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Lynnette K Nieman - One of the best experts on this subject based on the ideXlab platform.

  • Is prolactin measurement of value during inferior Petrosal Sinus Sampling in patients with adrenocorticotropic hormone-dependent Cushing's Syndrome?
    Journal of endocrinological investigation, 2013
    Co-Authors: S. T. Sharma, Lynnette K Nieman
    Abstract:

    Inferior Petrosal Sinus Sampling (IPSS) is considered the gold standard test to distinguish between Cushing's disease (CD) and ectopic ACTH syndrome (EAS). Anomalous venous drainage, abnormal venous anatomy, and lack of expertise can lead to false-negative IPSS results and thereby misclassification of patients with ACTH-dependent Cushing's syndrome. Prolactin measurement during IPSS can improve diagnostic accuracy and decrease false negative results. A baseline prolactin inferior Petrosal Sinus to peripheral (IPS/P) ratio (ipsilateral to the dominant post-CRH ACTH IPS/P ratio) of 1.8 or more suggests successful catheterization during IPSS. Prolactin-normalized ACTH IPS/P ratios can then be used to differentiate between a pituitary and ectopic source of ACTH. Values ≤ 0.7 are suggestive of EAS and those ≥ 1.3 are indicative of CD, but the implication of values between 0.7 and 1.3 remains unclear and needs further investigation. Larger prospective studies are also needed for further evaluation of the role of contralateral prolactin IPS/P ratios, post- CRH prolactin values, and prolactin-adjusted ACTH inter-Sinus ratios for tumor localization in CD.

  • the lateralization accuracy of inferior Petrosal Sinus Sampling in 501 patients with cushing s disease
    The Journal of Clinical Endocrinology and Metabolism, 2013
    Co-Authors: Lynnette K Nieman, Richard Chang, Joshua J Wind, Russell R Lonser, Hetty L Devroom, Edward H. Oldfield
    Abstract:

    Context: It is often difficult to find an adenoma in patients with Cushing's disease (CD) whose preoperative magnetic resonance imaging (MRI) is normal. Better localizing modalities are needed. Objective: The aim of this study was to determine the accuracy of inferior Petrosal Sinus Sampling (IPSS) in predicting adenoma lateralization. Design and Setting: We conducted a prospective observational study at a tertiary care clinical research center. Patients: A total of 501 consecutive patients (363 female) with confirmed ACTH adenomas and IPSS were included. Main Outcome Measure: We measured the accuracy of IPSS to predict the intrasellar location of an adenoma. Results: IPSS confirmed a pituitary source of ACTH secretion in 491 patients (98%). All 10 patients with false-negative results had peak IPSS ACTH concentrations (before or after CRH) of < 400 pg/ml. InterPetrosal (side-to-side) ratios were ≥ 1.4 in 491 patients (98%). This ratio correctly predicted lateralization in 273 of 396 patients (positive pre...

  • the hypothalamic pituitary adrenal axis in pregnancy challenges in disease detection and treatment
    Endocrine Reviews, 2005
    Co-Authors: John R Lindsay, Lynnette K Nieman
    Abstract:

    Pregnancy dramatically affects the hypothalamic-pituitary-adrenal axis leading to increased circulating cortisol and ACTH levels during gestation, reaching values in the range seen in Cushing’s syndrome (CS). The cause(s) of increased ACTH may include placental synthesis and release of biologically active CRH and ACTH, pituitary desensitization to cortisol feedback, or enhanced pituitary responses to corticotropin-releasing factors. In this context, challenges in diagnosis and management of disorders of the hypothalamic-pituitary-adrenal axis in pregnancy are discussed. CS in pregnancy is uncommon and is associated with fetal morbidity and mortality. The diagnosis may be missed because of overlapping clinical and biochemical features in pregnancy. The proportion of patients with primary adrenal causes of CS is increased in pregnancy. CRH stimulation testing and inferior Petrosal Sinus Sampling can identify patients with Cushing’s disease. Surgery is a safe option for treatment in the second trimester; oth...

