The role of desmopressin in bilateral and simultaneous inferior petrosal sinus sampling for differential diagnosis of ACTH‐dependent Cushing's syndrome

Machado, Márcio Carlos; de, Sandra Valeria; Domenice, Sorahia; Fragoso, Maria Candida Barisson Villares; Puglia, Paulo; Pereira, Maria Adelaide Albergaria; Mendonça, Berenice Bilharinho; Salgado, Luiz Roberto

doi:10.1111/j.1365-2265.2006.02700.x

Cited by 69 publications

(55 citation statements)

References 31 publications

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“…Alternatively, with persistence of hypercortisolism after surgery, the source of the unsuccessful surgery must be residual tumor that was not removed. Four factors influence incomplete tumor removal: 1) the removal of incidental adenomas (which occur in 15%-20% of pituitaries at autopsy but for unexplained reasons are much less likely to occur during surgical exploration in CD) rather than the corticotroph tumor(s) can occur; 59 2) mistakenly assuming an adenoma was found, resulting in the removal of a site that appears abnormal at surgery, but that proves to be normal gland on histological inspection; 3) incomplete removal of an ACTH-secreting adenoma contained within the pituitary; and 4) an invasive ACTH-secreting adenoma that was not recognized or incompletely removed at surgery can result in lack of biochemical remission.…”

Section: Risks Of Surgerymentioning

confidence: 99%

Cushing's disease: pathobiology, diagnosis, and management

Lonser

Nieman

Oldfield

2017

JNS

138

101

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Cushing's syndrome (CS) is caused by prolonged supraphysiological levels of circulating cortisol. Cushing's disease (CD) is the most common etiology (70%-80% of CS cases) of endogenous CS. It is caused by a pituitary adenoma that secretes adrenocorticotropic hormone (ACTH), which stimulates secretion of cortisol by the adrenal glands. If not effectively treated, CD is associated with hypertension, diabetes, obesity, osteoporosis, vascular disease, and shortened life span. Successful resection of a CD-associated ACTH-secreting pituitary adenoma results in immediate biochemical remission and preservation of pituitary function. Early identification of CD by clinical findings, endocrinological evaluation, and imaging studies is critical for diagnosis and effective surgical management. endocrinological and Clinical Features endocrinological Features Normal PhysiologyInsight into the normal and pathophysiological mechanisms of control of the hypothalamic-anterior pituitaryadrenal axis is critical to understanding the pathologic, diagnostic, and therapeutic features of CD (Fig. 1). 52 Under normal physiological conditions (circadian rhythm, where cortisol levels peak in early morning and nadir late at night), systemic inflammation (cytokine), or stress (physiological or psychological), corticotropin-releasing hormone (CRH; a 41-amino acid peptide) is released from the paraventricular hypothalamic nucleus via the median eminence. From the median eminence, CRH is transported in the hypophyseal portal venous system to the pituitary gland, where it binds to the CRH receptor-1 (CRH-R1) on pituitary corticotroph cells. CRH binding to CRH-R1 receptors activates adenylate cyclase and stimulates proopiomelanocortin (POMC) gene expression in the corticotroph cells.17,66 Proopiomelanocortin preprohormone is processed into ACTH (a 39-amino acid peptide) and b-lipotropin (a 93-amino acid peptide). Products of b-lipotropin include b-endorphin and a-lipotropin. ACTH is secreted into the systemic circulation and binds to receptors in the adrenal cortex, where it stimulates production and secretion of glucocorticoids, including cortisol. 83 Under normal conditions, circulating cortisol provides physiological control of this endocrine axis by its negative feedback inhibition on hypothalamic CRH and pituitary ACTH secretion. Cushing's disease (CD) is the result of excess secretion of adrenocorticotropic hormone (ACTH) by a benign monoclonal pituitary adenoma. The excessive secretion of ACTH stimulates secretion of cortisol by the adrenal glands, resulting in supraphysiological levels of circulating cortisol. The pathophysiological levels of cortisol are associated with hypertension, diabetes, obesity, and early death. Successful resection of the CD-associated ACTH-secreting pituitary adenoma is the treatment of choice and results in immediate biochemical remission with preservation of pituitary function. Accurate and early identification of CD is critical for effective surgical management and optimal prognosis. The authors review the cu...

