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Simultaneous pituitary and adrenal adenomas in a patient with non ACTH dependent Cushing syndrome; a case report with literature review. Int J Surg Case Rep 2022; 94:107038. [PMID: 35413671 PMCID: PMC9018131 DOI: 10.1016/j.ijscr.2022.107038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Cushing syndrome is a rare disorder with a variety of underlying etiologies, that can be exogenous or endogenous (adrenocorticotropic hormone (ACTH)-dependent or ACTH-independent). The current study aims to report a case of ACTH-independent Cushing syndrome with adrenal adenoma and nonfunctioning pituitary adenoma. Case report A 37–year–old female presented with amenorrhea for the last year, associated with weight gain. She had a moon face, buffalo hump, and central obesity. A 24-hour urine collection for cortisol was performed, revealed elevated cortisol. Cortisol level was non-suppressed after administering dexamethasone. MRI of the pituitary region revealed a pituitary microadenoma, and the CT scan of the abdomen with adrenal protocol revealed a left adrenal adenoma. Discussion Early diagnosis may be postponed due to the variety of clinical presentations and the referral of the patient to different subspecialists based on their dominant symptoms (gynecological, dermatological, cardiovascular, psychiatric); it is, therefore, critical to consider the entire clinical presentation for correct diagnosis. Conclusion Due to the diversity in the presentation of CS, an accurate clinical, physical and endocrine examination is always recommended. Cushing syndrome (CS) is a rare disorder with a variety of underlying etiologies. CS is expected to affect 0.2 to 5 people per million per year. Adrenal-dependent CS is an uncommon variant of CS. This study reports a rare occurrence of pituitary and adrenal adenoma with CS.
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Abstract
Due to the variable clinical features and its rarity diagnosis of Cushing's disease (CD) is often delayed. Clearly, awareness for CD needs to be raised, accompanied by the availability of simple and accurate screening tests. Late-night salivary cortisol (LNSC), 1 mg dexamethasone suppression test (DST), and urinary free cortisol (UFC) have all been extensively studied, demonstrating high sensitivity and specificity for the diagnosis of Cushing's syndrome. However, each of those well-established tests has its own distinctive features, making it preferable in specific clinical conditions and patient groups. To choose the most appropriate test in individual patients, an expert endocrinologist should be consulted. This review will discuss the pitfalls for each of those tests.
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Ceccato F, Marcelli G, Martino M, Concettoni C, Brugia M, Trementino L, Michetti G, Arnaldi G. The diagnostic accuracy of increased late night salivary cortisol for Cushing's syndrome: a real-life prospective study. J Endocrinol Invest 2019; 42:327-335. [PMID: 29987756 DOI: 10.1007/s40618-018-0921-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 06/26/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND AIM A prompt diagnosis of Cushing's Syndrome (CS) in high-risk populations is mandatory: 1-mg dexamethasone suppression test (1-mg DST), late night salivary cortisol (LNSC), and urinary-free cortisol (UFC) are recommended, despite thresholds calculated in retrospective studies. Our aim was to study the diagnostic accuracy of LNSC measured with chemiluminescence assay in a prospective study, confirming discrepancies with mass spectrometry (MS). MATERIALS AND METHODS We enrolled 117 controls and 164 suspected CS (CS = 47, non-CS = 117). In case of increased LNSC, high clinical suspicion of CS or adrenal incidentaloma, patients were hospitalized to exclude/confirm CS. RESULTS LNSC levels were higher in patients with suspected CS, CS, and non-CS than controls. Considering 16 nmol/L as threshold for CS, overall LNSC revealed SE 97% and SP 84% in the whole group of subjects considered, achieving positive/negative likelihood ratio of 5.56/0.045, respectively. 35 out of 81 subjects with increased LNSC were non-CS (15 diabetic and 20 obese): considering only those patients with increased likelihood to have a CS (the non-CS patients) SP decreased to 70%, and further reduced to 60% if we discharged subjects with adrenal incidentaloma. MS analyses reduced partially the number of false-positive LNSC. CONCLUSIONS LNSC measured in automated chemiluminescence is reliable in clinical practice: it present a high diagnostic accuracy to exclude hypercortisolism in patients with normal cortisol levels. MS could be used to reduce the number of false-positive results; nevertheless, some non-CS subjects with functional hypercortisolism could have a mild impairment of cortisol rhythm.