  • cushing s syndrome due to ectopic corticotropin secretion twenty years experience at the national institutes of health
    The Journal of Clinical Endocrinology and Metabolism, 2005
    Co-Authors: Ioannis Ilias, David J Torpy, Karel Pacak, Nancy Mullen, Robert Wesley, Lynnette K Nieman
    Abstract:

    Context: Ectopic ACTH secretion (EAS) is difficult to diagnose and treat. We present our experience with EAS from 1983 to 2004. Setting: The study was performed at a tertiary care clinical research center. Patients: Ninety patients, aged 8–72 yr, including 48 females were included in the study. Interventions and Outcome Measures: Tests included 8 mg dexamethasone suppression, CRH stimulation, inferior Petrosal Sinus Sampling (IPSS), computed tomography, octreotide scan, magnetic resonance imaging, and/or venous Sampling. Therapies, pathological examinations, and survival were noted. Results: Eighty-six to 94% of patients did not respond to CRH or dexamethasone suppression, whereas 66 of 67 had negative IPSS. To control hypercortisolism, 62 patients received medical treatment, and 33 had bilateral adrenalectomy. Imaging localized tumors in 67 of 90 patients. Surgery confirmed an ACTH-secreting tumor in 59 of 66 patients and cured 65%. Nonthymic carcinoids took longest to localize. Deaths included three of ...

  • cushing s syndrome during pregnancy personal experience and review of the literature
    The Journal of Clinical Endocrinology and Metabolism, 2005
    Co-Authors: John R Lindsay, Edward H. Oldfield, Jacqueline Jonklaas, Lynnette K Nieman
    Abstract:

    Cushing's syndrome (CS) occurs rarely during pregnancy. We investigated and treated four patients with pituitary-dependent Cushing's syndrome during pregnancy over a 15-yr period at the National Institutes of Health. Except for preservation of menses before conception, our patients presented with typical clinical features, increased urinary free cortisol, and loss of diurnal variation of cortisol. The diagnosis was facilitated, without complications, by the use of CRH testing and inferior Petrosal Sinus Sampling in three women. Transsphenoidal pituitary surgery achieved remission in three women, but there were two fetal/neonatal deaths. This experience and review of 136 previous reports suggest that: 1) urinary free cortisol in CS patients overlaps the normal pregnant range; 2) ACTH levels are not suppressed in adrenal causes of CS, which may be identified by the 8-mg dexamethasone test; 3) inferior Petrosal Sinus Sampling and transsphenoidal pituitary surgery, the optimal diagnostic test and treatment for nonpregnant patients with pituitary-dependent Cushing's syndrome, can safely facilitate the management of pregnant patients; and 4) surgery may achieve remission during pregnancy, but the prognosis for the fetus remains guarded. It is likely that earlier recognition and treatment would improve outcome. There is a need for development of criteria for interpretation of diagnostic tests and increased consideration of CS in pregnancy.

Edward H. Oldfield - One of the best experts on this subject based on the ideXlab platform.

  • The Hypoplastic Inferior Petrosal Sinus: A Potential Source of False-Negative Results in Petrosal Sampling for Cushing’s Disease
    2015
    Co-Authors: John L. Doppman, Richard Chang, Edward H. Oldfield, Constantine A Stratakis, George Chrousos, K. Nieman
    Abstract:

    Our purpose was to describe the hypoplastic or plexiform inferior Petrosal Sinus as a potential cause of false-negative Sampling results in patients with Cushing’s disease. Five hundred and one patients with surgically proven Cushing’s disease and negative or equivocal magnetic resonance imaging scans of the pituitary gland underwent Petrosal Sinus Sampling. Four patients (0.8%) with surgically proven Cushing’s disease had false-negative results of Petrosal Sinus sam-pling. Retrograde inferior Petrosal sinograms in these patients were reviewed to evaluate the anatomy of the inferior Petrosal Sinuses for abnormalities that could have contributed to this misdiagnosis. In addition, the retrograde inferior Petrosal sinograms of 100 consecu-tive patients were reviewed to establish the frequency of asymmetric and/or hypoplastic inferior Petrosal Sinuses. All four patients with false-negative results of Petrosal Sampling demonstrated a hypoplas

