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Giampietro RR, Cabral MVG, Pereira EG, Machado MC, Vilar L, Nunes-Nogueira VDS. Accuracy of the 10 μg desmopressin test for differential diagnosis of Cushing syndrome: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1332120. [PMID: 38352712 PMCID: PMC10861662 DOI: 10.3389/fendo.2024.1332120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
We evaluated the accuracy of the 10 μg desmopressin test in differentiating Cushing disease (CD) from non-neoplastic hypercortisolism (NNH) and ectopic ACTH syndrome (EAS). A systematic review of studies on diagnostic test accuracy in patients with CD, NNH, or EAS subjected to the desmopressin test obtained from LILACS, PubMed, EMBASE, and CENTRAL databases was performed. Two reviewers independently selected the studies, assessed the risk of bias, and extracted the data. Hierarchical and bivariate models on Stata software were used for meta-analytical summaries. The certainty of evidence was measured using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation Working Group) approach. In total, 14 studies were included: 3 studies on differentiated CD versus NNH and 11 studies on differentiated CD versus EAS. Considering ΔACTH in 8 studies involving 429 patients, the pooled sensitivity for distinguishing CD from EAS was 0.85 (95% confidence interval [CI]: 0.80-0.89, I2 = 17.6%) and specificity was 0.64 (95% CI: 0.49-0.76, I2 = 9.46%). Regarding Δcortisol in 6 studies involving 233 participants, the sensitivity for distinguishing CD from EAS was 0.81 (95% CI: 0.74-0.87, I2 = 7.98%) and specificity was 0.80 (95% CI: 0.61-0.91, I2 = 12.89%). The sensitivity and specificity of the combination of ΔACTH > 35% and Δcortisol > 20% in 5 studies involving 511 participants were 0.88 (95% CI: 0.79-0.93, I2 = 35%) and 0.74 (95% CI: 0.55-0.87, I2 = 27%), respectively. The pooled sensitivity for distinguishing CD from NNH in 3 studies involving 170 participants was 0.88 (95% CI: 0.79-0.93) and the specificity was 0.94 (95% CI: 0.86-0.97). Based on the desmopressin test for differentiating CD from EAS, considering ΔACTH, Δcortisol, or both percent increments, 15%, 19%, or 20% of patients with CD, respectively, would be incorrectly classified as having EAS. For CD versus NNH, 11% of patients with CD would be falsely diagnosed as having NNH, whereas 7% of patients with NNH would be falsely diagnosed as having CD. However, in all hierarchical plots, the prediction intervals were considerably wider than the confidence intervals. This indicates low confidence in the estimated accuracy, and the true accuracy is likely to be different. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=85634, identifier CRD42018085634; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=68317, identifier CRD42017068317.
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Affiliation(s)
- Rodrigo Rosa Giampietro
- Department of Internal Medicine, Sao Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | | | - Elizandra Gomes Pereira
- Department of Internal Medicine, Sao Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | - Marcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
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Espinosa-Cardenas E, Garcia-Saenz M, de Los Monteros-Sanchez ALE, Sosa-Eroza E. Non-Invasive Biochemical Testing of ACTH-dependent Cushing's Disease: Do We Still Need Petrosal Sinus Sampling? Arch Med Res 2023; 54:102882. [PMID: 37749028 DOI: 10.1016/j.arcmed.2023.102882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023]
Abstract
Differentiating between a pituitary from an ectopic source of ACTH could be a real one of the major challenges of clinical endocrinology. The Bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold standard for identifying the source of ACTH; however, is not available worldwide. After the SARS-CoV-2 pandemic, algorithms that include biochemical and imaging tests have gained importance as an alternative to BIPSS. This review summarizes the drawbacks in the differential diagnosis of ACTH-dependent Cushing; the evolution of diagnostic tests, and the evidence that exists on their performance. As well as a comparison between the advantages and disadvantages of invasive and non-invasive tests.