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Section: Risks Of Surgerymentioning

confidence: 99%

Cushing's disease: pathobiology, diagnosis, and management

Lonser

Nieman

Oldfield

2017

JNS

138

101

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“…This method remains the gold standard for the differential diagnosis of ACTH-dependent Cushing's syndrome with an accuracy of approximately 90-98% (143)(144)(145).…”

Section: Bilateral and Simultaneous Inferior Petrosal Sinus Samplingmentioning

confidence: 99%

“…The procedure is performed under stimulation of oCRH (145,152), hCRH or desmopressin (144,153,154) at the same doses as those used for dynamic secretion tests. Samples are taken at 0, 3, 5 and 10 minutes after the stimulus, and the peak is usually 3 to 5 min after stimulus.…”

Section: Bilateral and Simultaneous Inferior Petrosal Sinus Samplingmentioning

confidence: 99%

Recommendations of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism for the diagnosis of Cushing’s disease in Brazil

Machado

Fragoso

Moreira

et al. 2016

Arch. Endocrinol. Metab.

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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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“…Injection of desmopressin (10 mcg intravenous) alone (33) or concurrently with hCRH has been examined for its ability to increase the stimulation of ACTH release by corticotroph adenomas. Following hCRH and desmopressin injection, a post-stimulation central:peripheral ACTH ratio of > 2.0 produced a sensitivity of 97.9% and specificity of 100% for Cushing's disease (34).…”

Section: Bipss In the Diagnosis Of Cushing's Syndromementioning

confidence: 99%

The role of bilateral inferior petrosal sinus sampling in the diagnosis of Cushing's syndrome

Utz

2007

Arq Bras Endocrinol Metab

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Adrenocorticotropin hormone (ACTH)-dependent Cushing's syndrome is most often due to a pituitary corticotroph adenoma, with ectopic ACTH-secreting tumors representing approximately 15% of cases. Biochemical and radiological techniques have been established to help distinguish between these two entities, and thus aid in the localization of the neoplastic lesion for surgical resection. The test that offers the highest sensitivity and specificity is bilateral inferior petrosal sinus sampling (BIPSS). BIPSS is an interventional radiology procedure in which ACTH levels obtained from venous drainage very near the pituitary gland are compared to peripheral blood levels before and after corticotropin hormone (CRH) stimulation. A gradient between these two locations indicates pituitary Cushing's, whereas the absence of a gradient suggests ectopic Cushing's. Accurate BIPSS results require hypercortisolemia to suppress normal corticotroph ACTH production and hypercortisolemia at the time of the BIPSS to assure excessive ACTH secretion. In some cases, intrapituitary gradients from side-to-side can be helpful to localize small corticotroph adenomas within the sella. BIPSS has rare complications and is considered safe when performed at centers with experience in this specialized technique.

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The role of desmopressin in bilateral and simultaneous inferior petrosal sinus sampling for differential diagnosis of ACTH‐dependent Cushing's syndrome

Abstract: Desmopressin improves the differential diagnosis of ACTH-dependent Cushing's syndrome by amplifying the CEN:PER and IPS:IPS ACTH gradients, and is therefore a useful ACTH secretagogue in BIPSS.

Cited by 69 publications

References 31 publications

Cushing's disease: pathobiology, diagnosis, and management

Cushing's disease: pathobiology, diagnosis, and management

Recommendations of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism for the diagnosis of Cushing’s disease in Brazil

The role of bilateral inferior petrosal sinus sampling in the diagnosis of Cushing's syndrome

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