  • the lateralization accuracy of inferior Petrosal Sinus Sampling in 501 patients with cushing s disease
    The Journal of Clinical Endocrinology and Metabolism, 2013
    Co-Authors: Lynnette K Nieman, Richard Chang, Joshua J Wind, Russell R Lonser, Hetty L Devroom, Edward H. Oldfield
    Abstract:

    Context: It is often difficult to find an adenoma in patients with Cushing's disease (CD) whose preoperative magnetic resonance imaging (MRI) is normal. Better localizing modalities are needed. Objective: The aim of this study was to determine the accuracy of inferior Petrosal Sinus Sampling (IPSS) in predicting adenoma lateralization. Design and Setting: We conducted a prospective observational study at a tertiary care clinical research center. Patients: A total of 501 consecutive patients (363 female) with confirmed ACTH adenomas and IPSS were included. Main Outcome Measure: We measured the accuracy of IPSS to predict the intrasellar location of an adenoma. Results: IPSS confirmed a pituitary source of ACTH secretion in 491 patients (98%). All 10 patients with false-negative results had peak IPSS ACTH concentrations (before or after CRH) of < 400 pg/ml. InterPetrosal (side-to-side) ratios were ≥ 1.4 in 491 patients (98%). This ratio correctly predicted lateralization in 273 of 396 patients (positive pre...

  • an assessment of Petrosal Sinus Sampling for localization of pituitary microadenomas in children with cushing disease
    The Journal of Clinical Endocrinology and Metabolism, 2006
    Co-Authors: Dalia L Batista, Margaret F. Keil, Richard Chang, Monia Gennari, Jehan Riar, Edward H. Oldfield
    Abstract:

    CONTEXT: Pituitary adenomas in Cushing disease (CD) are usually small and difficult to visualize. Bilateral inferior Petrosal venous Sampling (BIPSS) before and after ovine CRH stimulation is reserved for patients who have ACTH-dependent Cushing syndrome and negative magnetic resonance imaging (MRI) or positive MRI but inconsistent biochemical data. OBJECTIVE: The objective of the study was to evaluate the usefulness of BIPSS as a tool for localization of a pituitary adenoma in children with CD. DESIGN: The study was a retrospective review of the records of 141 children who were admitted for evaluation of CD from 1982 to 2004. SETTING: The study was conducted at a tertiary care center. INTERVENTIONS AND OUTCOME MEASURES: Lateralization of ACTH secretion during BIPSS was compared with MRI and surgical findings for the localization of a microadenoma. RESULTS: A total of 94 patients, 49 males and 45 females with an age range of 5.3 to 18.7 yr (13 +/- 3.2 yr), underwent BIPSS. Localization of a microadenoma by BIPSS agreed with surgical location in only 58% of the cases (95% confidence interval, 43-66). The combined use of information from the MRI and inferior Petrosal venous Sampling did not predict the location of the tumor more frequently than MRI alone (P > 0.1), which in this study localized a lesion in 39% of the patients (95% confidence interval, 28-50). The procedure was completed successfully in all patients, and no serious complications were recorded. CONCLUSIONS: Although BIPSS was safe and well tolerated in an experienced center, lateralization of the ACTH gradient during BIPSS was a poor predictor of the site of the adenoma in children with CD.

  • cushing s syndrome during pregnancy personal experience and review of the literature
    The Journal of Clinical Endocrinology and Metabolism, 2005
    Co-Authors: John R Lindsay, Edward H. Oldfield, Jacqueline Jonklaas, Lynnette K Nieman
    Abstract:

    Cushing's syndrome (CS) occurs rarely during pregnancy. We investigated and treated four patients with pituitary-dependent Cushing's syndrome during pregnancy over a 15-yr period at the National Institutes of Health. Except for preservation of menses before conception, our patients presented with typical clinical features, increased urinary free cortisol, and loss of diurnal variation of cortisol. The diagnosis was facilitated, without complications, by the use of CRH testing and inferior Petrosal Sinus Sampling in three women. Transsphenoidal pituitary surgery achieved remission in three women, but there were two fetal/neonatal deaths. This experience and review of 136 previous reports suggest that: 1) urinary free cortisol in CS patients overlaps the normal pregnant range; 2) ACTH levels are not suppressed in adrenal causes of CS, which may be identified by the 8-mg dexamethasone test; 3) inferior Petrosal Sinus Sampling and transsphenoidal pituitary surgery, the optimal diagnostic test and treatment for nonpregnant patients with pituitary-dependent Cushing's syndrome, can safely facilitate the management of pregnant patients; and 4) surgery may achieve remission during pregnancy, but the prognosis for the fetus remains guarded. It is likely that earlier recognition and treatment would improve outcome. There is a need for development of criteria for interpretation of diagnostic tests and increased consideration of CS in pregnancy.

