Best Practice & Research Clinical Endocrinology & Metabolism 23 Suppl.

1 (2009) S5S14

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Best Practice & Research Clinical Endocrinology & Metabolism

journal homepage: www.elsevier.com/locate/beem

Diagnosis/differential diagnosis of Cushings syndrome: a review of best practice

John Newell-Price*
Academic Unit of Diabetes, Endocrinology & Metabolism, University of Shefeld Beech Hill Road, Shefeld S10 2RX, UK

Keywords: Cushings syndrome Cushings disease adrenocorticotrophic hormone (ACTH) pituitary

Endogenous Cushings syndrome is an uncommon endocrine disorder that can often prove challenging, for both initial diagnosis and subsequent differential diagnosis of the underlying cause. Understanding the advantages and pitfalls of the diagnostic methods used in Cushings syndrome is essential for accurate diagnosis and differential diagnosis, and guidelines outlining the most appropriate approaches have recently been published. We examine how current practice guidelines can be used in a real casebased scenario, and review the recommended strategies to achieve successful diagnosis and differential diagnosis. 2009 Elsevier Ltd. All rights reserved.

Introduction Endogenous Cushings syndrome is an uncommon endocrine disorder characterized by prolonged and inappropriately elevated levels of circulating cortisol, and is associated with insufciencies in the feedback mechanisms of the hypothalamopituitary-adrenal (HPA) axis and the circadian rhythm of cortisol secretion.1 Cushings syndrome can affect patients of any age, but is more prevalent in females than males.2 Exogenous sources of glucocorticoids (e.g. tablets, creams, inhalers or injections) are the most common cause of a Cushingoid phenotype. Endogenous Cushings syndrome is most commonly adrenocorticotrophic hormone (ACTH)-dependent (80% of cases), with ACTH secreted either by a pituitary adenoma (80% of ACTH-dependent cases) or by a non-pituitary source ectopic ACTH syndrome (20% of ACTH-dependent cases). The remaining 20% of cases are ACTH-independent, and are caused by autonomous secretion of cortisol from the adrenal gland(s); 60% of these cases are adenomas, 40% are carcinomas, and <2% are caused by the very rare conditions of massive adrenal hyperplasia, primary pigmented nodular adrenal disease (PPNAD), or McCune-Albright syndrome.3 Once Cushings syndrome is suspected, conrming hypercortisolism and establishing the source of oversecretion can prove challenging. An initial diagnosis of Cushings syndrome should be clearly established before any attempts are made at differential diagnosis, as inconclusive test results and factors such as patient characteristics, use of concomitant medication, and poor assay specicity can
* Correspondence: John Newell-Price, MA, PhD, FRCP. Academic Unit of Diabetes, Endocrinology & Metabolism, University of Shefeld, Beech Hill Road, Shefeld S10 2RX, UK. Tel.: +44 (0) 114 2261409; fax: +44 (0) 114 2711863. E-mail address: j.newellprice@shefeld.ac.uk (J. Newell-Price). 1521-690X/$ see front matter 2009 Elsevier Ltd. All rights reserved..