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Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, PD, Italy.
| | - G Marcelli
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Via Tronto 10B, 60020, Torrette, AN, Italy
| | - M Martino
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Via Tronto 10B, 60020, Torrette, AN, Italy
| | - C Concettoni
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Via Tronto 10B, 60020, Torrette, AN, Italy
| | - M Brugia
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Via Tronto 10B, 60020, Torrette, AN, Italy
| | - L Trementino
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Via Tronto 10B, 60020, Torrette, AN, Italy
| | - G Michetti
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Via Tronto 10B, 60020, Torrette, AN, Italy
| | - G Arnaldi
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Via Tronto 10B, 60020, Torrette, AN, Italy
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Lin DC, Tsai PS, Lin YC. Midnight salivary cortisol for the diagnosis of Cushing's syndrome in a Chinese population. Singapore Med J 2018; 60:359-363. [PMID: 30488082 DOI: 10.11622/smedj.2018154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cushing's syndrome is defined as chronic excess free cortisol in circulation. According to recent studies, midnight salivary cortisol is an accurate and non-stress method for screening and diagnosing Cushing's syndrome. However, there is limited data on midnight salivary cortisol for diagnosing Cushing's syndrome in the Chinese population. METHODS Among 61 suspected Chinese patients, 48 patients were confirmed to have Cushing's syndrome. We evaluated the midnight salivary cortisol, midnight serum cortisol and 24-hour urine free cortisol excretion for diagnosis. Midnight salivary cortisol was collected from 21 healthy volunteers for control purposes. RESULTS In the patient group, mean urine free cortisol excretion and midnight salivary cortisol levels were 296.50 ± 47.99 µg/day and 10.18 ± 1.29 ng/mL, respectively. Among the control group and normal participants, mean midnight salivary cortisol level was 0.53 ± 0.13 ng/mL and 0.50 ± 0.12 ng/mL, respectively. The cut-off value for midnight salivary cortisol was 1.7 ng/mL for diagnosing Cushing's syndrome, with a sensitivity of 98% and specificity of 100%. The diagnostic performance of midnight salivary cortisol (area under the curve [AUC] = 0.99) was superior to that of urine free cortisol (AUC = 0.89). CONCLUSION Our study confirmed the good diagnostic performance of midnight salivary cortisol for diagnosing Cushing's syndrome in a Chinese population. Correlation between midnight salivary cortisol and either urine free cortisol or midnight serum cortisol was good. Midnight salivary cortisol is a convenient and precise tool for diagnosing Cushing's syndrome and can be the screening test of choice for Chinese populations.