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Affiliation(s)
- Etual Espinosa-Cardenas
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Manuel Garcia-Saenz
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Ernesto Sosa-Eroza
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Ceccato F, Barbot M, Mondin A, Boscaro M, Fleseriu M, Scaroni C. Dynamic testing for differential diagnosis of ACTH-dependent Cushing Syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab 2022; 108:e178-e188. [PMID: 36453141 DOI: 10.1210/clinem/dgac686] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Diagnostic accuracy of testing currently used for the differential diagnosis of Cushing's disease (CD) vs ectopic -ACTH secretion (EAS) is difficult to interpret. The present study aimed to identify and evaluate the diagnostic accuracy of corticotropin-releasing hormone (CRH) test, desmopressin test, and high-dose dexamethasone suppression test (HDDST) when used to establish a CD or EAS diagnosis. DESIGN This study is a systematic review of the literature and meta-analysis. METHODS MEDLINE, OVID, and Web of Science databases were searched for articles published between the years 1990-2021. Articles included described at least one test(s) (CRH, desmopressin, or HDDST) and the diagnostic reference standard(s) (histopathology, petrosal sinus sampling, surgical remission, imaging, and long-term follow-up) used to establish a CD or EAS diagnosis. RESULTS Sixty-two studies were included: 43 reported the use of HDDST, 32 CRH test, and 21 desmopressin test. CRH test was found to have the highest sensitivity in detecting CD (ACTH 86.9%, 95% confidence interval [CI] 82.1-90.6, cortisol 86.2%, 95%CI 78.3-91.5) and the highest specificity in detecting EAS (ACTH 93.9%, 95%CI 87-98.3, cortisol 89.4%, 95%CI 82.8-93.7). This resulted in a high diagnostic odds ratio (58, 95%CI 43.25-77.47), large area under the curve, and a receiver-operating characteristic (ROC) of 0.934. The diagnostic accuracy of HDDST and desmopressin test(s) was lower than that of the CRH test. CONCLUSION The meta-analysis indicates that a patient with a positive ACTH response after a CRH test is highly likely to have CD. Further studies analysing role of dynamic testing in addition to imaging are needed.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Alessandro Mondin
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Maria Fleseriu
- Oregon Health & Science University, Pituitary Center, Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition and Department of Neurological Surgery, Portland, USA
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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Lyu X, Zhang D, Pan H, Zhu H, Chen S, Lu L. A noninvasive scoring model for the differential diagnosis of ACTH-dependent Cushing's syndrome: a retrospective analysis of 311 patients based on easy-to-use parameters. Endocrine 2022; 78:114-122. [PMID: 35925471 DOI: 10.1007/s12020-022-03081-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The differential diagnosis of ACTH-dependent Cushing's disease (CS) is challenging. The gold standard approach bilateral inferior petrosal sinus sampling (BIPSS) is expensive and invasive, while other noninvasive tests, like the high-dose dexamethasone suppression test (HDDST), provide unsatisfactory diagnostic accuracy. This study aimed to find a new noninvasive practical approach with higher diagnostic accuracy to differently diagnose ACTH-dependent CS, which can be used in centers where BIPSS cannot be applied. METHODS 264 Cushing's disease (CD) patients and 47 ectopic ACTH secretion syndrome (EAS) patients were analyzed in this single-center retrospective study (2011-2021). The multivariate logistic model was used to construct the scoring model. RESULTS Female (adjusted OR 3.030, 95%CI 1.229-7.471), hypokalemia (0.209, 0.076-0.576), ACTH (0.988, 0.982-0.994), MRI pituitary lesion positive (8.671, 3.521-21.352), and HDDST positive (2.768, 1.139-6.726) have a strong association with the differential diagnosis of ACTH-dependent CS and were included in the final multivariable logistic regression model. A -14-to-14-point noninvasive scoring model was built on the model. The AUC of the noninvasive scoring model was 0.915 (95% CI 0.869-0.960), significantly higher than the AUC of HDDST (0.756, 95% CI 0.685-0.825, P = 0.004). The optimal cutoff of the model was ≥0 to diagnose CD. The sensitivity of the noninvasive scoring model was 91.3% (95% CI 87.3%-94.1%), and the specificity was 80.9% (95% CI 67.5%-89.6%). When the model's sensitivity was 100.0%, the cutoff was ≥ -10 with a specificity of 19.2%; when the model's specificity was 100.0%, the cutoff was ≥ 13 with a sensitivity of 22.7%. CONCLUSIONS We developed a noninvasive scoring model to distinguish CD and EAS in ACTH-dependent CS patients with higher diagnostic utility than HDDST in the same cohort. The noninvasive scoring model might be applied in areas where BIPSS is unavailable, the CRH is hard to obtain, or the desmopressin stimulation is not widely applied. It also provided a triage tool for selecting patients that might benefit the most from a further BIPSS test.
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Affiliation(s)
- Xiaohong Lyu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China
- Eight-year Program of Clinical Medicine, Peking Union Medical College, 100730, Beijing, China
| | - Dingyue Zhang
- Eight-year Program of Clinical Medicine, Peking Union Medical College, 100730, Beijing, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China
| | - Shi Chen
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China.
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China.
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Pinelli S, Barbot M, Scaroni C, Ceccato F. Second-Line Tests in the Diagnosis of Adrenocorticotropic Hormone-Dependent Hypercortisolism. Ann Lab Med 2021; 41:521-531. [PMID: 34108279 PMCID: PMC8203434 DOI: 10.3343/alm.2021.41.6.521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/17/2020] [Accepted: 05/17/2021] [Indexed: 11/19/2022] Open
Abstract
Cushing’s syndrome (CS) is a rare disease caused by chronic and excessive cortisol secretion. When adrenocorticotropin hormone (ACTH) is measurable, autonomous adrenal cortisol secretion could be reasonably ruled out in a differential diagnosis of CS. ACTH-dependent CS accounts for 80%–85% of cases and involves cortisol production stimulated by uncontrolled pituitary or ectopic ACTH secretion. Pituitary adenoma is not detected in up to one-third of cases with pituitary ACTH secretion, whereas cases of CS due to ectopic ACTH secretion may be associated with either malignant neoplasia (such as small cell lung carcinoma) or less aggressive neuroendocrine tumors, exhibiting only the typical symptoms and signs of CS. Since the differential diagnosis of ACTH-dependent CS may be a challenge, many strategies have been proposed. Since none of the available tests show 100% diagnostic accuracy, a step-by-step approach combining several diagnostic tools and a multidisciplinary evaluation in a referral center is suggested. In this review, we present a clinical case to demonstrate the diagnostic work-up of ACTH-dependent CS. We describe the most commonly used dynamic tests, as well as the applications of conventional or nuclear imaging and invasive procedures.