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hinder diagnosis and the need for subsequent patient care. In this review, we examine a case-based diagnostic dilemma encountered in clinical practice, and provide an overview of current practice strategies for the accurate diagnosis and differential diagnosis of Cushings syndrome/disease. Case study: diagnostic complexity in Cushings syndrome A 57-year-old man was referred to our neuroendocrine clinic. He had a history of iron-deciency anaemia. Endoscopy had shown an irregular gastric mucosa, and biopsy revealed a gastric carcinoid. A computed tomography (CT) scan had shown abnormalities in the body and fundus of the stomach, but a normal pancreas and liver. He had elevated corrected levels of serum calcium (2.9 mmol/L) and parathyroid hormone (PTH) (31.1 pmol/L), consistent with primary hyperparathyroidism. He also had a history of chronic renal impairment, hypertension, and controlled type II diabetes, and drank 23 large glasses of wine per night, with even more at weekends. He appeared generally well, but with some truncal obesity, thin arms, and mild bruising. Medications being taken at the time included lansoprazole, bendroumethazide, atenolol, aspirin, ferrous sulphate, and simvastatin. Initial investigations in the clinic again showed elevated calcium and PTH values of 2.97 mmol/L and 330 ng/L, respectively. Impaired renal function was reected by an elevated serum creatinine of 165 mmol/L (eGF 40 mL/min/1.73 m2 ). Considering his physical appearance, a 48-h 2 mg/day lowdose dexamethasone suppression test (LDDST) was performed and showed no suppression, with basal serum cortisol levels of 505 nmol/L (2+0 h) and 566 nmol/L post dexamethasone (2+48 h). The ACTH concentration was 42.1 ng/L (normal range <55 ng/L). Based on these results, conrmation of Cushings syndrome was still questionable, considering the patients history of excessive alcohol intake and renal impairment. Repeat LDDST testing after no alcohol intake for approximately 4 weeks yielded lower cortisol levels at 2+0 h (394 nmol/L) and 2+48 h (176 nmol/L), indicating some suppression, but not below 50 nmol/L. A series of urinary free cortisol (UFC) tests were done as a secondary measure to conrm Cushings syndrome. Initial UFC measurements were just above the normal range at 263 and 271 nmol/24 h. Repeat UFC measurements showed levels that were still elevated at 276 and 295 nmol/24 h. As the patient had no suppression on several LDDST evaluations and consistently elevated UFC, despite signicant renal impairment, a diagnosis of ACTH-dependent Cushings syndrome was conrmed, although mild in clinical phenotype. In association with Cushings syndrome, diagnoses of primary hyperparathyroidism and a gastric carcinoid were also established, raising the likelihood of multiple endocrine neoplasia type 1 (MEN1). In view of the diagnosis of a gastric carcinoid, gut peptides were investigated as part of the initial step towards establishing the source of excessive cortisol secretion (i.e. pituitary or ectopic). Levels of gastrin, pancreatic polypeptide, glucagon, and chromogranin A were all elevated (>400, >500, 104, and 452 pmol/L, respectively). Repeat gut peptide results remained highly elevated despite cessation of protein-pump inhibitor (PPI) medication. Bone mineral density (BMD) imaging revealed an extremely low T score of 5.8 for the spine; T score values for the hip (3.0) and forearm (2.9) were consistent with the changes seen in cortisol excess and hyperparathyroidism. Magnetic resonance imaging (MRI) of the pituitary gland revealed a possible small abnormality (Fig. 1). The patient then had a standard corticotrophin-releasing hormone (CRH) test of up to 60 min with no signicant changes observed in ACTH (36.434.8 ng/L) or serum cortisol (704744 nmol/L). Bilateral inferior petrosal sinus sampling (BIPSS) showed no gradient between the peripheral and left and right inferior petrosal sinus, or after stimulation with 100 mg human sequence CRH at 0 min, suggesting a non-pituitary source of ACTH hypersecretion (Table 1). In investigations for an ectopic source of the ACTH, CT imaging showed no abnormality in the thorax, although the hyperplastic parathyroid glands were clearly visible. CT imaging of the abdomen showed profound gastric rugae consistent with hypergastrinaemia (Fig. 2), along with ve or more pancreatic neuroendocrine tumours, and hyperplasia of the left and right adrenal glands (Fig. 3). An octreotide scan demonstrated uptake in various neuroendocrine tumours in the pancreas, with a small metastasis in the fundus of the stomach further complicating conrmation of a pituitary or ectopic source of hypersecretion.

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Fig. 1. Pituitary MRI showing a small abnormality consistent with a potential pituitary source of excessive cortisol production.

Table 1 Bilateral inferior petrosal sinus sampling test for the case study patient Time (min) ACTH (ng/L) Peripheral 0 5 10 15 39.4 53.2 50.0 52.5 Left inferior petrosal 39.5 61.9 75.2 61.1 Right inferior petrosal 39.2 53.3 61.4 60.4

ACTH, adrenocorticotrophic hormone.

Fig. 2. CT scan of the stomach showing excessive gastric rugae.