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Affiliation(s)
- Dao-Chen Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Shan Tsai
- Department of Radiology, Mackay Memorial Hospital, Taipei, Taiwan.,Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, Taipei, Taiwan
| | - Yi-Chun Lin
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
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Cardoso EMDL, Arregger AL, Budd D, Zucchini AE, Contreras LN. Dynamics of salivary cortisol in chronic kidney disease patients at stages 1 through 4. Clin Endocrinol (Oxf) 2016; 85:313-9. [PMID: 26800302 DOI: 10.1111/cen.13023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/10/2016] [Accepted: 01/13/2016] [Indexed: 12/30/2022]
Abstract
CONTEXT End-stage renal disease has been associated with derangement of the HPA function. The dynamics of this axis in early stages of renal disease (CKD) has not been assessed. OBJECTIVES To evaluate in patients with CKD at stages 1-4 (KDOQI): the diurnal variation of salivary cortisol; the suppressibility of cortisol in saliva and serum after an overnight oral 1 mg dexamethasone suppression test (1 mg DST) with simultaneous measurement of circulating dexamethasone. DESIGN AND METHODS 80 CKD outpatients and 40 healthy subjects were included. All CKD collected whole saliva at 08·00 and 23·00 h (SAF23 ) on two nonconsecutive days. Thereafter at 08·00 h, following 1 mg DST, saliva and blood were obtained. Salivary and serum cortisol as well as CBG were assessed by RIA, dexamethasone by ELISA and serum free cortisol was calculated. RESULTS SAF23 correlated negatively with glomerular filtration rate (GFR). The fraction of free cortisol in serum and saliva after 1 mg DST, correlated positively and significantly in both patients with CKD and healthy subjects (r: 0·86 and r: 0·85, respectively; P < 0·0001 for both). Ten percent of CKD with GFR < 90 ml/min/1·73 m(2) had false positive results unrelated to dexamethasone and CBG concentrations. CONCLUSIONS False positive responses to 1 mg DST were associated with GFR < 90 ml/min/1·73 m(2) . This could not be ascribed to either defects in dexamethasone absorption or CBG concentrations. Higher dexamethasone doses were necessary to achieve adequate HPA suppression. Salivary cortisol was useful to assess circadian cortisol levels and feed-back regulation in CKD.
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Affiliation(s)
- Estela María Del Luján Cardoso
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
- Unidad Ejecutora Instituto de Investigaciones Médicas, National Council of Technical and Scientific Research, Buenos Aires, Argentina
- Laboratory of Salivary Glands, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina
| | - Alejandro Luis Arregger
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Dianne Budd
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Alfredo Enrique Zucchini
- Chief Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Liliana Noemí Contreras
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
- Unidad Ejecutora Instituto de Investigaciones Médicas, National Council of Technical and Scientific Research, Buenos Aires, Argentina
- Laboratory of Salivary Glands, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina
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D’Aurizio F, Tozzoli R, Dorizzi RM, Brescia V, Esposito E, Fortunato A, Giovanella L, Guzzaloni G. La diagnostica di laboratorio delle malattie del surrene. Raccomandazioni pratiche per la sindrome di Cushing. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13631-015-0088-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Danet-Lamasou M, Asselineau J, Perez P, Vivot A, Nunes ML, Loiseau H, San-Galli F, Cherifi-Gatta B, Corcuff JB, Tabarin A. Accuracy of repeated measurements of late-night salivary cortisol to screen for early-stage recurrence of Cushing's disease following pituitary surgery. Clin Endocrinol (Oxf) 2015; 82:260-6. [PMID: 24975391 DOI: 10.1111/cen.12534] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/23/2014] [Accepted: 06/18/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The performance of late-night salivary cortisol (LNSC) to accurately screen for postoperative recurrence of Cushing's disease (CD) at an early stage is unknown. The aim of this study was to compare the accuracy of multiple sampling strategies to suggest the optimal number of LNSC samples needed for diagnosing post-surgical recurrences of CD at an early stage. DESIGN Retrospective analysis in a single centre. PATIENTS AND MEASUREMENTS Thirty-six patients in surgical remission of CD had successive measurements of LNSC, defined as 'sequences', using a locally modified RIA assay as part of long-term follow-up (69·2 ± 10·6 months). Patients underwent an extensive biochemical evaluation within 3 months before or after a sequence of saliva sampling and were classified as being in remission or in early-stage recurrence. The accuracy of three diagnostic strategies combining two, three or four LNSC results from a sequence was estimated using areas under the ROC curves (AUC), sensitivity, specificity and predictive values. RESULTS Forty-four sequences of LNSC measurements were available. Fifty-two percent of sequences were performed during early-stage recurrence. The intrasequence variability of LNSC was higher during recurrence than during remission (medians of SDs: 2·1 vs 0·5 nm; P < 0·0001). AUCs from ROC curves ranged from 0·93 to 0·96 depending on the strategy. For 90% sensitivities, the best specificities (92·9% and 90·9%) were achieved by strategies taking into account three or four measurements summarized either by their mean or their maximum value. CONCLUSIONS Increase in LNSC concentration is an early abnormality during post-surgical recurrence of CD. However, due to a major within-patient variability of LNSC from 1 day to another, a screening strategy using three or four samples collected on successive days may be recommended to detect early-stage recurrence of CD with a high accuracy.
