Maximizing the accuracy of Inferior petrosal sinus sampling: validation of the use of Prolactin as a marker of pituitary venous effluent in the diagnosis of Cushing’s disease

Grant, Paul; Dworakowska, Dorota; Carroll, Paul

doi:10.1111/j.1365-2265.2011.04257.x

Cited by 40 publications

(24 citation statements)

References 21 publications

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“…With broadened experience with BIPSS, it clearly appears that the actual accuracy of BIPSS in clinical practice is lower than expected; both false-negative (19, 60, 61, 62, 63, 64, 65, 66, 67) and, less commonly, false-positive results have been reported (68, 69, 70). …”

Section: Diagnostic Accuracy Of Bipssmentioning

confidence: 95%

Bilateral inferior petrosal sinus sampling

Zampetti

Grossrubatscher

Ciaramella

et al. 2016

Endocrine Connections

104

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Simultaneous bilateral inferior petrosal sinus sampling (BIPSS) plays a crucial role in the diagnostic work-up of Cushing’s syndrome. It is the most accurate procedure in the differential diagnosis of hypercortisolism of pituitary or ectopic origin, as compared with clinical, biochemical and imaging analyses, with a sensitivity and specificity of 88–100% and 67–100%, respectively. In the setting of hypercortisolemia, ACTH levels obtained from venous drainage of the pituitary are expected to be higher than the levels of peripheral blood, thus suggesting pituitary ACTH excess as the cause of hypercortisolism. Direct stimulation of the pituitary corticotroph with corticotrophin-releasing hormone enhances the sensitivity of the procedure. The procedure must be undertaken in the presence of hypercortisolemia, which suppresses both the basal and stimulated secretory activity of normal corticotrophic cells: ACTH measured in the sinus is, therefore, the result of the secretory activity of the tumor tissue. The poor accuracy in lateralization of BIPSS (positive predictive value of 50–70%) makes interpetrosal ACTH gradient alone not sufficient for the localization of the tumor. An accurate exploration of the gland is recommended if a tumor is not found in the predicted area. Despite the fact that BIPSS is an invasive procedure, the occurrence of adverse events is extremely rare, particularly if it is performed by experienced operators in referral centres.

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Section: Diagnostic Accuracy Of Bipssmentioning

confidence: 95%

Bilateral inferior petrosal sinus sampling

Zampetti

Grossrubatscher

Ciaramella

et al. 2016

Endocrine Connections

104

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“…Although each invasive neuroradiologist's skill may vary, an easy way to verify that the tip of the catheter is very close to the venous drainage of the pituitary is to measure other pituitary hormones in the blood samples obtained from the catheter tip. A convenient hormone that we and others 25,35 advocate measuring is prolactin. Simultaneous measurements of prolactin and ACTH in central and peripheral blood samples have provided independent confir-mation on catheter placement and consequently reduced the rate of false-negative results of the procedure.…”

Section: Inferior Petrosal Sinus Samplingmentioning

confidence: 99%

“…Simultaneous measurements of prolactin and ACTH in central and peripheral blood samples have provided independent confir-mation on catheter placement and consequently reduced the rate of false-negative results of the procedure. 25,35 The ratio of central/peripheral prolactin concentrations should be at least 2 or higher. Any level below 2 (especially below 1.5) suggests poor placement of the catheter tip, which impacts the interpretation of the ACTH data.…”

Section: Inferior Petrosal Sinus Samplingmentioning

confidence: 99%

Pitfalls in the diagnosis and management of Cushing's syndrome

Bansal¹,

Asmar²,

Selman³

et al. 2015

FOC

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Despite many recent advances, the management of patients with Cushing's disease continues to be challenging. Cushing's syndrome is a complex metabolic disorder that is a result of excess glucocorticoids. Excluding the exogenous causes, adrenocorticotropic hormone–secreting pituitary adenomas account for nearly 70% of all cases of Cushing's syndrome. The suspicion, diagnosis, and differential diagnosis require a logical systematic approach with attention paid to key details at each investigational step. A diagnosis of endogenous Cushing's syndrome is usually suspected in patients with clinical symptoms and confirmed by using multiple biochemical tests. Each of the biochemical tests used to establish the diagnosis has limitations that need to be considered for proper interpretation. Although some tests determine the total daily urinary excretion of cortisol, many others rely on measurements of serum cortisol at baseline and after stimulation (e.g., after corticotropin-releasing hormone) or suppression (e.g., dexamethasone) with agents that influence the hypothalamic-pituitary-adrenal axis. Other tests (e.g., measurements of late-night salivary cortisol concentration) rely on alterations in the diurnal rhythm of cortisol secretion. Because more than 90% of the cortisol in the circulation is protein bound, any alteration in the binding proteins (transcortin and albumin) will automatically influence the measured level and confound the interpretation of stimulation and suppression data, which are the basis for establishing the diagnosis of Cushing's syndrome. Although measuring late-night salivary cortisol seems to be an excellent initial test for hypercortisolism, it may be confounded by poor sampling methods and contamination. Measurements of 24-hour urinary free-cortisol excretion could be misleading in the presence of some pathological and physiological conditions. Dexamethasone suppression tests can be affected by illnesses that alter the absorption of the drug (e.g., malabsorption, celiac disease) and by the concurrent use of medications that interfere with its metabolism (e.g., inducers and inhibitors of the P450 enzyme system). In this review, the authors aim to review the pitfalls commonly encountered in the workup of patients suspected to have hypercortisolism. The optimal diagnosis and therapy for patients with Cushing's disease require the thorough and close coordination and involvement of all members of the management team.