The nal diagnosis conrmed that the patient had ACTH-dependent Cushings syndrome with gastric carcinoid, multiple pancreatic neuroendocrine tumours, primary hyperparathyroidism, severe osteoporosis, gastrinoma with Zollinger-Ellison syndrome (controlled on PPI), and MEN1 conrmed by genetic testing. The patients corrected serum calcium increased to 3.34 mmol/L, requiring

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Fig. 3. Abdominal CT showing ve pancreatic neuroendocrine tumours and hyperplasia of both the left and right adrenal glands.

urgent intervention, and he underwent 3.5-gland parathyroidectomy with cervical exploration and autotransplant to the right sternocleidomastoid, which lowered serum calcium levels to 2.38 nmol/L. Histology also revealed parathyroid hyperplasia. In view of the patients severe osteoporosis, hypertension, and diabetes mellitus, urgent attention was also needed for his ACTH-dependent Cushings syndrome. Considering his diagnosis of MEN1, the source of ACTH could either be from the pituitary or any of the neuroendocrine tumours in his pancreas. Based on inconclusive biochemical data, combined with a lack of a central to peripheral gradient on BIPSS and the patients reluctance to consider a total pancreatectomy, he underwent a bilateral adrenalectomy, leading to improved truncal obesity, considerable weight loss, and a fasting glucose of 4.4 mmol/L. The patients osteoporosis was managed with calcium, vitamin D supplements, and weekly bisphosphonate, resulting in an improvement in his BMD. Causes of Cushings syndrome Once exogenous glucocorticoid use has been excluded, the majority of cases of Cushings syndrome are caused by ACTH-dependent tumours, and ~7080% of these are due to pituitary adenomas (Cushings disease), with the remainder attributable to ectopic ACTH sources, which may be occult and difcult to nd.3 Ectopic sources of ACTH are most frequently small-cell lung carcinomas (SCLC) and bronchial carcinoid tumours, but can also arise from many other organs in the body.46 When the ACTH source develops from SCLC, the presentation may be rapid, with weight loss, weakness, and pigmentation, rather than the classic Cushingoid phenotype. However, when a carcinoid tumour is the source of ACTH, the phenotype and biochemistry can exactly mimic that of Cushings disease. ACTH-independent Cushings syndrome generally arises from an adrenal adenoma or carcinoma, which consequently suppresses pituitary ACTH,7,8 although in very rare cases (12%), it can be caused by other sources, e.g. PPNAD, the Carney complex, ACTH-independent macronodular adrenal hyperplasia (AIMAH), or McCune-Albright syndrome.3 Cushings syndrome: strategies for diagnosis The biochemical hallmark of Cushings syndrome is inappropriate cortisol secretion not subject to the normal negative feedback effects of circulating glucocorticoids. Diagnostic tests are based on demonstration of excessive cortisol secretion, loss of its circadian rhythm, and abnormal feedback regulation of the HPA axis. Patients with Cushings syndrome generally demonstrate resistance to negative feedback during testing. In Cushings disease, adenomas hypersecreting ACTH retain some negative feedback, whereas ectopic neoplasms are generally unresponsive.

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Exclude exogenous glucocorticoid Perform one of the following tests

24-h UFC (2 levels)

Overnight 1-mg DST

Late night salivary cortisol (2 tests)

Consider caveats for each test Use 48-h, 2-mg DST in certain populations

ANY ABNORMAL RESULT

Normal (CS unlikely)

Exclude physiological causes of hypercortisolism

Consult endocrinologist Perform 1 or 2 other studies shown above Suggest reconsidering or repealing the abnormal study Suggest Dex-CRH or midnight serum cortisol in certain populations

Discrepant ABNORMAL (suggest additional evaluation) Cushings syndrome

Normal (CS unlikely)

Fig. 4. Recommended steps in diagnosing suspected Cushings syndrome. Reproduced from Nieman et al. (2008).9

Before biochemical testing to conrm Cushings syndrome, a complete drug history should be taken to rule out exogenous glucocorticoid use (oral, rectal, inhaled, topical, or injected).9 Exogenous glucocorticoids can produce clinical features similar to those of Cushings syndrome, confounding test results and delaying appropriate patient care. The rst-line screening methods recommended to conrm suspected Cushings syndrome are UFC ( 2 measurements), late-night salivary cortisol (2 measurements), and a 1 mg overnight dexamethasone suppression test (DST) (Fig. 4).9 Care should be taken with each diagnostic test to ensure the testing parameters are specic to patient characteristics. In instances where the results appear abnormal (suggesting Cushings syndrome) or inconclusive, testing should be repeated for accuracy. Alternatively, use of the dexamethasone-CRH or midnight serum cortisol tests may be more appropriate, depending on patient characteristics. Urinary free cortisol In normal conditions, ~1% of unbound cortisol is excreted in the urine. However, in Cushings syndrome, excessive amounts of cortisol saturate circulating cortisol-binding globulin (CBG), resulting in detectable increases of >4 times the upper limit of normal of free ltered cortisol in the urine.10 UFC testing is performed over a 24-h collection period, and it is important to use the upper limit of the assay to dene a positive Cushings syndrome result. Creatinine levels and urine volume should also be checked to assess collection adequacy. False-positive results can occur if high amounts of urine (>5 L) are passed in a 24-h period,9 and can also arise from drugs that inhibit 11-b-hydroxysteroid dehydrogenase or synthetic glucocorticoid use, either of which can lead to immunoassay cross-