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Affiliation(s)
- Marie Danet-Lamasou
- Departement d'Endocrinologie et Maladies Metaboliques, CHU de Bordeaux, Hopital du Haut Leveque, Pessac, France
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Elias PCL, Martinez EZ, Barone BFC, Mermejo LM, Castro M, Moreira AC. Late-night salivary cortisol has a better performance than urinary free cortisol in the diagnosis of Cushing's syndrome. J Clin Endocrinol Metab 2014; 99:2045-51. [PMID: 24628557 DOI: 10.1210/jc.2013-4262] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The comparison of variability, reproducibility, and diagnostic performance of late-night salivary cortisol (LNSF) and urinary free cortisol (UFC) using concurrent and consecutive samples in Cushing's syndrome (CS) is lacking. Objectives, Patients, and Methods: In a prospective study, we evaluated 3 simultaneous and consecutive samples of LNSF by RIA and UFC by liquid chromatography associated with tandem mass spectrometry in Cushing's disease (CD) patients (n = 43), adrenal CS patients (n = 9), and obese subjects (n = 18) to compare their diagnostic performances. In CS patients, we also performed a modified CS severity index. RESULTS There was no difference in the coefficient of variation (percentage) between LNSF and UFC among the 3 samples obtained for each patient with Cushing's disease (35 ± 26 vs 31 ± 24), adrenal CS (28 ± 14 vs 22 ± 14), and obesity (39 ± 37 vs 48 ± 20). LNSF confirmed the diagnosis of hypercortisolism even in the presence of normal UFC in 17.3% of CS, whereas the inverse situation was not observed for UFC. The area under the receiver-operating characteristic curves for LNSF was 0.999 (95% credible interval [CI] 0.990-1.00) and for UFC was 0.928 (95% CI 0.809-0.987). The ratio between areas under the curve was 0.928 (95% CI 0.810-0.988), indicating better performance of LNSF than UFC in diagnosing CS. There was no association between the CS severity index and the degree of biochemical hypercortisolism. CONCLUSION Our data show that despite similar variability between both methods, LNSF has a superior diagnostic performance than UFC and should be used as the primary biochemical diagnostic test for CS diagnosis.
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Affiliation(s)
- Paula C L Elias
- Division of Endocrinology Department of Medicine (P.C.L.E., B.F.C.B., L.M.M., M.C., A.C.M.) and Division of Statistics Department of Social Medicine (E.Z.M.), Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo 14049-900, Brazil
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Zhang Q, Dou J, Gu W, Yang G, Lu J. Reassessing the reliability of the salivary cortisol assay for the diagnosis of Cushing syndrome. J Int Med Res 2013; 41:1387-94. [PMID: 24065452 DOI: 10.1177/0300060513498017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The cortisol concentration in saliva is 10-fold lower than total serum cortisol and accurately reflects the serum concentration, both levels being lowest around midnight. The salivary cortisol assay measures free cortisol and is unaffected by confounding factors. This study analysed published data on the sensitivity and specificity of salivary cortisol levels in the diagnosis of Cushing syndrome. Methods Data from studies on the use of different salivary cortisol assay techniques in the diagnosis of Cushing syndrome, published between 1998 and 2012 and retrieved using Ovid MEDLINE®, were analysed for variance and correlation. Results For the 11 studies analysed, mean sensitivity and specificity of the salivary cortisol assay were both >90%. Repeated measurements were easily made with this assay, enabling improved diagnostic accuracy in comparison with total serum cortisol measurements. Conclusions This analysis confirms the reliability of the saliva cortisol assay as pragmatic tool for the accurate diagnosis of Cushing syndrome. With many countries reporting a rising prevalence of metabolic syndrome, diabetes and obesity – in which there is often a high circulating cortisol level – salivary cortisol measurement will help distinguish these states from Cushing syndrome.
