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Transsphenoidal Surgery for Cushing Disease After Nondiagnostic Inferior Petrosal Sinus Sampling

Sheth, Sameer A. MD, PhD*,‡; Mian, Matthew K. BSE*,‡; Neal, Jonathan BS*,‡; Tritos, Nicholas A. MD‡,§; Nachtigall, Lisa MD‡,§; Klibanski, Anne MD‡,§; Biller, Beverly M.K. MD‡,§; Swearingen, Brooke MD*,‡

doi: 10.1227/NEU.0b013e31824f8e2e
Research-Human-Clinical Studies: Editor's Choice
Editor's Choice
CNS University of Neurosurgery

BACKGROUND: Inferior petrosal sinus sampling (IPSS) is a useful technique for confirming a pituitary source of adrenocorticotropic hormone (ACTH) overproduction in Cushing disease. Uncertainty remains regarding the appropriate course of therapy when an ectopic tumor is predicted by IPSS but none can be found and in circumstances when the procedure cannot be successfully completed owing to technical or anatomic limitations.

OBJECTIVE: To determine an appropriate course of action after nondiagnostic IPSS.

METHODS: We reviewed 288 IPSS procedures in 283 patients between 1986 and 2010 at our center. An IPS:peripheral ACTH ratio ≥ 2 at baseline or ≥ 3 after corticotrophin-releasing hormone was considered predictive of a pituitary source of ACTH. A procedure was considered nondiagnostic if the procedure was successfully performed and the results predicted an ectopic source but none could be found despite extensive imaging or if the IPS could not be bilaterally cannulated because of technical difficulties or anatomic variants.

RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value of IPSS for detecting a pituitary source in Cushing disease were 94%, 50%, 98%, and 29%, respectively. We identified 3 categories of nondiagnostic IPSS comprising 44 of the total procedures. These patients underwent exploratory transsphenoidal surgery, and in 42 of these patients (95%), a pituitary source was surgically proven, with a remission rate of 83%.

CONCLUSION: Transsphenoidal surgery should be considered in cases of ACTH-dependent Cushing disease and noncentralized or technically unsuccessful IPSS without evidence of ectopic tumor.

ABBREVIATIONS: ACTH, adrenocorticotropic hormone

CD, Cushing disease

CRH, corticotrophin-releasing hormone

CS, Cushing syndrome

IPS:P, inferior petrosal sinus:peripheral

IPSS, inferior petrosal sinus sampling

TSS, transsphenoidal surgery

UFC, urine free cortisol

*Department of Neurosurgery and

§Department of Medicine, Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts

Harvard Medical School, Boston, Massachusetts

Correspondence: Sameer A. Sheth, MD, PhD, 55 Fruit St, White 502, Boston, MA 02114. E-mail:

Received July 4, 2011

Accepted January 11, 2012

Copyright © by the Congress of Neurological Surgeons