  • the hypoplastic inferior Petrosal Sinus a potential source of false negative results in Petrosal Sampling for cushing s disease
    The Journal of Clinical Endocrinology and Metabolism, 1999
    Co-Authors: John L. Doppman, Richard Chang, George P Chrousos, Edward H. Oldfield, Constantine A Stratakis, Lynnette K Nieman
    Abstract:

    Our purpose was to describe the hypoplastic or plexiform inferior Petrosal Sinus as a potential cause of false-negative Sampling results in patients with Cushing's disease. Five hundred and one patients with surgically proven Cushing's disease and negative or equivocal magnetic resonance imaging scans of the pituitary gland underwent Petrosal Sinus Sampling. Four patients (0.8%) with surgically proven Cushing's disease had false-negative results of Petrosal Sinus Sampling. Retrograde inferior Petrosal sinograms in these patients were reviewed to evaluate the anatomy of the inferior Petrosal Sinuses for abnormalities that could have contributed to this misdiagnosis. In addition, the retrograde inferior Petrosal sinograms of 100 consecutive patients were reviewed to establish the frequency of asymmetric and/or hypoplastic inferior Petrosal Sinuses. All four patients with false-negative results of Petrosal Sampling demonstrated a hypoplastic or plexiform inferior Petrosal Sinus ipsilateral to an ACTH-secreting microadenoma. When the Sampling catheter was in the hypoplastic Petrosal Sinus, retrograde sinograms from the contralateral side demonstrated anomalous drainage patterns on the side of the hypoplastic Sinus. Because the negative results of Petrosal Sinus Sampling false-suggested the presence of the ectopic ACTH syndrome, curative transsphenoidal surgery in these four patients was delayed up to 31 months. We conclude that the presence of a unilateral hypoplastic or plexiform inferior Petrosal Sinus can result in anomalous drainage from the pituitary gland that may lead to false-negative Sampling results in patients with Cushing's disease.

Hershel Raff - One of the best experts on this subject based on the ideXlab platform.

  • Cushing syndrome: update on testing.
    Endocrinology and metabolism clinics of North America, 2014
    Co-Authors: Hershel Raff
    Abstract:

    Endogenous hypercortisolism (Cushing syndrome) is one of the most enigmatic diseases in clinical medicine. The diagnosis and differential diagnosis of Cushing syndrome depend on proper laboratory evaluation. In this review, an update is provided on selected critical issues in the diagnosis and differential diagnosis of Cushing syndrome: the use of late-night salivary cortisol in initial diagnosis and for postoperative surveillance, and the use of prolactin measurement to improve the performance of inferior Petrosal Sinus Sampling to distinguish Cushing disease from ectopic adrenocorticotropic hormone (ACTH) syndrome during differential diagnosis of ACTH-dependent Cushing syndrome.

  • Journal of Clinical Endocrinology and Metabolism Printed in U.S.A. Copyright © 1997 by The Endocrine Society Effectiveness Versus Efficacy: The Limited Value in Clinical Practice of High Dose Dexamethasone Suppression Testing in the Differential Diagnosis
    2013
    Co-Authors: David C. Aron, Hershel Raff, W. Findling
    Abstract:

    High dose dexamethasone suppression testing has been widely employed in the differentiation between pituitary ACTH-dependent hypercortisolism [Cushing’s disease (CD)] and the ectopic ACTH syndrome. We hypothesized that the high dose dexamethasone suppression test as it is performed in practice does not improve the ability to differentiate between these two types of ACTH-dependent Cushing’s syndrome. Cases were drawn from 112 consecutive patients with ACTH-dependent Cushing’s syndrome, who were then classified based upon results of inferior Petrosal Sinus Sampling for ACTH levels. Analysis of test characteristics of high dose dexamethasone suppression testing was performed in the 73 patients for whom results are available. Statistical modeling was performed using the 68 cases with complete data on all assessed variables. Logistic regression models were use