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Affiliation(s)
- Silvia Pinelli
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy.,Department of Neuroscience DNS, University of Padova, Padova, Italy
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Qiao J, Li J, Zhang W, Wang C, Li J, Jiang S, Tan H, Chen Y, Liu H, Cai B, Yu Y. The usefulness of the combined high-dose dexamethasone suppression test and desmopressin stimulation test in establishing the source of ACTH secretion in ACTH-dependent Cushing's syndrome. Endocr J 2021; 68:839-848. [PMID: 33790062 DOI: 10.1507/endocrj.ej20-0837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Bilateral inferior petrosal sinus sampling (BIPSS) is the current gold standard test for differentially diagnosing ACTH-dependent Cushing's syndrome (CS). However, BIPSS is an invasive procedure, and its availability is limited. We retrospectively analysed the 24-hour urinary free cortisol (UFC) level during the high-dose dexamethasone suppression test (HDDST) and plasma ACTH/cortisol levels after the desmopressin stimulation test (DDAVP test) in subjects with confirmed Cushing's disease (CD) (n = 92) and ectopic ACTH-dependent CS (EAS) (n = 16), and evaluated the positive predictive value (PPV) of the two combined-tests in the aetiological diagnosis of ACTH-dependent CS. The percent changes in UFC levels after the HDDST and in ACTH/cortisol levels after DDAVP administration relative to the corresponding basal levels and the area under the receiver operating characteristic (ROC) curve (AUC) were analysed. UFC suppression below 62.7% suggested a pituitary origin with a sensitivity (SE) of 80% (95% CI: 70-88) and a specificity (SP) of 80% (95% CI: 52-96). A threshold increase in the ACTH level after DDAVP stimulation of 44.6% identified CD with an SE of 91% (95% CI: 83-97) and an SP of 75% (95% CI: 48-93). The combination of both tests yielded an SE of 95.5% and PPV of 98.4% for CD, and significantly improved the efficiency of the differential diagnosis between CD and EAS. These dual non-invasive endocrine tests may substantially reduce the need for BIPSS in the etiological investigation of ACTH-dependent CS.
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Affiliation(s)
- Jingtao Qiao
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jiaqi Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Weiwei Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Chun Wang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shu Jiang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yaxi Chen
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Hui Liu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bowen Cai
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yerong Yu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Świątkowska-Stodulska R, Berlińska A, Stefańska K, Kłosowski P, Sworczak K. Cyclic Cushing's Syndrome - A Diagnostic Challenge. Front Endocrinol (Lausanne) 2021; 12:658429. [PMID: 33967962 PMCID: PMC8101412 DOI: 10.3389/fendo.2021.658429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
Cyclic Cushing's syndrome (also known as intermittent or periodic) is a disease characterized by periods of transient hypercortisolemia shifting into periods of normo- and/or hypocortisolemia. Diagnosis of cyclic Cushing's syndrome is based on at least three periods of confirmed hypercortisolemia interspersed by two periods of normocortisolemia. Cyclic Cushing's syndrome is one of the greatest challenges in modern endocrinology due to its diverse clinical picture, unpredictable duration and frequency of phases, and various etiologies. We discuss a diagnostic algorithm for periodic hypercortisolemia with special regard to hair cortisol analysis and desmopressin stimulation test which both seem to be helpful in finding the correct answer.
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Affiliation(s)
- Renata Świątkowska-Stodulska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Agata Berlińska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Katarzyna Stefańska
- Department of Obstetrics, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Przemysław Kłosowski
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Barbot M, Trementino L, Zilio M, Ceccato F, Albiger N, Daniele A, Frigo AC, Mardari R, Rolma G, Boscaro M, Arnaldi G, Scaroni C. Second-line tests in the differential diagnosis of ACTH-dependent Cushing's syndrome. Pituitary 2016; 19:488-95. [PMID: 27236452 DOI: 10.1007/s11102-016-0729-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Diagnosing Cushing's syndrome (CS) can be a challenge, especially in ACTH-dependent CS, when it comes to detecting the origin of ACTH secretion. MATERIALS AND METHODS Retrospective data were collected on 170 patients with ACTH-dependent CS (149 CD, 21 EAS) referring to two endocrinology units, focusing on three non-invasive tests: dexamethasone 8 mg overnight challenge (HDDST); corticotrophin-releasing hormone (CRH) assay and the desmopressin (DDAVP) test. RESULTS Patients with EAS were slightly older and had higher ACTH, serum and urinary cortisol levels than patients with CD (p < 0.01). CD patients had a stronger ACTH and cortisol response after CRH injection (p < 0.0001), and a more pronounced reduction in cortisol levels after HDDST (p < 0.0001). A threshold percentage ACTH increase after CRH stimulation of 72.4 % was able to identify CD with a sensitivity (SE) of 76 % (95 % CI 68-83) and a specificity (SP) of 100 % (95 % CI 83-100). As for HDDST, a cortisol suppression >52.7 % below the basal level suggested a pituitary origin with a SE of 88 % (95 % CI 81-93) and a SP of 90 % (95 % CI 68-99). There were no cases of EAS with positive responses to both these tests. Increases in ACTH and cortisol levels after the DDAVP test were also higher in CD than in EAS (p < 0.01), though the SE and SP were lower. CONCLUSIONS Patients with CD showed a stronger response to HDDST and CRH, and the adopted cut-offs showed a good SE and SP in discriminating them from patients with EAS. Concordant tests indicated CD when positive, whereas no response to either test was highly suggestive of EAS. The DDAVP test was of limited utility in the diagnostic phase. In conclusion, the choice of tests may play an important part in the differential diagnosis of ACTH-dependent CS.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