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Affiliation(s)
- Qian Zhang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology, General Hospital of Beijing PLA Military Command, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Guoqing Yang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Juming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
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Ceccato F, Barbot M, Zilio M, Ferasin S, Occhi G, Daniele A, Mazzocut S, Iacobone M, Betterle C, Mantero F, Scaroni C. Performance of salivary cortisol in the diagnosis of Cushing's syndrome, adrenal incidentaloma, and adrenal insufficiency. Eur J Endocrinol 2013; 169:31-6. [PMID: 23610124 DOI: 10.1530/eje-13-0159] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Salivary cortisol has recently been suggested for studies on the hypothalamic-pituitary-adrenal (HPA) axis. The lack of circadian rhythm is a marker of Cushing's syndrome (CS), and some authors have reported that low salivary cortisol levels may be a marker of adrenal insufficiency. The aim of our study was to define the role of salivary cortisol in specific diagnostic settings of HPA axis disease. SUBJECTS AND METHODS We analyzed morning salivary cortisol (MSC) and late-night salivary CORTISOL (LNSC) levels in 406 SUBJECTS: 52 patients with Cushing's disease (CD), 13 with ectopic CS, 17 with adrenal CS, 27 with CD in remission (a mean follow-up of 66±39 months), 45 with adrenal incidentaloma, 73 assessed as having CS and then ruled out for endogenous hypercortisolism, 75 with adrenal insufficiency, and 104 healthy subjects. RESULTS A LNSC value above 5.24 ng/ml differentiated CS patients from controls with high sensitivity (96.3%) and specificity (97.1%); we found higher LNSC levels in ectopic CS patients than in CD patients. We found no difference in MSC and LNSC levels between patients with CD in remission and healthy subjects. Both MSC and LNSC levels were higher in patients with adrenal incidentaloma than in healthy controls. A MSC value below 2.65 ng/ml distinguished patients with adrenal insufficiency from controls with high sensitivity (97.1%) and specificity (93.3%). CONCLUSIONS Salivary cortisol is a useful tool to assess endogenous cortisol excess or adrenal insufficiency and to evaluate stable CD in remission.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105, 35128 Padova, Italy
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Cardoso EML, Arregger AL, Monardes G, Contreras LN. An accurate, non-invasive approach to diagnose Cushing's syndrome in at-risk populations. Steroids 2013; 78:476-82. [PMID: 23485687 DOI: 10.1016/j.steroids.2013.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 01/30/2013] [Accepted: 02/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prevalence of Cushing's syndrome (CS) in at-risk populations in developing countries remains uncertain. Evening urinary cortisol (UFC(22-23)) and salivary cortisol after treatment with 1-mg DST (SAFdex) have seldom been used as diagnostic tools in these populations. OBJECTIVES (1) To establish the prevalence of CS in adults with cortisol-related morbidities using UFC22-23 and SAFdex as markers along with all first-line diagnostic tests recommended for CS; and (2) to assess the performance of each test and define a non-invasive diagnostic approach for CS in at-risk outpatient subjects. METHODS A total of 128 outpatients were evaluated, including type 1 and 2 diabetic patients with poor metabolic control (DM1 and DM2), hypertensive subjects with central obesity (HBP) and premenopausal women with osteoporosis (OS). Controls included 100 healthy volunteers and 23 patients with CS. Total urinary cortisol (UFC), UFC(22-23), late-night salivary cortisol (SAF23) and suppression of cortisol levels in saliva (SAFdex) and serum (Fdex) after treatment with 1-mg DST were assessed. RESULTS CS was diagnosed in one DM2 and one HBP patient; both women exhibited central obesity. Among CS patients, UFC showed more within-person variability than UFC(22-23) or SAF23. UFC(22-23) and SAF23 were positively and significantly correlated in all groups (r > or = 0.70; p < or = 0.0001). UFC(22-23) > 44.0 ng/mg creatinine or SAF23 > 3.8 nM were 100% sensitive (S) and specific (E) for CS. Furthermore, SAFdex > 2.0 nM or Fdex > 50.0 nM were 100% S and 97.3% E for CS. CONCLUSION CS was diagnosed in 1.5% of at-risk patients. The combination of UFC(22-23) or SAF23 with SAFdex offers a non-invasive diagnostic tool to assess cortisol nadir and feed-back status in outpatients.