  • cushing s syndrome important issues in diagnosis and management
    The Journal of Clinical Endocrinology and Metabolism, 2006
    Co-Authors: James W Findling, Hershel Raff
    Abstract:

    Context: The diagnosis, differential diagnosis, and treatment of Cushing’s syndrome are challenging problems in clinical endocrinology. We focus on critical questions addressing screening for Cushing’s syndrome, differentiation of Cushing’s subtypes, and treatment options. Evidence Acquisition: Ovid’s MEDLINE (1996 through April 2006) was used to search the general literature. We also relied on previously published reviews and a recent monograph and cite a mix of primary articles and recent reviews. Evidence Synthesis: Although this article represents our opinion, it draws heavily on a recent consensus statement from experts in the field and a recent monograph on Cushing’s syndrome. Conclusions: We concluded that: 1) measurement of late-night or bedtime salivary cortisol is a useful approach to screen for Cushing’s syndrome; 2) measurement of suppressed plasma ACTH by immunometric assay is useful to differentiate ACTH-dependent and -independent Cushing’s syndrome; 3) inferior Petrosal Sinus Sampling for A...

  • identification of patients with cushing s disease with negative pituitary adrenocorticotropin gradients during inferior Petrosal Sinus Sampling prolactin as an index of pituitary venous effluent
    The Journal of Clinical Endocrinology and Metabolism, 2004
    Co-Authors: James W Findling, Michael E Kehoe, Hershel Raff
    Abstract:

    Inferior Petrosal Sinus Sampling for ACTH differentiates pituitary ACTH-dependent Cushing’s (CD) from the ectopic ACTH syndrome (EAS). Petrosal Sinus to peripheral (IPS:P) ACTH ratios greater than 2.0 in the basal state or a peak greater than 3.0 after CRH are diagnostic of CD. However, false-negative rates of 1–10% have been reported. We report three patients with features of CD with peak IPS:P ACTH ratios less than 3.0 after CRH suggesting EAS. We compared IPS:P prolactin (PRL) as an index of pituitary venous effluent in these three index cases with 44 patients with CD and five with EAS. The dominant basal IPS:P PRL ratio was greater than 1.8 in all 49 patients but was less than 1.2 in the three index cases. The IPS:P ACTH ratio normalized to IPS:P PRL was greater than 0.8 in all CD patients but was less than 0.6 in EASpatients.TheIPS:PACTHratiosnormalizedtoIPS:PPRL were greater than 1.2 in the index cases, which was similar to those with CD. The three index cases had clinical and biochemical remissions after pituitary surgery. PRL is an index of pituitary venous effluent during inferior Petrosal Sinus Sampling in patients with CD who fail to have a peak IPS:P ACTH ratio greater than 3.0 after CRH. IPS:P PRL should be measured when results indicate EAS. (J Clin Endocrinol Metab 89: 6005–6009, 2004)

Franco Mantero - One of the best experts on this subject based on the ideXlab platform.

  • the role of inferior Petrosal Sinus Sampling in acth dependent cushing s syndrome review and joint opinion statement by members of the italian society for endocrinology italian society for neurosurgery and italian society for neuroradiology
    Neurosurgical Focus, 2015
    Co-Authors: Francesca Pecori Giraldi, Luigi Maria Cavallo, F Tortora, Rosario Pivonello, Annamaria Colao, Paolo Cappabianca, Franco Mantero
    Abstract:

    In the management of adrenocorticotropic hormone (ACTH)–dependent Cushing's syndrome, inferior Petrosal Sinus Sampling (IPSS) provides information for the endocrinologist, the neurosurgeon, and the neuroradiologist. To the endocrinologist who performs the etiological diagnosis, results of IPSS confirm or exclude the diagnosis of Cushing's disease with 80%–100% sensitivity and over 95% specificity. Baseline central-peripheral gradients have suboptimal accuracy, and stimulation with corticotropin-releasing hormone (CRH), possibly desmopressin, has to be performed. The rationale for the use of IPSS in this context depends on other diagnostic means, taking availability of CRH and reliability of dynamic testing and pituitary imaging into account. As regards the other specialists, the neuroradiologist may collate results of IPSS with findings at imaging, while IPSS may prove useful to the neurosurgeon to chart a surgical course. The present review illustrates the current standpoint of these 3 specialists on the...