| | - Laura Trementino
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Nora Albiger
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Andrea Daniele
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital, Padua, Italy
| | | | | | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Giorgio Arnaldi
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
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Machado MC, Fragoso MCBV, Moreira AC, Boguszewski CL, Vieira L, Naves LA, Vilar L, de Araújo LA, Czepielewski MA, Gadelha MR, Musolino NRC, Miranda PAC, Bronstein MD, Ribeiro-Oliveira A. Recommendations of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism for the diagnosis of Cushing's disease in Brazil. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:267-86. [PMID: 27355856 PMCID: PMC10522300 DOI: 10.1590/2359-3997000000174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/10/2016] [Indexed: 11/22/2022]
Abstract
Although it is a rare condition, the accurate diagnosis and treatment of Cushing's disease is important due to its higher morbidity and mortality compared to the general population, which is attributed to cardiovascular diseases, diabetes mellitus and infections. Screening for hypercortisolism is recommended for patients who present multiple and progressive clinical signs and symptoms, especially those who are considered to be more specific to Cushing's syndrome, abnormal findings relative to age (e.g., spinal osteoporosis and high blood pressure in young patients), weight gain associated with reduced growth rate in the pediatric population and for those with adrenal incidentalomas. Routine screening is not recommended for other groups of patients, such as those with obesity or diabetes mellitus. Magnetic resonance imaging (MRI) of the pituitary, the corticotropin-releasing hormone (CRH) test and the high-dose dexamethasone suppression test are the main tests for the differential diagnosis of ACTH-dependent Cushing's syndrome. Bilateral and simultaneous petrosal sinus sampling is the gold standard method and is performed when the triad of initial tests is inconclusive, doubtful or conflicting. The aim of this article is to provide information on the early detection and establishment of a proper diagnosis of Cushing's disease, recommending follow-up of these patients at experienced referral centers. Arch Endocrinol Metab. 2016;60(3):267-86.
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Affiliation(s)
- Márcio Carlos Machado
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Maria Candida Barisson Vilares Fragoso
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Ayrton Custódio Moreira
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasilDivisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil;
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e MetabologiaHospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrasilServiço de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil;
| | - Leonardo Vieira
- Serviço de EndocrinologiaHospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrasilServiço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF/UFRJ), Rio de Janeiro, RJ, Brasil;
| | - Luciana A. Naves
- Serviço de EndocrinologiaHospital Universitário de BrasíliaUniversidade de BrasíliaBrasíliaDFBrasilServiço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil;
| | - Lucio Vilar
- Serviço de EndocrinologiaHospital de ClínicasUniversidade Federal de PernambucoRecifePEBrasilServiço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil;
| | | | - Mauro A. Czepielewski
- Hospital de Clínicas de Porto AlegreFaculdade de MedicinaUniversidade Federal do Rio Grande do SulPorto AlegreRSBrasilServiço de Endocrinologia, Hospital de Clínicas de Porto Alegre (HCPA), Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil;
| | - Monica R. Gadelha
- Serviço de EndocrinologiaHospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrasilServiço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF/UFRJ), Rio de Janeiro, RJ, Brasil;
| | - Nina Rosa Castro Musolino
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Divisão de Neurocirurgia Funcional, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP;Brasil
| | - Paulo Augusto C Miranda
- Serviço de EndocrinologiaSanta Casa de Belo HorizonteBelo HorizonteMGBrasilServiço de Endocrinologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil;
| | - Marcello Delano Bronstein
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Antônio Ribeiro-Oliveira
- Universidade Federal de Minas GeraisServiço de EndocrinologiaHospital de ClínicasBelo HorizonteMGBrasilServiço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brasil
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10
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Vilar L, Albuquerque JL, Lyra R, Trovão Diniz E, Rangel Filho F, Gadelha P, Thé AC, Ibiapina GR, Gomes BS, Santos V, Melo da Fonseca M, Frasão Viana K, Lopes IG, Araújo D, Naves L. The Role of Isotretinoin Therapy for Cushing's Disease: Results of a Prospective Study. Int J Endocrinol 2016; 2016:8173182. [PMID: 27034666 PMCID: PMC4789464 DOI: 10.1155/2016/8173182] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/20/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. This prospective open trial aimed to evaluate the efficacy and safety of isotretinoin (13-cis-retinoic acid) in patients with Cushing's disease (CD). Methods. Sixteen patients with CD and persistent or recurrent hypercortisolism after transsphenoidal surgery were given isotretinoin orally for 6-12 months. The drug was started on 20 mg daily and the dosage was increased up to 80 mg daily if needed and tolerated. Clinical, biochemical, and hormonal parameters were evaluated at baseline and monthly for 6-12 months. Results. Of the 16 subjects, 4% (25%) persisted with normal urinary free cortisol (UFC) levels at the end of the study. UFC reductions of up to 52.1% were found in the rest. Only patients with UFC levels below 2.5-fold of the upper limit of normal achieved sustained UFC normalization. Improvements of clinical and biochemical parameters were also noted mostly in responsive patients. Typical isotretinoin side-effects were experienced by 7 patients (43.7%), though they were mild and mostly transient. We also observed that the combination of isotretinoin with cabergoline, in relatively low doses, may occasionally be more effective than either drug alone. Conclusions. Isotretinoin may be an effective and safe therapy for some CD patients, particularly those with mild hypercortisolism.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - José Luciano Albuquerque