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J. Newell-Price / Best Practice & Research Clinical Endocrinology & Metabolism 23 (2009) S5S14 Table 2 Dexamethasone suppression tests for initial Cushings syndrome diagnosis Test 1 mg overnight Classical 2 mg/day LDDST Dexamethasone dose 1 mg at 23.00 h 0.5 mg 6-hourly for 48 h Serum cortisol 09.00 h 2+0 09.00 h 2+48 09.00 h

reactivity. To avoid missing mild disease, at least two to three 24-h urine collections should be done. Special attention should also be given to patients with renal impairment, as a glomerular ltration rate (GFR) <60 mL/min may reduce UFC. Late-night salivary cortisol The late-night salivary cortisol test is a simple and reliable screening method for Cushings syndrome, with the patient only needing to provide a saliva sample in a tube for testing. The late-night salivary cortisol test is stable at room temperature and has a cut-off of 4 nmol/L in best-validated enzyme immunoassays and tandem mass spectrometry. However, there must be no blood contamination in the salivary sample, as this can lead to false-positive results. Patients with stress and those who work during the night incur changes in their circadian rhythm, which can also produce false-positive results. Despite the reliability and sensitivity of the late-night salivary cortisol assay, it is limited by low specicity, particularly in relation to age and comorbidities. Patients with increased age or with comorbidities such as hypertension and diabetes had a higher incidence of false-positive results when assay cut-off levels were set between 410 nmol/L, making it difcult to identify those with a true disease phenotype.11 Dexamethasone suppression test The DST assay is designed to demonstrate impaired feedback regulation of the HPA axis (i.e. no suppressive response), which is a hallmark of Cushings syndrome. DST tests at the 1 mg or 2 mg dexamethasone dose are available (Table 2), with the 2 mg test being more cumbersome, but suitable for outpatient use with adequate instruction. The standard cortisol cut-off for an abnormal result is generally set at 50 nmol/L (1.8 mg/dL). However, ~5% of patients with Cushings disease will suppress to <50 nmol/L. Thus if the clinical index of suspicion is high, to avoid missing patients with mild disease, it is recommended that the test is repeated or that other tests are used. Concomitant medications should also be considered when using the DST. Medications such as phenytoin, phenobarbitone, carbamazepine, and rifampicin can increase the metabolism of dexamethasone by induction of CYP450 3A4, resulting in a false positive.9 In contrast, medications such as aprepitant/fosaprepitant, itraconazole, ritonavir, uoxetine, diltiazem, and cimetidine can impair dexamethasone metabolism and produce false-negative results.9 Medications associated with increases in CBG, such as oral oestrogen and mitotane, can also lead to false elevations in cortisol levels, and should be stopped for a period of 46 weeks prior to testing.12 Recommendations for diagnosis in special populations and conditions Establishing active disease in certain patient populations can prove challenging, as test results can be altered based on individual patient characteristics. Use of the DST is not recommended in pregnant patients, since the elevated CBG may cause lack of suppression of serum cortisol, leading to falsepositive results.13 It is also advised to avoid the DST in patients on anti-epileptic drugs, as these can enhance dexamethasone clearance.9 The midnight serum cortisol test would thus be a better alternative in this latter patient group.14 UFC testing should be avoided in patients with impaired renal function, because diminished GFR may cause a false-negative response.15 Patients with suspected cyclic disease should be tested with

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Measure Plasma ACTH <5 pg/ml on more than two occasions ACTH-independent Cushings >15 pg/ml

ACTH-dependent Cushings Pituitary MRI and CRH test: Small/no adenoma inconclusive BIPS No ACTH gradient CT/MRI thorax and abdomen +/ Somatostatin scintigraphy Ectopic ACTH ?Ectopic