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“…P. Grant и соавт. [24] провели ретро-спективный анализ данных среди 83 пациентов, ко-торым проводился селективный забор крови с ру-тинным определением уровня пролактина. Среди этих больных у 67 пациентов был подтвержден диа-гноз БИК, а в 16 случаях забор крови показал отри-цательный результат.…”

Section: Discussionunclassified

“…Возможно, такой результат обусловлен характером стимуляционного агента, так как максимальный градиент АКТГ после введения десмопрессина был парадоксально ниже градиента АКТГ до введения стимуляционного агента, и это стало причиной большого количества ложноотрицательных резуль-татов. В работах [15,18,24], которые описывают по-вышение именно чувствительности метода, исполь-зовали кортиколиберин. Кроме того, согласно ре-зультатам настоящего исследования, нужно с осто-рожностью интерпретировать АКТГ/пролактин-нормализованное отношение, если градиент базаль-ного пролактина оказался очень высоким.…”

Section: Discussionunclassified

The role of prolactin gradient and normalized ACTH/prolactin ratio in the improvement of sensitivity and specificity of selective blood sampling from inferior petrosal sinuses for differential diagnostics of ACTH-dependent hypercorticism

Белая¹,

Рожинская²,

Melnichenko³

et al. 2013

Probl Endokrinol (Mosk)

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The present study included patients with confirmed diagnosis of ACTH-dependent hypercorticism admitted to the Department of Neuroendocrinology and Osteopathies, Endocrinological Research Centre, between 2008 and 2012. Selective blood sampling from the inferior petrosal sinuses was performed with the stimulation by decompressin administered intravenously at a dose of 8 mcg. The normalized ACTH/prolactin ratio was calculated by dividing the maximum ACTH gradient following decompressin stimulation by the ipsilateral prolactin gradient. The cut off values were calculated from the operating characteristic curves as follows: 1.5 for the prolactin gradient (sensitivity 92.5%, specificity 100%) and 1.18 for the normalized ACTH/prolactin ratio (sensitivity 85.9%; 95% CI 76.8-93.4, specificity 100%; 95% CI 60.9-100). In the study cohort (n=70), the normalized ACTH/prolactin ratio proved to be a more specific but less sensitive parameter than the routine analysis of the ACTH gradient (sensitivity 98.4%, specificity 83.3%). Areas under the operating characteristic curves were on the whole identical. However, comparison of the diagnostic value of selective blood sampling from the inferior petrosal sinuses in combination of the determination of the prolactin gradient and normalized ACTH/prolactin ratio with the results obtained in the patients in whom the catheter position was not controlled (n=47) revealed the advantages of the former approach in terms of both the number of unverified causes of hypercorticism (1 versus 6) and the area under the operating characteristic curves 0.964 (95% CI 0.897-1.032) among 70 patients and 0.910 (95% CI 0.821-0.998) among the first 47 patients (included in the analysis confined to the confirmed cases). It is concluded that the determination of the prolactin gradient and calculation of the normalized ACTH/prolactin ratio allow to increase the diagnostic value of selective blood sampling from the inferior petrosal sinuses under decompressin stimulation. This inference is especially true of doubtful cases.

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Maximizing the accuracy of Inferior petrosal sinus sampling: validation of the use of Prolactin as a marker of pituitary venous effluent in the diagnosis of Cushing’s disease

Cited by 40 publications

References 21 publications

Bilateral inferior petrosal sinus sampling

Bilateral inferior petrosal sinus sampling

Pitfalls in the diagnosis and management of Cushing's syndrome

The role of prolactin gradient and normalized ACTH/prolactin ratio in the improvement of sensitivity and specificity of selective blood sampling from inferior petrosal sinuses for differential diagnostics of ACTH-dependent hypercorticism

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