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Ruy Lyra
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Erik Trovão Diniz
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Frederico Rangel Filho
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Patrícia Gadelha
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Ana Carolina Thé
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - George Robson Ibiapina
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Barbara Sales Gomes
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Vera Santos
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Maíra Melo da Fonseca
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Karoline Frasão Viana
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Isis Gabriella Lopes
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Douglas Araújo
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Luciana Naves
- Division of Endocrinology, Brasilia University Hospital, Brasilia, DF, Brazil
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11
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Mendoza CF, Ontiveros P, Xibillé DX, Rivera HM. Ectopic ACTH secretion (EAS) associated to a well-differentiated peritoneal mesothelioma: case report. BMC Endocr Disord 2015; 15:40. [PMID: 26253127 PMCID: PMC4528349 DOI: 10.1186/s12902-015-0031-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/12/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The association between mesotheliomas and ectopic ACTH secretion has been rarely reported; we present the first case of ectopic ACTH secretion (EAS) associated with a well-differentiated peritoneal mesothelioma in whom the high dose dexamethasone suppression test (HDDST) results and plasmatic ACTH levels were similar to those found in Cushing's disease (CD). CASE PRESENTATION A 43-year-old hispanic woman with a 20 year history of treatment resistant diabetes mellitus and arterial hypertension. She had a full moon face, a buffalo hump, increased volume in both supraclavicular regions, purple striae in her arms and abdomen, truncal obesity, polymenorrhea and umbilical hernia. A cortisol suppression test with low dose dexamethasone (LDDST) with a result of 16.6 μg/dL and ACTH plasma levels were measured at 32.6 pg/mL. The high dose dexamethasone test suppression percentage was 84.8% and magnetic resonance imaging (MRI) showed no evidence of pituitary alterations, computed tomography (CT) showed images suggestive of uterine fibroid and an intra-abdominal tumor that correlated with an umbilical hernia, which reinforcement after contrast. Surgery was performed, finding uterine fibroids and paracolic tumor implants as well as on the omentum, bladder, bowel, ovaries and appendix. Pathology reported a well-differentiated peritoneal mesothelioma with positive immunohistochemistry for ACTH. CONCLUSIONS Although most cases of ectopic secretion of ACTH derive from rapidly-developing lung tumors, with very high plasma ACTH levels and cortisol suppression percentages with high doses of dexamethasone under 60%, there is a small percentage of slow-developing, chronic tumors that are biochemically undistinguishable from Cushing's disease. Following the expert recommendations regarding imaging techniques it is possible to identify the associated tumor in most cases.
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Affiliation(s)
- Carmen F Mendoza
- Endocrinology Department, Universidad Autónoma del Estado de Morelos and Hospital General de Cuernavaca, Iztaccihuatl Esq. Leñeros S/N, Los Volcanes, 62350, Cuernavaca, Morelos, Mexico.
| | | | - Daniel X Xibillé
- Universidad Autónoma del Estado de Morelos and Hospital General de Cuernavaca, Morelos, Mexico.
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12
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Casulari LA, Dondi D, Celotti F, da Silva FVP, Reis CEG, da Costa THM. Effects of caloric restriction and low glycemic index diets associated with metformin on glucose metabolism and cortisol response in overweight/obese subjects: a case series study. Diabetol Metab Syndr 2015; 7:65. [PMID: 26269722 PMCID: PMC4533768 DOI: 10.1186/s13098-015-0057-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 06/23/2015] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND To determine whether cortisol secretion and glucocorticoid receptors in lymphocytes and monocytes are altered in patients with impaired glucose tolerance, and whether treatment with a hypocaloric diet and metformin could interfere with these aspects. METHODS This is an analytical, interventional, case series study. Patients with impaired glucose tolerance were included. They received 500 mg of metformin twice daily and followed a low glycemic index diet for 16 weeks. Cortisol levels were assessed at 8:00 A.M. before and after use of 0.25 mg of dexamethasone at 11:00 P.M. the day before. RESULTS Sixteen subjects (9 men) were included. Normal basal levels of cortisol and adequate responses to the low dose of dexamethasone were observed before and after treatment. There was no significant correlation between the parameters evaluated and cortisol levels. Nevertheless, there was a strong correlation between the number of glucocorticoid receptors, BMI (r = 0.88; p = 0.02), and insulin AUC (r = 0.94; p = 0.005) before treatment; after treatment, all these associations ceased to exist. CONCLUSION The cortisol secretion remained normal in the group of patients with impaired glucose tolerance. Treatment with metformin and diet did not change this condition. However, glucocorticoid receptor number had a strong correlation with insulin, due to insulin resistance, but this characteristic was lost after treatment.
