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      Diagnostic accuracy and comparison of BIPSS in response to lysine vasopressin and hCRH

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          Abstract

          Context

          Bilateral inferior petrosal sinus sampling (BIPSS) using hCRH is currently considered the ‘gold standard’ test for the differential diagnosis of ACTH-dependent Cushing’s syndrome (CS). Vasopressin is more potent than CRH to stimulate ACTH secretion as shown in animal studies; however, no comparative data of its use are available during BIPSS.

          Objective

          To study the diagnostic accuracy and comparison of hCRH and lysine vasopressin (LVP) stimulation during BIPSS.

          Patients and methods

          29 patients (27-Cushing’s disease, 2-ectopic CS; confirmed on histopathology) underwent BIPSS and were included for the study. Patients were randomized to receive hCRH, 5 U LVP or 10 U LVP during BIPSS for ACTH stimulation. BIPSS and contrast-enhanced magnetic resonance imaging (CEMRI) were compared with intra-operative findings of trans-sphenoidal surgery (TSS) for localization and lateralization of the ACTH source.

          Results

          BIPSS correctly localized the source of ACTH excess in 29/29 of the patients with accuracy of 26/26 patients, using any of the agent, whereas sensitivity and PPV for lateralization with hCRH, 5 U LVP and 10 U LVP was seen in 10/10, 6/10; 10/10,8/10 and 7/7,6/7 patients respectively. Concordance of BIPSS with TSS was seen in 20/27, CEMRI with BIPSS in 16/24 and CEMRI with TSS in 18/24 of patients for lateralizing the adenoma. Most of the side effects were transient and were comparable in all the three groups.

          Conclusion

          BIPSS using either hCRH or LVP (5 U or 10 U) confirmed the source of ACTH excess in all the patients, while 10 U LVP correctly lateralized the pituitary adenoma in three fourth of the patients.

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          Most cited references30

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          Cushing's syndrome.

          Cushing's syndrome results from lengthy and inappropriate exposure to excessive glucocorticoids. Untreated, it has significant morbidity and mortality. The syndrome remains a challenge to diagnose and manage. Here, we review the current understanding of pathogenesis, clinical features, diagnostic, and differential diagnostic approaches. We provide diagnostic algorithms and recommendations for management.
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            • Article: not found

            The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's states.

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              • Abstract: found
              • Article: not found

              Cushing's Syndrome: important issues in diagnosis and management.

              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. 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. 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. 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 ACTH should be performed in patients with ACTH-dependent hypercortisolism in whom a pituitary magnetic resonance imaging is normal or equivocal (in the absence of a pituitary ACTH gradient, prolactin levels should be measured to confirm the integrity of venous sampling); 4) computed tomography of the chest and abdomen and somatostatin receptor scintigraphy should be performed in patients with the occult ectopic ACTH syndrome; and 5) patients with Cushing's disease should be referred to a neurosurgeon with extensive experience operating on corticotroph microadenomas. Bilateral laparoscopic adrenalectomy should be considered in patients with Cushing's disease who fail therapies directed at the pituitary.
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                Author and article information

                Journal
                Endocr Connect
                Endocr Connect
                EC
                Endocrine Connections
                Bioscientifica Ltd (Bristol )
                2049-3614
                March 2018
                12 February 2018
                : 7
                : 3
                : 425-432
                Affiliations
                [1 ]Department of Endocrinology Post Graduate Institute of Medical Education and Research, Chandigarh, India
                [2 ]Department of Radio-diagnosis Post Graduate Institute of Medical Education and Research, Chandigarh, India
                [3 ]Department of Neurosurgery Post Graduate Institute of Medical Education and Research, Chandigarh, India
                [4 ]Department of Psychiatry Post Graduate Institute of Medical Education and Research, Chandigarh, India
                [5 ]Department of Histopathology Post Graduate Institute of Medical Education and Research, Chandigarh, India
                Author notes
                Correspondence should be addressed to R Walia: ramawalia@ 123456rediffmail.com
                Article
                EC180046
                10.1530/EC-18-0046
                5834768
                29440131
                aff56d2b-ac6e-4dcc-aea7-741e665328b8
                © 2018 The authors

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 07 February 2018
                : 12 February 2018
                Categories
                Research

                bilateral inferior petrosal sinus sampling (bipss),hcrh (human corticotrophin releasing hormone),lvp (lysine vasopressin),contrast-enhanced magnetic resonance imaging (cemri)

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