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Cost-effectiveness and accuracy of the tests used in the differential diagnosis of Cushing's syndrome.

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Abstract

Aim: Establish the minimal biochemical and radiological examinations necessary and their cost-effectiveness to accurately diagnose the etiology of Cushing's syndrome (CS).

Material and Methods: In 71 patients with CS followed between 1982 and 1997 biochemical studies (basal ACTH, 8mg dexamethasone suppression test -HDST-, metyrapone stimulation test -MST-, or inferior petrosal sinus catheterization sinus catheterization -IPSC-) and radiological investigations (abdominal CT scan, pituitary CT scan or MRI) were performed. Once pathology confirmed the diagnosis (48 pituitary Cushing's disease-CD, 17 adrenal neoplasms, 2 bilateral macronodular hyperplasia -BMH-, and 4 ectopic ACTH syndrome -ES-), the sensitivity, specificity, positive and negative predictive value of the different studies was calculated to establish the most accurate and cost-effective diagnostic protocol.

Results: In ACTH-independent CS (ACTH ≤ 9 pg/ml; normal 9 to 54) a unilateral tumor was identified on abdominal CT scanning in 17, and BMH in 1; the other BMH had detectable ACTH (43.2 pg/ml). In ACTH-dependent CS, ACTH was > 9 pg/ml and IPSC (performed in 22) correctly identified 20 patients with CD and differentiated them from 2 with an ES (100 % specificity and sensitivity). Pituitary MRI or CT did not disclose an adenoma in 41.7% of patients with CD, and was reported to exhibit a microadenoma in 2 of the 4 patients with ES. HDST and MST were of no additional use in the differentiation between CD and ES.

Conclusions: Once CS is diagnosed low ACTH and an abdominal CT scan correctly identified all patients of adrenal origin. In ACTH-dependent CS IPSC was the best predictive test to differentiate CD from ES. BMH may behave as ACTH-dependent or independent. The other biochemical and radiological studies performed are not cost-effective and may even be misleading, and should not be routinely performed.

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Authors and Affiliations

  1. Hospital de Sant Pau, Autonomous University of Barcelona, Spain

    Jaume Puig, Anna Wägner, Agueda Caballero & Susan Mary Webb

  2. Departments of Endocrinology and Nutrition and Biochemistry*, Hospital de Sant Pau, Autonomous University of Barcelona, Spain

    José Rodríguez-Espinosa*

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  1. Jaume Puig
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  2. Anna Wägner
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  3. Agueda Caballero
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  4. José Rodríguez-Espinosa*
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  5. Susan Mary Webb
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Puig, J., Wägner, A., Caballero, A. et al. Cost-effectiveness and accuracy of the tests used in the differential diagnosis of Cushing's syndrome.. Pituitary 1, 125–132 (1999). https://doi.org/10.1023/A:1009936622150

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