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Affiliation(s)
- Luiz Augusto Casulari
- />Unit of Endocrinology, University Hospital Brasilia, University of Brasilia, Brasilia, Brazil
- />CLINEN – Clínica de Neurologia e Endocrinologia. SCN quadra 1, bloco F, Ed. America Office Tower, sala 1111, Brasília, DF 70711-905 Brazil
| | - Donatella Dondi
- />Dipartimento di Scienze Farmacologiche e Biomolecolari, Sezione di Biomedicina ed Endocrinologia, Università di Milano, Milan, Italy
| | - Fabio Celotti
- />Dipartimento di Scienze Farmacologiche e Biomolecolari, Sezione di Biomedicina ed Endocrinologia, Università di Milano, Milan, Italy
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13
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Ceccato F, Barbot M, Zilio M, Ferasin S, Occhi G, Daniele A, Mazzocut S, Iacobone M, Betterle C, Mantero F, Scaroni C. Performance of salivary cortisol in the diagnosis of Cushing's syndrome, adrenal incidentaloma, and adrenal insufficiency. Eur J Endocrinol 2013; 169:31-6. [PMID: 23610124 DOI: 10.1530/eje-13-0159] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Salivary cortisol has recently been suggested for studies on the hypothalamic-pituitary-adrenal (HPA) axis. The lack of circadian rhythm is a marker of Cushing's syndrome (CS), and some authors have reported that low salivary cortisol levels may be a marker of adrenal insufficiency. The aim of our study was to define the role of salivary cortisol in specific diagnostic settings of HPA axis disease. SUBJECTS AND METHODS We analyzed morning salivary cortisol (MSC) and late-night salivary CORTISOL (LNSC) levels in 406 SUBJECTS: 52 patients with Cushing's disease (CD), 13 with ectopic CS, 17 with adrenal CS, 27 with CD in remission (a mean follow-up of 66±39 months), 45 with adrenal incidentaloma, 73 assessed as having CS and then ruled out for endogenous hypercortisolism, 75 with adrenal insufficiency, and 104 healthy subjects. RESULTS A LNSC value above 5.24 ng/ml differentiated CS patients from controls with high sensitivity (96.3%) and specificity (97.1%); we found higher LNSC levels in ectopic CS patients than in CD patients. We found no difference in MSC and LNSC levels between patients with CD in remission and healthy subjects. Both MSC and LNSC levels were higher in patients with adrenal incidentaloma than in healthy controls. A MSC value below 2.65 ng/ml distinguished patients with adrenal insufficiency from controls with high sensitivity (97.1%) and specificity (93.3%). CONCLUSIONS Salivary cortisol is a useful tool to assess endogenous cortisol excess or adrenal insufficiency and to evaluate stable CD in remission.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105, 35128 Padova, Italy
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Günes M, Celik O, Kadioglu P. Reliability of the diagnostic tests for Cushing's syndrome performed in a tertiary referral center. Pituitary 2013; 16:139-45. [PMID: 22466318 DOI: 10.1007/s11102-012-0387-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The study aimed to retrospectively evaluate the reliability of the diagnostic and location tests in Cushing's Syndrome (CS). Eighty-seven patients diagnosed with CS between 1995 and 2007 by Endocrinology Metabolism Department of Cerrahpasa Medical School were included in the study. The control group consisted of 91 patients who presented to the outpatient clinic because of obesity. The diagnostic tests were as follows: 1 mg dexamethasone suppression test (DST), 24-h urinary free cortisol (UFC), midnight cortisol level (MCL), ACTH level and overnight 8 mg DST. The sensitivity and specificity of UFC were 81 and 66 % respectively for the cut-off point of 50 μg/day, whereas they were 64 and 76 % respectively for the cut-off point of 100 μg/day. For the cut-off value of 1.8/μg/dL for MCL and 1 mDST, the sensitivity rates were 100 and 98 %, while the specificity rates were 88 and 33 %, respectively. Among the location tests, the sensitivity and specificity of ACTH under 10 pg/mL for adrenal CS were 92 and 94 % respectively. The sensitivity and specificity of ACTH higher than 30 pg/mL for ACTH-dependent CS were 69 and 100 % respectively. The sensitivity rates of 8 mg DST for 50 and 60 % suppressions were 83 and 79 % respectively, whereas the specificity rates were 75 and 88 % respectively. 1 mg DST (cut-off <1.8 μg/dL) and UFC (50 μg/24 h) are appropriate tests for screening CS. Overnight 8 mg DST with 60 % suppression for Cushing's Disease (CD) and ACTH levels <10 pg/mL for adrenal CS, ACTH levels >30 pg/mL for ACTH dependency were identified as the best tests for the differential diagnosis of the subtypes.
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Affiliation(s)
- Mutlu Günes
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey
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15
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Manetti L, Rossi G, Grasso L, Raffaelli V, Scattina I, Del Sarto S, Cosottini M, Iannelli A, Gasperi M, Bogazzi F, Martino E. Usefulness of salivary cortisol in the diagnosis of hypercortisolism: comparison with serum and urinary cortisol. Eur J Endocrinol 2013; 168:315-21. [PMID: 23211575 DOI: 10.1530/eje-12-0685] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Several tests have been proposed to diagnose patients with Cushing's syndrome (CS). The aims of the study were: i) to evaluate the performance of salivary cortisol (SC) in hypercortisolism and ii) to compare SC with serum cortisol (SeC) and urinary cortisol. DESIGN AND PATIENTS This was a diagnostic study. Twenty-seven patients with untreated Cushing's disease (CD untr), 21 women consuming oral contraceptive pill (OCP), 18 pregnant women, and 89 healthy subjects (controls) were enrolled. METHODS SC and SeC at baseline and after the low-dose dexamethasone suppression test (LDDST) and urinary free cortisol (UFC) were measured. RESULTS Midnight SC had a sensitivity of 100% in the CD untr group and a specificity of 97.7% in the controls. Specificity remained high (95.2%) in women taking OCP, while in pregnant women, it decreased to 83.3%. SC after the LDDST showed a sensitivity of 96.3% in the CD untr group; specificity was 97.7% in the controls and 90.5% in OCP women. Midnight SeC had a sensitivity of 100% in the CD untr group. SeC after the LDDST had a sensitivity of 100% in the CD untr group while specificity was 97.7% in the controls and 61.9% in women taking OCP. For UFC, sensitivity was 92.6% in the CD untr group while specificity was 97.7% in the controls and 100% in the OCP group. CONCLUSIONS SC is a reliable parameter for the diagnosis of severe hypercortisolism, with high sensitivity and specificity. In women during pregnancy or taking OCP, the measurement of SC, identifying the free fraction, could be helpful to exclude CS.
