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. 2008 Dec;93(12):4624-32.
doi: 10.1210/jc.2008-0979. Epub 2008 Sep 16.

Selective use of bilateral inferior petrosal sinus sampling in patients with adrenocorticotropin-dependent Cushing's syndrome prior to transsphenoidal surgery

Sigrid Jehle  1 , Jane E Walsh, Pamela U Freda, Kalmon D Post
Affiliations

Selective use of bilateral inferior petrosal sinus sampling in patients with adrenocorticotropin-dependent Cushing's syndrome prior to transsphenoidal surgery

Sigrid Jehle et al. J Clin Endocrinol Metab. 2008 Dec.

Abstract

Context: Few data are available on the selective use of bilateral inferior petrosal sinus sampling (BIPSS) in the presurgical evaluation of patients with ACTH-dependent Cushing's syndrome, so we investigated whether its use only in patients without a clear adenoma on magnetic resonance imaging and/or inconsistent biochemical testing affected remission and long-term outcome after surgery in patients with Cushing's disease (CD).

Setting: This was a retrospective review of patients treated for CD by one pituitary neurosurgeon at tertiary medical centers in New York City.

Patients: A total of 193 consecutive adult patients who underwent initial transsphenoidal surgery (TS) for presumed CD between 1987 and 2005 were included.

Main outcome measures: We examined preoperative pituitary imaging and biochemical data, results of BIPSS and surgical pathology, and outcome based on biochemical tests after initial TS and long term after subsequent therapies.

Results: Remission rate after the first TS was 80.8% overall, 79.1% in the BIPSS group (n = 105), and 83.0% in the No-BIPSS group (n = 88). Recurrences occurred in 13.5% after the first TS at a mean of 4.8 +/- 3.5 yr (range, 0.7-12.4 yr) with no difference between BIPSS and No-BIPSS groups. Long-term remission was achieved after surgeries and radiotherapy in 85% (86.7% of BIPSS group, 83.0% of No-BIPSS group). CD was ultimately confirmed in all but one patient in each group.

Conclusions: Selective use of BIPSS in the preoperative evaluation of patients with presumed CD did not lead to misdiagnosis in the No-BIPSS group or adversely affect remission rates or long-term outcome.

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Figures

Figure 1
Figure 1
Results of preoperative pituitary imaging, pathological analyses, and remission rate after first TS in the BIPSS and No-BIPSS groups. In six patients with normal preoperative pituitary imaging, BIPSS could not be done: one patient refused the procedure, two patients had an allergy to the radio-contrast dye, one patient was unable to lie supine, and two patients could not receive the contrast agent because of renal insufficiency.
Figure 2
Figure 2
Recurrence of CD after first TS. A, Recurrence rate in BIPSS and No-BIPSS groups after initial successful TS. B, Histogram for BIPSS and No-BIPSS groups showing absolute numbers of recurrences in relation to the number of years after surgery at which they occurred.
Figure 3
Figure 3
Initial and persistent remission after first TS alone as well as recurrences after first TS in the BIPSS and No-BIPSS groups of patients.
Figure 4
Figure 4
Long-term remission after additional therapy(ies) including second TS, third TS, and/or RT. Med, Medical therapy; BA, bilateral adrenalectomy; F/U, follow-up.
Figure 5
Figure 5
Correlation of tumor localization at surgery with the quartiles of the interpetrosal sinus ACTH ratios obtained during IPSS.
See this image and copyright information in PMC

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