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Affiliation(s)
- Estela M L Cardoso
- Endocrine Research Department, Instituto de Investigaciones Médicas A. Lanari, University of Buenos Aires, Argentina
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Doi SAR, Clark J, Russell AW. Concordance of the late night salivary cortisol in patients with Cushing's syndrome and elevated urine-free cortisol. Endocrine 2013; 43:327-33. [PMID: 23238876 DOI: 10.1007/s12020-012-9855-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/03/2012] [Indexed: 11/29/2022]
Abstract
The concordance of the late night salivary cortisol (LNSC) results with the 24-h urine-free cortisol (UFC) results in the biochemical screening for Cushing's syndrome is unknown. We investigated this in a population of Cushing's syndrome subjects. We used meta-analytic methods to pool proportions of LNSC-positive subjects from diagnostic evaluations of Cushing's syndrome subjects where both tests were performed and the UFC was elevated (any level). Cushing's syndrome was confirmed in all subjects by two out of three conventional tests. LNSC was collected between 22:00 to 24:00 h and measured around the same time period as the UFC. Minimum cutoffs of ≥4 and ≥10 nmol/L were used to determine concordance with the UFC and studies were limited to those that used radioimmunoassays or electrochemiluminiscence immunoassays for LNSC. The concordance of LNSC ≥4 nmol/L was 97 % (95 % CI 95-99 %) and studies were homogeneous. With LNSC ≥10 nmol/L, there was heterogeneity and two groups were discernible with a pooled concordance of 69 % (95 % CI 60-77 %) and 95 % (95 % CI 92-97 %). Within these sub-groups, studies were homogeneous and there was no difference between them in collection methods, assays used, geographic location, year of publication, or the quality of the underlying studies. The LNSC at a very specific cutoff detects at best 95 % of cases and at worst 69 % of cases of Cushing's syndrome that are UFC positive. The two tests become equivalent at the more sensitive cutoff (>4 nmol/L). We conclude that, given its many benefits and the currently documented equivalence to the UFC, the LNSC should replace the conventional 24-h UFC as the frontline test when screening for Cushing's syndrome.
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Affiliation(s)
- Suhail A R Doi
- School of Population Health, University of Queensland, Brisbane, QLD, Australia.