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Affiliation(s)
- Luca Manetti
- Department of Endocrinology and Metabolism, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124 Pisa, Italy.
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16
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Jang YM, Lee EJ, Kim DL, Kim SK, Song KH. The Association between Midnight Salivary Cortisol and Metabolic Syndrome in Korean Adults. Diabetes Metab J 2012; 36:245-50. [PMID: 22737665 PMCID: PMC3380129 DOI: 10.4093/dmj.2012.36.3.245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 02/16/2012] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The common characteristics of metabolic syndrome (MetS) and Cushing's syndrome suggest that excess cortisol may be involved in the pathogenesis of MetS. Salivary cortisol measurements are simple and can be surrogates for plasma free cortisol, which is the most biologically active form. We evaluated the association between levels of midnight salivary cortisol and MetS in Korean adults. METHODS A total of 46 subjects, aged 20 to 70 years, who visited the Health Care Center at Konkuk University Hospital from August 2008 to August 2009 were enrolled. We compared the levels of midnight salivary cortisol in subjects with MetS with those in subjects without MetS. We analyzed the associations between midnight salivary cortisol levels and components of MetS. RESULTS Midnight salivary cortisol levels were higher in the MetS group (70±42.4 ng/dL, n=12) than that in the group without MetS (48.1±36.8 ng/dL, n=34) (P=0.001). Positive correlations were observed between midnight salivary cortisol levels and waist circumference, fasting blood glucose, and homeostasis model assessment of insulin resistance. The risk for MetS was significantly higher in subjects with midnight salivary cortisol levels ≥100 ng/dL than in those with levels <50 ng/dL (odds ratio, 5.9; 95% confidence interval, 2.35 to 36.4). CONCLUSION The results showed a positive correlation between midnight salivary cortisol levels and MetS, suggesting that hypercortisolism may be related to MetS.
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Affiliation(s)
- Yun-Mi Jang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Eun Jung Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Dong Lim Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Suk Kyeong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kee-Ho Song
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Alexandraki KI, Grossman AB. Is urinary free cortisol of value in the diagnosis of Cushing's syndrome? Curr Opin Endocrinol Diabetes Obes 2011; 18:259-63. [PMID: 21681089 DOI: 10.1097/med.0b013e3283487193] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Cushing's syndrome results from prolonged and inappropriately high exposure of tissues to glucocorticoids. Biochemical tests are always needed to confirm the clinical suspicion: these include measurement of excess total endogenous cortisol secretion assessed by 24-h urinary free cortisol (UFC), loss of the normal feedback of the hypothalamo-pituitary-adrenal axis assessed by suppressibility after dexamethasone testing, and disturbance of the normal circadian rhythm of cortisol secretion assessed by midnight serum or salivary cortisol. This review focuses on recent data emerging on the value of UFC as a screening test for Cushing's syndrome. RECENT FINDINGS Considerable evidence has emerged regarding the utility of UFC in the diagnosis of Cushing's syndrome because of its long-term use in clinical practice. Despite the fact that UFC assesses the active (free) component of cortisol, the methodological difficulties in 24-h urine collection and in assay precision have rendered this screening technique increasingly unpopular. Furthermore, the increased prevalence of mild, preclinical or cyclic Cushing's syndrome along with the fact that cortisol is not uniformly secreted during the day do not support its use as a screening test, although strikingly high levels can be useful. SUMMARY Since the sensitivity and specificity of UFC are less than ideal when compared with other diagnostic modalities, we suggest the use of other more novel tests as first-step diagnostic tests to screen for hypercortisolaemia.
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Affiliation(s)
- Krystallenia I Alexandraki
- Centre for Endocrinology, William Harvey Research Institute, Barts and London School of Medicine, Queen Mary University of London, London, UK
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18
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Caldas ADA, Porto AL, Motta LDCD, Casulari LA. Relationship between insulin and hypogonadism in men with metabolic syndrome. ACTA ACUST UNITED AC 2010; 53:1005-11. [PMID: 20126854 DOI: 10.1590/s0004-27302009000800015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 05/21/2009] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the incidence of hypogonadism in men with metabolic syndrome and its correlation with serum insulin levels. METHODS Observational, transversal study with 80 men with metabolic syndrome. The individuals were divided into two groups: Group 1: 56 patients (70%) with total testosterone > 300 ng/dL (normal gonadal function); Group 2: 24 patients (30%) with total testosterone < 300 ng/dL (hypogonadic). RESULTS The subjects from Group 2 compared to Group 1 presented higher body mass index (BMI), waist and hip circumferences, insulin, homeostasis model assessment insulin resistance index (Homa-IR) and beta cell (Homa-beta), and triglycerides, but lower SHBG and free testosterone values. Inverse correlations between insulin levels and total testosterone and SHBG, as well as between Homa-IR and total testosterone were observed. CONCLUSION In this series of men with metabolic syndrome, hypogonadism was associated with insulin resistance and may be a marker of metabolic abnormalities.