Adrenal imaging

Adrenal lesion

No adrenal lesion

Adenoma > 6 mm AND Positive CRH response AND Suppression on dexamethasone +ve ACTH

Adenoma Carcinoma AIMAH

PPNAD Reconsider exogenous glucocorticoid

Cushings disease

90%

10%

Fig. 5. Recommended steps in the differential diagnosis of conrmed Cushings syndrome. Reproduced from Newell-Price & Grossman (2007).7

UFC or the late-night salivary cortisol test and not DST, as DST results could appear normal when the patients hypercortisolism is at a low level.9 Second-line diagnostics The dexamethasone-CRH suppression test has been reported to be valuable in differentiating patients with mild non-autonomous hypercortisolaemia (depression, obesity, etc.) from those with classic Cushings syndrome, but data are conicting, with recent series suggesting little advantage over conventional DST.16 Caution should be exercised when using the dexamethasone-CRH suppression test, because of the low precision of serum cortisol assays at the recommended cut-off of 38 nmol/L. The serum midnight cortisol test has high sensitivity for the identication of disease, but lacks specicity if applied uncritically. It may be very useful for ruling out Cushings syndrome in cases of doubt, as a midnight serum cortisol of <50 nmol/L (1.8 mg/dL) effectively excludes Cushings syndrome at the time of testing. Differential diagnosis Attempts should only be made to determine the source of cortisol excess once the diagnosis of Cushings syndrome is rmly established. The rst step is to measure plasma ACTH (Fig. 5).3 If ACTH levels are <5 pg/mL on several occasions, the patient is likely to have ACTH-independent disease. Conversely, if ACTH levels are persistently >15 pg/mL, the source is likely to be ACTH-dependent. ACTH-independent Cushings syndrome In cases where ACTH-independent Cushings syndrome is conrmed, adrenal imaging with CT is used to establish the existence of an adrenal lesion. If an adrenal lesion is identied, the patient is likely to have an adrenal adenoma, a carcinoma, or much less commonly, AIMAH as the aetiology of Cushings syndrome. If no adrenal lesion is detected after CT, the patient could have PPNAD, a rare form of adrenal

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Cushings syndrome that may not be visible on CT. Alternatively, it may be necessary to reconsider the possibility that the patient is taking exogenous hydrocortisone.

ACTH-dependent Cushings syndrome In contrast, when ACTH-dependent Cushings syndrome has been conrmed, establishing the source of ACTH hypersecretion (i.e. pituitary or ectopic) can be more difcult. In women in particular, there is a 9:1 ratio of Cushings disease to ectopic tumours as the source of ACTH, thus any diagnostic test must improve upon this pre-test probability, and great care is needed in the differential diagnosis.7 Pituitary imaging combined with CRH testing is generally recommended as the most appropriate initial step in the differential diagnosis of ACTH-dependent Cushings syndrome. In general, if pituitary imaging uncovers an adenoma of >6 mm, and these ndings are combined with positive CRH response and dexamethasone suppression, it can be concluded that the patient has a pituitary source of ACTH excess (i.e. Cushings disease). It is important to note, however, that negative CRH and DST tests both have poor negative predictive value in excluding Cushings disease. Imaging and biochemical results are often inconclusive and differential diagnosis can then be more challenging. In some cases, pituitary MRI may show a very small adenoma, but this is not conclusive evidence of a pituitary source of ACTH. Further evaluation with BIPSS can be used to differentiate between a pituitary and an ectopic source of ACTH hypersecretion, and is generally recommended in most patients with ACTH-dependent disease unless there is a clear tumour on MRI and the other tests are highly suggestive of Cushings disease. Great care must be taken in catheter placement, and venography is needed to conrm position in the petrosal sinuses. This technique should only be performed when Cushings syndrome is present, as cyclical disease can lead to both false-negative and false-positive results. Up to 40% of patients with conrmed Cushings disease will have a normal pituitary MRI scan, hence BIPSS can also prove advantageous under these conditions.17 A positive central-to-peripheral gradient of ACTH on BIPSS is a strong indicator of Cushings disease. However, if no ACTH gradient is detected, further evaluation of the thorax and abdomen by CT or MRI, and possibly somatostatin scintigraphy, is recommended to test for an ectopic source, since up to 5% of patients with Cushings disease will have a falsely negative gradient.7

