of a substantial rate of false negative results, whereas false positive results are scarce. 63 In practice, the actual merit for a patient undergoing BIPSS is that a positive result is highly confirmatory of Cushing's disease.…”

Section: Bilateral Inferior Petrosal Sinus Sampling (Bipss)mentioning

confidence: 99%

“…The measurement of prolactin in order to normalize ACTH values in cases without a gradient can confirm whether the catheterization was successful or not 62 . The diagnostic accuracy of BIPSS is hampered by the occurrence of a substantial rate of false negative results, whereas false positive results are scarce 63 . In practice, the actual merit for a patient undergoing BIPSS is that a positive result is highly confirmatory of Cushing's disease.…”

Section: Diagnostic Means To Establish the Pituitary Origin Of Excess...mentioning

confidence: 99%

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Diagnostic workup of Cushing’s syndrome

Balomenaki

Margaritopoulos

Vassiliadi

et al. 2022

J Neuroendocrinology

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Cushing's syndrome (CS) is a rare but detrimental endocrine disorder. Early diagnosis and prompt treatment are essential since the duration of hypercortisolism has an adverse impact on the extent of comorbidities and overall survival. The diagnostic approach involves a stepwise process that includes (1) screening and confirming the diagnosis and (2) establishing the aetiology of CS. The tests currently used to confirm the diagnosis of CS include urinary free cortisol measurements, the dexamethasone suppression test and late‐ night salivary cortisol or midnight serum cortisol measurements. None of these tests are ideal; all have pitfalls and require careful interpretation. Following confirmation of CS, measurement of ACTH discriminates between ACTH‐dependent and non‐ACTH dependent causes of CS. Adrenal imaging provides clues for the aetiology of non‐ACTH dependent forms. Differentiation between the ACTH‐dependent forms that involve pituitary corticotroph adenomas and ectopic ACTH sources is more complex and include pituitary MRI imaging, the high dose dexamethasone suppression test, the CRH test, bilateral inferior petrosal sinus sampling and, when required imaging modalities to detect ectopic ACTH secreting lesions. This review, which is part of a special issue on "Update of Cushing's syndrome: 100 years after Minnie G" will provide an update on our current diagnostic workup for the confirmation and differential diagnosis of CS.

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Section: Bilateral Inferior Petrosal Sinus Sampling (Bipss)mentioning

confidence: 99%

Section: Diagnostic Means To Establish the Pituitary Origin Of Excess...mentioning

confidence: 99%

Diagnostic workup of Cushing’s syndrome

Balomenaki

Margaritopoulos

Vassiliadi

et al. 2022

J Neuroendocrinology

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“…However, pituitary MRI can be negative in up to 40% to 60% of Cushing disease cases. There can also be false-positive pituitary MRI findings in patients with EAS (76). BIPSS is the gold standard to differentiate between Cushing disease and EAS.…”

Section: Differentiation Between Cushing Disease and Ectopic Acth Sec...mentioning

confidence: 99%

“…During this procedure, plasma ACTH levels are withdrawn simultaneously from each petrosal sinus (venous drainage of the pituitary) and a peripheral vein. Sensitivity can be increased by obtaining ACTH levels under CRH stimulation (1,76,78).…”

Section: Differentiation Between Cushing Disease and Ectopic Acth Sec...mentioning

confidence: 99%

Approach to the Patient: Diagnosis of Cushing Syndrome

Savas

Mehta

Agrawal

et al. 2022

The Journal of Clinical Endocrinology &Amp; Metabolism

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Cushing’s syndrome results from supraphysiological exposure to glucocorticoids and is associated with significant morbidity and mortality. The pathogenesis includes administration of corticosteroids (exogenous Cushing’s syndrome) or autonomous cortisol overproduction, whether or not adrenocorticotropin hormone (ACTH) dependent (endogenous Cushing’s syndrome). An early diagnosis of Cushing’s syndrome is warranted, however, in clinical practice very challenging partly due to resemblance with other common conditions (i.e. pseudo-Cushing’s syndrome). Initial workup should start with excluding local and systemic corticosteroid use. First-line screening tests including the 1-mg dexamethasone suppression test, 24-hour urinary free cortisol excretion, and late-night salivary cortisol measurement should be performed to screen for endogenous Cushing’s syndrome. Scalp-hair cortisol/cortisone analysis helps in the assessment of long-term glucocorticoid exposure as well as in detection of transient periods of hypercortisolism as observed in cyclical Cushing’s syndrome. Interpretation of results can be difficult due to individual patient characteristics and hence requires awareness of test limitations. Once endogenous Cushing’s syndrome is established, measurement of plasma ACTH concentrations differentiates between ACTH-dependent (80-85%) or ACTH-independent (15-20%) causes. Further assessment with different imaging modalities and dynamic biochemical testing including bilateral inferior petrosal sinus sampling helps further pinpoint the cause of Cushing’s syndrome. In this issue of ‘Approach to the patient’ the diagnostic workup of Cushing’s syndrome is discussed with answering the questions when to screen, how to screen and how to differentiate the different causes. In this respect, latest developments in biochemical and imaging techniques are discussed as well.

