Journal of the Chinese Medical Association
Volume 70, Issue 1 , Pages 4-10, January 2007

Assessment of Bilateral Inferior Petrosal Sinus Sampling (BIPSS) in the Diagnosis of Cushing's Disease

  • Liang-Yu Lin

      Affiliations

    • Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Tao-Yuan, Taiwan, R.O.C.
    • ,
  • Michael Mu-Huo Teng

      Affiliations

    • Division of Neuroradiology, Department of Radiology, Taipei Veterans General Hospital, Tao-Yuan, Taiwan, R.O.C.
    • National Yang-Ming University School of Medicine, Taipei, Tao-Yuan, Taiwan, R.O.C.
    • ,
  • Chun-I Huang

      Affiliations

    • Department of Emergency Medicine, Taipei Veterans General Hospital, Tao-Yuan, Taiwan, R.O.C.
    • National Yang-Ming University School of Medicine, Taipei, Tao-Yuan, Taiwan, R.O.C.
    • ,
  • Wen-Ya Ma

      Affiliations

    • Division of Endocrinology and Metabolism, Department of Internal Medicine, Tao-Yuan Veterans Hospital, Tao-Yuan, Taiwan, R.O.C.
    • ,
  • Kang-Ling Wang

      Affiliations

    • Department of Medicine, Tao-Yuan Armed Forces General Hospital, Tao-Yuan, Taiwan, R.O.C.
    • ,
  • Hong-Da Lin

      Affiliations

    • Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Tao-Yuan, Taiwan, R.O.C.
    • National Yang-Ming University School of Medicine, Taipei, Tao-Yuan, Taiwan, R.O.C.
    • ,
  • Justin G.S. Won

      Affiliations

    • Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Tao-Yuan, Taiwan, R.O.C.
    • National Yang-Ming University School of Medicine, Taipei, Tao-Yuan, Taiwan, R.O.C.
    • Corresponding Author InformationCorrespondence to: Dr Justin G.S. Won, Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, R.O.C.

Received 8 June 2006; received in revised form 17 November 2006

Article Outline

Background

The differential diagnosis of adrenocorticotropin (ACTH)-dependent Cushing's syndrome (CS) remains a challenging issue for clinical endocrinologists. In this respect, bilateral inferior petrosal sinus sampling (BIPSS) appears to be the most sensitive and specific test. Here, we report our 15-year experience of analyzing the performance of BIPSS, both in the correct diagnosis and in the precise lateralization of tumors in patients with Cushing's disease (CD).

Methods

Between 1992 and 2006, 18 patients with CD (16 females, 2 males; age range, 14-56 years) were admitted to Taipei Veterans General Hospital and subjected to BIPSS plus ovine corticotropin-releasing hormone (oCRH) stimulation. Four of them had previously undergone transsphenoidal hypophysectomy (TSH) and had a recurrence thereafter. BIPSS was performed by inserting a catheter in the right and left inferior petrosal sinus for ACTH assay via a femoral vein puncture. An inferior petrosal sinus/peripheral ACTH ratio (C/P ratio) = 2 at baseline or = 3 after oCRH injection indicated a pituitary origin of ACTH secretion, and an interpetrosal ACTH gradient (IPS ratio) = 1.4 at baseline or after oCRH indicated evidence of lateralization.

Results

Positive BIPSS results were found in 16 patients at baseline and in 17 patients after oCRH injection. In 17 out of 18 patients, TSH was subsequently carried out and a pituitary source was confirmed on histopathologic examination. The only 1 false-negative test result was noted in a patient who had undergone previous TSH. Thus, the sensitivities of BIPSS for the diagnosis of CD before and after oCRH stimulation were 89% and 94%, respectively. Moreover, using an IPS ratio = 1.4 as a criterion, BIPSS correctly lateralized the tumor in 9 of 17 and 10 of 17 patients at baseline and after oCRH stimulation, respectively, including in 2 patients who had a centrally located tumor and who had an IPS ratio < 1.4. Thus, the sensitivities of lateralization of BIPSS were 53% and 59%, respectively. None of the 4 patients who had previous TSH were precisely localized by BIPSS. If these 4 patients were excluded, the sensitivities of BIPSS for localizing in the patients who had not undergone previous operation increased to 70% (9/13) at baseline and 77% (10/13) after oCRH stimulation, respectively.

