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. 2022 Mar;45(3):629-637.
doi: 10.1007/s40618-021-01695-1. Epub 2021 Oct 26.

Indication to dynamic and invasive testing in Cushing's disease according to different neuroradiological findings

E Ferrante #  1 , M Barbot #  2 , A L Serban  1   3 , F Ceccato  2 , G Carosi  1   4 , L Lizzul  2 , E Sala  1 , A Daniele  2 , R Indirli  1   4 , M Cuman  2 , M Locatelli  5   6 , R Manara  7 , M Arosio  1   4 , M Boscaro  2 , G Mantovani  8   9 , C Scaroni  2
Affiliations

Indication to dynamic and invasive testing in Cushing's disease according to different neuroradiological findings

E Ferrante et al. J Endocrinol Invest. 2022 Mar.

Abstract

Purpose: Dynamic testing represents the mainstay in the differential diagnosis of ACTH-dependent Cushing's syndrome. However, in case of undetectable or detectable lesion < 6 mm on MRI, bilateral inferior petrosal sinus sampling (BIPSS) is suggested by current guidelines. Aim of this study was to analyze the performance of CRH, desmopressin and high-dose dexamethasone suppression test (HDDST) in the differential diagnosis of ACTH-dependent Cushing's syndrome as well as the impact of invasive and noninvasive tests on surgical outcome in patients affected by Cushing's disease (CD).

Methods: Retrospective analysis on 148 patients with CD and 26 patients with ectopic ACTH syndrome.

Results: Among CD patients, negative MRI/lesion < 6 mm was detected in 97 patients (Group A); 29 had a 6-10 mm lesion (Group B) and 22 a macroadenoma (Group C). A positive response to CRH test, HDSST and desmopressin test was recorded in 89.4%, 91·4% and 70.1% of cases, respectively. Concordant positive response to both CRH/HDDST and CRH/desmopressin tests showed a positive predictive value of 100% for the diagnosis of CD. Among Group A patients with concordant CRH test and HDDST, no difference in surgical outcome was found between patients who performed BIPSS and those who did not (66.6% vs 70.4%, p = 0.78).

Conclusions: CRH, desmopressin test and HDDST have high accuracy in the differential diagnosis of ACTH-dependent CS. In patients with microadenoma < 6 mm or non-visible lesion, a concordant positive response to noninvasive tests seems sufficient to diagnose CD, irrespective of MRI finding. In these patients, BIPSS should be reserved to discordant tests.

Keywords: ACTH-dependent Cushing’s syndrome; Bilateral inferior petrosal sinus sampling; Cushing’s disease; Differential diagnosis.

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Conflict of interest statement

All authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Different groups of patients according to MRI findings
Fig. 2
Fig. 2
Remission rate in patients of Group A with concordant positive tests
See this image and copyright information in PMC

References

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