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“…Therefore, in the guideline for the treatment of CS issued in 2015, it was suggested that, if feasible, all patients with ACTHdependent CS and patients with pituitary tumors <6 mm be immediately referred to a pituitary tumor center of excellence to complete BIPSS to identify CD and EAS (23). The results show that if the basal IPS/P ACTH ratio is >2, and/or the CRH or DDAVP-stimulated ratio is >3, CD is indicated, and if otherwise, EAS is indicated (20,21,24,25). However, some authors have put forward different opinions on BIPSS over the past 2 years, including the view that a combination of some non-invasive examinations including CRH and DDAVP stimulation test, pituitary MRI, and whole body thin-layer CT scan exempt about 50% of patients with ACTH-dependent CS from BIPSS (26).…”

Section: A B C Dmentioning

confidence: 99%

Localization diagnosis of adrenocorticotrophic hormone-dependent Cushing’s syndrome: two case reports and literature review

et al. 2022

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Background: The common causes of adrenocorticotrophic hormone (ACTH)-dependent Cushing's syndrome (CS) include Cushing's disease (CD) and ectopic ACTH syndrome (EAS). The differential diagnosis and lesion location of CD and EAS often bring great difficulties to clinical diagnosis and treatment. This article reports the localization diagnosis, treatment, and follow-up results of two patients with ACTHdependent CS with different causes and reviews the literature. Case Description: Case 1: a 29-year-old female patient attended the clinic because of irregular menstruation, weight gain, and violaceous striae. The low dose dexamethasone suppression test (LDDST) was not suppressed, and the high dose dexamethasone suppression test (HDDST) suggested the results of serum cortisol and 24-h urine free cortisol were contradictory. Magnetic resonance imaging (MRI) indicated pituitary microadenoma, and bilateral inferior petrosal sinus sampling (BIPSS) indicated ACTH was centrally secreted. CD was diagnosed. The patient underwent transsphenoidal surgery, and the symptoms of CS were improved after the operation. A natural pregnancy occurred more than half a year after the surgery, and a healthy baby boy was delivered 9 months later. Case 2: a 29-year-old female patient complained of facial redness and elevated blood pressure. Examination showed refractory hypokalemia and abnormally elevated serum cortisol and ACTH. Androgens also increased. Neither LDDST nor HDDST was inhibited.Chest-to-pelvis computed tomography (CT) scan revealed a soft tissue mass in the anterior mediastinum, considered as a possible thymoma. EAS and thymoma were diagnosed. An anterior mediastinal mass resection was performed, and pathological results suggested thymic carcinoid weakly positive for ACTH.After the operation, hypertension and hypokalemia were relieved, and cortisol, ACTH and androgens returned to normal levels. Conclusions:The differentiation between CD and EAS should be comprehensively evaluated in combination with the medical history, function tests, pituitary MRI, and other tests. If the function test results are discordant or pituitary MRI shows the lesion diameter is less than 6 mm, BIPSS should be further performed to confirm the diagnosis. The lesions of EAS are complex and diverse, and it is necessary to pay attention to imaging examinations of the neck-to-pelvis to locate lesion and provide direction for subsequent treatment.

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Inferior petrosal sinus sampling in Cushing’s syndrome: usefulness and pitfalls

Cited by 21 publications

References 79 publications

Diagnostic workup of Cushing’s syndrome

Diagnostic workup of Cushing’s syndrome

Approach to the Patient: Diagnosis of Cushing Syndrome

Localization diagnosis of adrenocorticotrophic hormone-dependent Cushing’s syndrome: two case reports and literature review

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