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Affiliation(s)
- Amanda D A Caldas
- Departamento de Endocrinologia, Hospital das Forças Armadas, Brasília, DF, Brasil
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Azevedo MF, Xekouki P, Keil MF, Lange E, Patronas N, Stratakis CA. An unusual presentation of pediatric Cushing disease: recurrent corticotropinoma of the posterior pituitary lobe. J Pediatr Endocrinol Metab 2010; 23:607-12. [PMID: 20662335 PMCID: PMC4727444 DOI: 10.1515/jpem.2010.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cushing's syndrome (CS) is rare in childhood and adolescence and its diagnosis and work up are often challenging. We report the case of a 15-year-old girl with a recurrent corticotrophin (ACTH)-secreting adenoma, located in the posterior lobe of the pituitary gland. At the age of 11, she presented with classic CS symptoms; biochemical investigation was compatible with ACTH-dependent Cushing disease, although pituitary gland imaging did not show any tumor. Following transsphenoidal surgery (TSS), histopathological analysis identified an ACTH-secreting pituitary microadenoma arising from the posterior gland. The patient went into remission but 4 years later she presented with recurrent CS; this time, pituitary gland imaging showed a microadenoma located in the posterior lobe, which was resected after TSS. Posterior lobe pituitary adenomas are very rare and often hard to diagnose and treat; this is the first case of such a tumor causing recurrent Cushing's disease in a child.
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Affiliation(s)
- Monalisa F Azevedo
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology Genetics (PDEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
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20
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Vilar L, Naves LA, Azevedo MF, Arruda MJ, Arahata CM, Moura E Silva L, Agra R, Pontes L, Montenegro L, Albuquerque JL, Canadas V. Effectiveness of cabergoline in monotherapy and combined with ketoconazole in the management of Cushing's disease. Pituitary 2010; 13:123-9. [PMID: 19943118 DOI: 10.1007/s11102-009-0209-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The expression of dopamine receptor subtypes has been reported in corticotroph adenomas, and this finding support the possibility for medical treatment of Cushing's disease (CD) with dopamine agonists when conventional treatment has failed. The aim of this study was to evaluate the effectiveness of cabergoline (at doses of up 3 mg/week), alone or combined with relatively low doses of ketoconazole (up to 400 mg/day), in 12 patients with CD unsuccessfully treated by transsphenoidal surgery. After 6 months of cabergoline therapy, normalization of 24 h urinary free cortisol (UFC) levels occurred in three patients (25%) at doses ranging from 2-3 mg/week, whereas reductions ranging from 15.0 to 48.4% were found in the remaining. The addition of ketonocazole to the nine patients without an adequate response to cabergoline was able to normalize UFC excretion in six patients (66.7%) at doses of 200 mg/day (three patients), 300 mg/day (two patients) and 400 mg/day (one patient). In the remaining patients UFC levels did not normalize but a significant reduction ranging from to 44.4 to 51.7% was achieved. In two of the six responsive patients to combination therapy, the weekly dose of cabergoline could be later reduced from 3 to 2 mg. Our findings demonstrated that cabergoline monotherapy was able to reverse hypercortisolism in 25% of patients with CD unsuccessfully treated by surgery. Moreover, the addition of relatively low doses of ketoconazole led to normalization of UFC in about two-thirds of patients not achieving a full response to cabergoline.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil.
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Raff H. Utility of salivary cortisol measurements in Cushing's syndrome and adrenal insufficiency. J Clin Endocrinol Metab 2009; 94:3647-55. [PMID: 19602555 DOI: 10.1210/jc.2009-1166] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The measurement of cortisol in saliva is a simple, reproducible, and reliable test to evaluate the normal and disordered control of the hypothalamic-pituitary-adrenal (HPA) axis. There are a variety of simple methods to obtain saliva samples without stress, making this a robust test applicable to many different experimental and clinical situations. EVIDENCE ACQUISITION Ovid Medline and PubMed from 1950 to present were searched using the following strategies: [<saliva or salivary>and<cortisol or hydrocortisone>and<Cushing or Cushing's>] and [<saliva or salivary>and<cortisol or hydrocortisone>and<adrenal insufficiency or hypoadrenalism or hypopituitarism or Addison's disease>]. The bibliographies of all relevant citations were evaluated for any additional appropriate citations. EVIDENCE SYNTHESIS Measurement of an elevated late-night (2300 to 2400 h) salivary cortisol has a greater than 90% sensitivity and specificity for the diagnosis of endogenous Cushing's syndrome. Late-night salivary cortisol measurements are also useful to monitor patients for remission and/or recurrence after pituitary surgery for Cushing's disease. Because it is a surrogate for plasma free cortisol, the measurement of salivary cortisol may be useful during an ACTH stimulation test in patients with increased plasma binding protein concentrations due to increased estrogen, or decreased plasma binding protein concentrations during critical illness. Most reference laboratories now offer salivary cortisol testing. CONCLUSIONS It is expected that the use of the measurement of salivary cortisol will become routine in the evaluation of patients with disorders of the HPA axis.
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Affiliation(s)
- Hershel Raff
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin 53215, USA.
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