Identifying sources of ectopic ACTH Three recent studies have evaluated the reliability of commonly used biochemical and imaging methods in the differential diagnosis of ectopic disease, and each represents the largest collection of data on the ectopic ACTH syndrome from Europe, USA and South America, respectively.46 In these studies, patients with ectopic disease did not always demonstrate evidence of ACTH elevation, complicating the distinction between ectopic and pituitary sources of disease.46 High levels of cortisol overwhelm 11-b-hydroxysteroid dehydrogenase II, allowing cortisol to act as a mineralocorticoid.18 Thus, the severity of hypercortisolaemia will determine whether hypokalaemia develops. It is seen in nearly all ectopic ACTH secretion due to a SCLC, but is also present in up to 70% of patients with a carcinoid tumour as an ACTH source. In addition, 10% of patients with Cushings disease have hypokalaemia. High-dose dexamethasone testing alone is a poor diagnostic tool, since 75% of patients with ectopic ACTH-dependent syndrome fail to suppress cortisol to <50% of baseline, but 20% of patients with Cushings disease also present with similar results, diminishing the diagnostic utility of this assay.46 Therefore, high-dose dexamethasone testing is recommended only in cases where BIPSS testing is not available. Patients with ectopic ACTH-dependent syndrome generally have no response on CRH testing. Two of the three studies showed CRH to be reliable in most cases, identifying 90% and 94% of patients with known ectopic disease,5,6 but the test failed to identify patients in one of the studies.4 Desmopressin testing proved highly unreliable,4 probably because the V3 receptor, which is stimulated by desmopressin, is expressed both in the pituitary and in a range of ectopic ACTH-secreting tumours.19,20

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BIPSS proved the most reliable biochemical assay for distinguishing between pituitary and ectopic sources of ACTH hypersecretion in all three studies, with a negative ACTH gradient response seen in 84100% of patients.46 Tumour markers such as gastrin, calcitonin, 5-hydroxyindoleacetic acid and carcinoembryonic antigen were also suggested as useful indications of ectopic disease in all three studies. The three studies also highlighted the limitations of available imaging options. While axial CT and MRI imaging were reliable for identifying an ectopic source, the source of ACTH could be identied only in 7090% of cases.46 Thus, these studies reported patients seen over several decades and with advances in axial imaging, the number of patients with an identiable source of ectopic ACTH secretion is likely to increase. There is also a real risk of false-positive ndings on pituitary MRI in patients with ectopic disease. In one study, pituitary MRI imaging identied subtle abnormalities in 17 of 65 cases in patients with proven ectopic disease, leaving uncertainty as to whether these patients had some level of pituitary dysfunction.5 Octreotide scanning, although widely used, identied only 2560% of ectopic ACTH tumours, and is unlikely to locate an occult source of ectopic ACTH that has not already been identied by axial imaging.46 Conclusions Accurately diagnosing and identifying a source of ACTH hypersecretion in Cushings syndrome patients can prove a difcult task, particularly if not approached methodically. Our case illustrates some of the potential pitfalls in diagnosis and differential diagnosis of Cushings syndrome. Available diagnostic methods for initial and differential diagnosis of Cushings syndrome can be effective, but understanding the limitations of the assays will increase the chances of an accurate initial diagnosis. The pre-test likelihood of Cushings syndrome should be considered prior to biochemical assessment, especially in female patients, who are more likely than men to present with Cushings disease. To prevent misdiagnosis, it is essential to select an appropriate assay based on the individual characteristics of the patient. Steps towards differential diagnosis should never be performed until initial diagnosis is condently conrmed. Currently, BIPSS remains the best discriminator of pituitary and ectopic disease but, as demonstrated in the case, it may not always be possible to be sure of the source of ACTH and denitive management by adrenalectomy may be needed. The recommendations put forth by the Endocrine Society9 are useful in avoiding common pitfalls of diagnosis. Acknowledgements The author wishes to thank the NEON programme (a CME programme supported by an unrestricted educational grant from Novartis Pharma) for funding the NEON Endocrinology meeting, on which this review is based. The author would also like to acknowledge CME Scholar Europe for preparation of this manuscript, which was then reviewed and amended by the author. CME Scholar Europe is a provider of accredited CME programmes whose contribution to this manuscript was also funded by Novartis Pharma. Conict of interest statement JNP: None declared. References
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