Conclusion

BIPSS combined with oCRH stimulation is a safe and reliable examination both in the differential diagnosis of CD and in the correct lateralization of pituitary microadenoma in patients without previous pituitary surgery. Nevertheless, this procedure may provide misleading results in patients who have received previous pituitary surgery.

Key Words:  corticotropin-releasing hormone , Cushing's disease , inferior petrosal sinus sampling

No full text is available. To read the body of this article, please view the PDF online.

 

Back to Article Outline

References 

  1. Freda PU , Wardlaw SL . Diagnosis and treatment of pituitary tumors . J Clin Endocrinol Metab . 1999;84:3859–3866
  2. Newell-Price J , Trainer PJ , Besser M , Grossman A . The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's state . Endocr Rev . 1998;19:647–672
  3. Tabarin A, Greselle JF, San-Galli F, Leprat F, Caille JM, Latapie JL, et al  Usefulness of the corticotropin-releasing hormone test during bilateral inferior petrosal sinus sampling for the diagnosis of Cushing's disease . J Clin Endocrinol Metab . 1991;73:53–59
  4. Tyrrell JB , Brooks RM , Fitzgerald PA , Cofoid PB , Forsham PH , Wilson CB . Selective transsphenoidal resection of pituitary microadenomas . N Engl J Med . 1978;298:753–758
  5. Kaye TB , Crapo L . The Cushing's syndrome: an update on diagnostic tests . Ann Intern Med . 1990;112:434–444
  6. Oldfield EH, Chrousos GP, Schulte HM, Schaaf M, McKeever PE, Krudy AG, et al  Preoperative lateralization of ACTH-secreting pituitary microadenomas by bilateral and simultaneous inferior petrosal sinus sampling . N Engl J Med . 1985;312:100–103
  7. Giraldi FP , Moro M , Cavagnini F . Gender-related differences in the presentation and course of Cushing's disease . J Clin Endocrinol Metab . 2003;88:1554–1558
  8. Papanicolaou DA , Yanovski JA , Culter GB , Chrousos GP , Nieman LK . A single midnight serum cortisol measurement distinguishes Cushing's syndrome from pseudo-Cushing states . J Clin Endocrinol Metab . 1998;83:1163–1167
  9. Gorges R , Knappe G , Gerl H , Ventz M , Stahl F . Diagnosis of Cushing's syndrome: re-evaluation of midnight plasma cortisol vs. urinary free cortisol and low-dose dexamethasone suppression test in a large patient group . J Endocrinol Invest . 1999;22:241–249
  10. Lee TI, Lin SY, Won JG, Tang KT, Jap TS, Kwok CF, et al. A reappraisal of the ovine corticotropin-releasing hormone test in the differential diagnosis of Cushing's syndrome: a comparison with the standard high-dose dexamethasone suppression test . J Chin Med Assoc . 2002;65:474–482
  11. Findling JW , Raff H . Diagnosis and differential diagnosis of Cushing's syndrome . Endocrinol Metab Clin North Am . 2001;30:729–747
  12. Colombo N , Loli P , Vignati F , Scialfa G . MR of corticotropin-secreting pituitary microadenomas . Am J Neuroradiol . 1994;15:1591–1595
  13. de Herder WW, Uitterlinden P, Pieterman H, Tanghe HL, Kwekkeboom DJ, Pols HA, et al  Pituitary tumour localization in patients with Cushing's disease by magnetic resonance imaging: is there a place for petrosal sinus sampling? . Clin Endocrinol (Oxf) . 1994;40:87–92
