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Cushing?s Syndrome: Important Issues in Diagnosis and Management

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From http://jcem.endojournals.org/cgi/content/abstract/91/10/3746


Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2006-0997


The Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 10 3746-3753

Copyright ? 2006 by The Endocrine Society



Cushing?s Syndrome: Important Issues in Diagnosis and Management

James W. Findling and Hershel Raff


Endocrine-Diabetes Center (J.W.F.) and Endocrine Research Laboratory (H.R.), St. Luke?s Medical Center, Milwaukee, Wisconsin 53215; and Department of Medicine (J.W.F., H.R.), Medical College of Wisconsin, Milwaukee, Wisconsin 53226


Address all correspondence and requests for reprints to: Hershel Raff, Ph.D., Endocrinology, St. Luke?s Physician?s Office Building, 2801 West KK River Parkway, Suite 245, Milwaukee, Wisconsin 53215. E-mail: hraff@mcw.edu.


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 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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