  • the role of inferior Petrosal Sinus Sampling in acth dependent cushing s syndrome review and joint opinion statement by members of the italian society for endocrinology italian society for neurosurgery and italian society for neuroradiology
    Neurosurgical Focus, 2015
    Co-Authors: Francesca Pecori Giraldi, Luigi Maria Cavallo, F Tortora, Rosario Pivonello, Annamaria Colao, Paolo Cappabianca, Franco Mantero
    Abstract:

    In the management of adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome, inferior Petrosal Sinus Sampling (IPSS) provides information for the endocrinologist, the neurosurgeon, and the neuroradiologist. To the endocrinologist who performs the etiological diagnosis, results of IPSS confirm or exclude the diagnosis of Cushing's disease with 80%-100% sensitivity and over 95% specificity. Baseline central-peripheral gradients have suboptimal accuracy, and stimulation with corticotropin-releasing hormone (CRH), possibly desmopressin, has to be performed. The rationale for the use of IPSS in this context depends on other diagnostic means, taking availability of CRH and reliability of dynamic testing and pituitary imaging into account. As regards the other specialists, the neuroradiologist may collate results of IPSS with findings at imaging, while IPSS may prove useful to the neurosurgeon to chart a surgical course. The present review illustrates the current standpoint of these 3 specialists on the role of IPSS.

  • cyclical cushing s syndrome in a patient with a bronchial neuroendocrine tumor typical carcinoid expressing ghrelin and growth hormone secretagogue receptors
    The Journal of Clinical Endocrinology and Metabolism, 2003
    Co-Authors: Giorgio Arnaldi, Tatiana Mancini, Blerina Kola, Gloria Appolloni, S Freddi, Carolina Concettoni, I Bearzi, A Masini, Marco Boscaro, Franco Mantero
    Abstract:

    A 56-yr-old woman was referred with a diagnosis of Cushing’s disease. Hypertension and severe hypokalemia were present and high urinary free cortisol/cortisone ratio was detected, raising a suspicion of an ectopic ACTH syndrome. Inferior Petrosal Sinus Sampling, thoracic computed tomography, and octreotide scans were negative. Remission and relapse periods lasting 3–4 months were observed during the 3.5 yr of follow-up. Finally a thoracic computed tomography scan showed a basal paracardic nodule in the left lung. After surgery, a well-differentiated neuroendocrine tumor (typical bronchial carcinoid) was diagnosed, staining positively for ACTH. RT-PCR revealed expression of proopiomelanocortin, CRH receptor, and V3 vasopressin receptor. Somatostatin receptor type 1, 2, 3, and 5 mRNA was detected only in tumoral tissue. Interestingly, we observed the simultaneous presence of ghrelin and both GH secretagogue (GHS) receptors (1a and 1b) mRNA in tumoral tissue but not in the normal lung. This finding correlate...

G Lombardi - One of the best experts on this subject based on the ideXlab platform.

  • inferior Petrosal Sinus Sampling in the differential diagnosis of cushing s syndrome results of an italian multicenter study
    European Journal of Endocrinology, 2001
    Co-Authors: Annamaria Colao, Francesca Pecori Giraldi, Rosario Pivonello, A. Faggiano, F. Cavagnini, G Lombardi
    Abstract:

    Objective: To evaluate the diagnostic accuracy of inferior Petrosal Sinus Sampling (IPSS) in the differential diagnosis of ACTH-dependent Cushing’s syndrome as compared with pituitary imaging techniques. Design and Methods: We retrospectively studied the diagnostic accuracy of basal and post corticotropin-releasing hormone (CRH) IPSS, magnetic resonance imaging and computed tomography in distinguishing pituitary from ectopic ACTH secretion in 97 Cushing’s syndrome patients: 74 with Cushing’s disease (CD) and 10 with ectopic ACTH secretion (EAS). Thirteen patients were excluded because of unconfirmed diagnosis. The difference between IPSS and pituitary imaging techniques in the correctly localized pituitary adenoma in the patients with CD was also investigated. Results: The basal ACTH inferior Petrosal Sinus:periphery (IPS:P) ratio was $ 2 in 63/74 patients with CD (85%), and in 1/10 EAS patients (10%); after stimulation with CRH, the ratio was $ 3 in 60/ 68 patients with CD (88%) and , 3 in all patients with EAS. The basal and post-CRH ACTH IPS:P ratios had a diagnostic accuracy of 86% and 90% respectively. The diagnostic accuracy of IPSS with both ratios was significantly higher than magnetic resonance imaging (50%) and computed tomography (40%). The IPS:P ratio suggested by receiver-operator characteristic (ROC) analysis that better distinguished CD from EAS was 2.10 for the basal and 2.15 for the post-CRH ratios. Using these cut-offs, the specificity of basal ratio and the sensitivity of the post-CRH test rose to 100% and 93% respectively. Diagnostic accuracy remained substantially unchanged for the basal ratio (87% vs 86%), while it rose from 90% to 94% for the post-CRH ratio. The sensitivity of IPSS was significantly higher than that of magnetic resonance and computerized tomography. IPSS was less reliable in identifying the adenoma site found at surgery than magnetic resonance imaging or computed tomography (65% vs 75% and 79% respectively). Conclusion: In conclusion, IPSS improved the diagnostic performance of imaging techniques. It can help in excluding transsphenoidal surgery in EAS patients. More striking results were obtained when a $ 2:1 : 1 basal ratio or a $ 2:15 : 1 post-CRH ratio were considered as criteria to distinguish between patients with CD and EAS. To establish correctly the location of the pituitary adenoma, IPSS is less reliable than imaging techniques.

  • Inferior Petrosal Sinus Sampling in the differential diagnosis of Cushing's syndrome: results of an Italian multicenter study
    2001
    Co-Authors: A Colao, Rosario Pivonello, A. Faggiano, Pecori F. Giraldi, F. Cavagnini, G Lombardi
    Abstract:

    OBJECTIVE: To evaluate the diagnostic accuracy of inferior Petrosal Sinus Sampling (IPSS) in the differential diagnosis of ACTH-dependent Cushing's syndrome as compared with pituitary imaging techniques. DESIGN AND METHODS: We retrospectively studied the diagnostic accuracy of basal and post corticotropin-releasing hormone (CRH) IPSS, magnetic resonance imaging and computed tomography in distinguishing pituitary from ectopic ACTH secretion in 97 Cushing's syndrome patients: 74 with Cushing's disease (CD) and 10 with ectopic ACTH secretion (EAS). Thirteen patients were excluded because of unconfirmed diagnosis. The difference between IPSS and pituitary imaging techniques in the correctly localized pituitary adenoma in the patients with CD was also investigated. RESULTS: The basal ACTH inferior Petrosal Sinus:periphery (IPS:P) ratio was > or = 2 in 63/74 patients with CD (85%), and in 1/10 EAS patients (10%); after stimulation with CRH, the ratio was > or = 3 in 60/68 patients with CD (88%) and or = 2.1:1 basal ratio or a > or = 2.15:1 post-CRH ratio were considered as criteria to distinguish between patients with CD and EAS. To establish correctly the location of the pituitary adenoma, IPSS is less reliable than imaging techniques

  • corticotropin releasing hormone test improvement of the diagnostic accuracy of simultaneous and bilateral inferior Petrosal Sinus Sampling in patients with cushing syndrome
    World Journal of Surgery, 1995
    Co-Authors: L Zarrilli, A Colao, B Merola, G La Tessa, R Spaziante, Francesca S Tripodi, A Di Sarno, L A Marzano, G Lombardi
    Abstract:

    Twenty-six consecutive patients with ACTH-dependent Cushing syndrome were subjected to simultaneous, bilateral inferior Petrosal Sinus Sampling for ACTH assay before and after ACTH-releasing hormone (CRH) stimulation. The baseline ACTH inferior Petrosal Sinus/periphery (IPS/P) ratio was > or = 2 in 12 of 26 patients (46%), whereas the CRH-stimulated IPS/P ratio was > or = 3 in 19 of 26 patients (73%). A pituitary adenoma, ACTH-secreting at immunostaining, was surgically proved in all of the 19 patients who had an ACTH IPS/P ratio > or = 2 basally or > or = 3 after the CRH test but also in three other patients who did not have such ratios. The value of the basal IPS/P ratio and the complete lack of ACTH increase after CRH led to the diagnosis of an ectopic ACTH syndrome in four patients: a bronchial carcinoid was found in three patients, and the site of the tumor was still unknown in the other. In conclusion, the CRH test improved the diagnostic accuracy of inferior Petrosal Sinus Sampling from 61.5% (12 pituitary, 4 ectopic) to 92.0% (19 pituitary, 4 ectopic). Thus it should be performed during the diagnostic process.

  • Simultaneous and bilateral inferior Petrosal Sinus Sampling for the diagnosis of Cushing's syndrome: comparison of multihormonal assay, baseline multiple Sampling and ACTH-releasing hormone test
    1993
    Co-Authors: A Colao, B Merola, G La Tessa, R Spaziante, Francesca S Tripodi, A Di Sarno, V. Esposito, P. Marzullo, G Lombardi
    Abstract:

    In 29 consecutive patients with adrenocorticotropin (ACTH)-dependent Cushing's syndrome, we compared the usefulness of multiple baseline ACTH evaluations (10/29), multiple hormone evaluation (29/29) and ACTH-releasing hormone (CRH) stimulation (21/29) during simultaneous and bilateral inferior Petrosal Sinus Sampling. The basal inferior Petrosal Sinus/periphery ratio for ACTH concentrations was greater than 2 in 18 of the 29 patients and CRH challenge caused the appearance of an inferior Petrosal Sinus/periphery ratio greater than 3 in 6 other patients. The presence of an ACTH-secreting adenoma was surgically proven in all the 24 patients who had an ACTH inferior Petrosal Sinus/periphery ratio greater than 2 basally or greater than 3 after the CRH test but also in 1 patient who had an inferior Petrosal Sinus/periphery ratio lower than 2 basally or 3 after the CRH test. In 4 patients, both the very high peripheral ACTH levels, the inferior Petrosal Sinus/periphery ratio and the complete lack of ACTH increase after CRH indicated the presence of an ectopic ACTH syndrome: a bronchial carcinoid was found in 2 patients, whereas the site of the tumor is still unknown in the remaining 2. An ACTH interSinus gradient greater than 1.4 was found in 23 patients. Among these 23 patients, the side of the adenoma was correctly predicted in 19 patients and wrongly in 4

  • Bilateral and simultaneous inferior Petrosal Sinus Sampling in the early diagnosis of an ACTH-producing pituitary microadenoma and its detection by magnetic resonance one year later
    1992
    Co-Authors: B Merola, A Colao, R Spaziante, R. Rossi, A. Manco, C. Oliver, G Lombardi
    Abstract:

    This study describes a case of pituitary-dependent Cushing's syndrome where standard biochemical and radiological techniques were discordant in localizing the origin of the autonomous adrenocorticotropic hormone (ACTH) hypersecretion in the pituitary. Hormonal evaluation suggested a pituitary genesis for the disease, but both sellar computed tomography and cranial magnetic resonance (MR) were unable to give clear-cut evidence for a pituitary neoplasm. Simultaneous and bilateral inferior Petrosal Sinus Sampling (SBIPS) correctly identified the left side of the pituitary gland as the source of autonomous ACTH production. One year later, the shaded signs of a pituitary lesion in the left side of the gland were seen with MR imaging, and a 0.5-cm in height adenoma was surgically removed. At the 2-year follow-up the patient's symptoms had completely disappeared, and her menses were restored. In this case, SBIPS correctly diagnosed the presence of an ACTH-secreting pituitary microadenoma one year before shaded signs of the pituitary lesion appeared with MR imaging. This is a clear-cut demonstration of the accuracy of the SBIPS technique in localizing small pituitary lesions