  14. Hall WA , Luciano MG , Doppman JL , Patronas NJ , Oldfield EH . Pituitary magnetic resonance imaging in normal human volunteers: occult adenoma in the general population . Ann Intern Med . 1994;120:817–820
  15. Oldfield EH, Doppman JL, Nieman LK, Chrousos GP, Miller DL, Katz DA, et al  Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome . N Engl J Med . 1991;325:897–905
  16. Kaltsas GA, Giannulis MG, Newell-Price JD, Dacie JE, Thakkar C, Afshar F, et al  A critical analysis of the value of simultaneous inferior petrosal sinus sampling in Cushing's disease and the occult ectopic adrenocorticotropin syndrome . J Clin Endocrinol Metab . 1999;84:487–492
  17. Bonelli FS , Huston J , Carpenter PC , Erickson D , Young WFJ , Meyer FB . Adrenocorticotropic hormone-dependent Cushing's syndrome: sensitivity and specificity of inferior petrosal sinus sampling . Am J Neuroradiol . 2000;21:690–696
  18. Colao A , Faggiano A , Pivonello R , Giraldi FP , Cavagnini F , Lombardi G . Inferior petrosal sinus sampling in the differential diagnosis of Cushing's syndrome: results of an Italian multi-center study . Eur J Endocrinol . 2001;144:499–507
  19. Swearingen B, Katznelson L, Miller K, Grinspoon S, Waltman A, Dorer DJ, et al  Diagnostic errors after inferior pet-rosal sinus sampling . J Clin Endocrinol Metab . 2004;89:3752–3763
  20. Liu C, Lo JC, Dowd CF, Wilson CB, Kunwar S, Aron DC, et al. Cavernous and inferior petrosal sinus sampling in the evaluation of ACTH-dependent Cushing's syndrome . Clin Endocrinol . 2004;61:478–486
  21. Mampalam TJ , Wilson C . Transsphenoidal microsurgery for Cushing's disease: a report of 216 cases . Ann Intern Med . 1988;109:487–493
  22. Lefournier V, Martinie M, Vasdev A, Bessou P, Passagia JG, Labat-Moleur F, et al  Accuracy of bilateral inferior petrosal or cavernous sinuses sampling in predicting the lateralization of Cushing's disease pituitary microadenoma: influence of catheter position and anatomy of venous drainage . J Clin Endocrinol Metab . 2003;88:196–203
  23. Lopez J, Barcelo B, Lucas T, Salame F, Alameda C, Boronat M, et al  Petrosal sinus sampling for diagnosis of Cushing's disease: evidence of false negative results . Clin Endocrinol . 1996;45:146–156
  24. Vignati F , Berselli ME , Scialfa G , Boccardi E , Loli P . Bilateral and simultaneous venous sampling of inferior petrosal sinuses for ACTH and PRL determination: preoperative localization of ACTH-secreting microadenomas . J Endocrinol Invest . 1989;12:235–238
  25. Miller DL , Doppman JL , Peterman SB , Nieman LK , Oldfield EH , Chang R . Neurologic complications of petrosal sinus sampling . Radiology . 1992;185:527–528
  26. Wiggam MI, Heaney AP, McIlrath EM, McCance DR, Sheridan B, Hadden DR, et al. Bilateral inferior petrosal sinus sampling in the differential diagnosis of adrenocorticotropin-dependant Cushing's syndrome . J Clin Endocrinol Metab . 2000;85:1525–1532
  27. Invitti C , Giraldi FP , de Martin M , Cavagnini F . Diagnosis and management of Cushing's syndrome: results of an Italian mul-ticentre study . J Clin Endocrinol Metab . 1999;84:440–448

PII: S1726-4901(09)70293-X

doi:10.1016/S1726-4901(09)70293-X

Journal of the Chinese Medical Association
Volume 70, Issue 1 , Pages 4-10, January 2007

Article Tools