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Manetti L, Rossi G, Grasso L, Raffaelli V, Scattina I, Del Sarto S, Cosottini M, Iannelli A, Gasperi M, Bogazzi F, Martino E. Usefulness of salivary cortisol in the diagnosis of hypercortisolism: comparison with serum and urinary cortisol. Eur J Endocrinol 2013; 168:315-21. [PMID: 23211575 DOI: 10.1530/eje-12-0685] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Several tests have been proposed to diagnose patients with Cushing's syndrome (CS). The aims of the study were: i) to evaluate the performance of salivary cortisol (SC) in hypercortisolism and ii) to compare SC with serum cortisol (SeC) and urinary cortisol. DESIGN AND PATIENTS This was a diagnostic study. Twenty-seven patients with untreated Cushing's disease (CD untr), 21 women consuming oral contraceptive pill (OCP), 18 pregnant women, and 89 healthy subjects (controls) were enrolled. METHODS SC and SeC at baseline and after the low-dose dexamethasone suppression test (LDDST) and urinary free cortisol (UFC) were measured. RESULTS Midnight SC had a sensitivity of 100% in the CD untr group and a specificity of 97.7% in the controls. Specificity remained high (95.2%) in women taking OCP, while in pregnant women, it decreased to 83.3%. SC after the LDDST showed a sensitivity of 96.3% in the CD untr group; specificity was 97.7% in the controls and 90.5% in OCP women. Midnight SeC had a sensitivity of 100% in the CD untr group. SeC after the LDDST had a sensitivity of 100% in the CD untr group while specificity was 97.7% in the controls and 61.9% in women taking OCP. For UFC, sensitivity was 92.6% in the CD untr group while specificity was 97.7% in the controls and 100% in the OCP group. CONCLUSIONS SC is a reliable parameter for the diagnosis of severe hypercortisolism, with high sensitivity and specificity. In women during pregnancy or taking OCP, the measurement of SC, identifying the free fraction, could be helpful to exclude CS.
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Affiliation(s)
- Luca Manetti
- Department of Endocrinology and Metabolism, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124 Pisa, Italy.
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Juszczak A, Grossman A. The investigation of Cushing syndrome: essentials in optimizing appropriate diagnosis and management. Ann Saudi Med 2012; 32:455-61. [PMID: 22871612 PMCID: PMC6080996 DOI: 10.5144/0256-4947.2012.455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The investigation of Cushing syndrome (CS) should start with careful history taking and clinical examination, and exogenous steroid usage must be excluded. It is essential to confirm hypercortisolism before further investigations are undertaken. The recommended first-line tests include midnight salivary cortisol and/or the 1 mg overnight or low-dose dexamethasone suppression tests. The next step is to differentiate adrenocorticotrophin (ACTH)-dependent from ACTH-independent CS by measuring ACTH. With ACTH-dependence, further investigations should differentiate pituitary-dependent from ectopic ACTH-dependent CS. Many dynamic tests may be considered, but we suggest that bilateral inferior petrosal sinus sampling should be performed in almost all patients with ACTH-dependent CS, except for patients with a pituitary macroadenoma. Imaging should include MR scanning of the pituitary, and CT scanning of the chest and abdomen to look for an ectopic source. Confirmation of the diagnosis of CS and accurate localization of its source are vital to optimize therapy for this complex disorder.
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Carrasco CA, García M, Goycoolea M, Cerda J, Bertherat J, Padilla O, Meza D, Wohllk N, Quiroga T. Reproducibility and performance of one or two samples of salivary cortisol in the diagnosis of Cushing's syndrome using an automated immunoassay system. Endocrine 2012; 41:487-93. [PMID: 22270871 DOI: 10.1007/s12020-012-9597-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/22/2011] [Indexed: 10/14/2022]
Abstract
The purpose of this article is to evaluate the variability and reproducibility of late night salivary cortisol (LNSC) using electrochemiluminescence immunoassay (ECLIA) and compare the accuracy of one or two samples in diagnosis of Cushing's syndrome (CS). We prospectively included 64 healthy volunteers (HV), 35 patients with clinically suspected CS (S), and 26 patients with confirmed CS. Nine patients in the CS group had 24-h urinary free cortisol (UFC) less than two times the upper limit of normal (mild CS). UFC and two consecutive LNSC (LNSC1, LNSC2) were collected at home. All patients in the S group had normal UFC and low-dose dexamethasone suppression test. No differences were found between the HV and S groups in UFC, LNSC1, and LNSC2. Intra-individual variability between the two samples of LNSC was 22% in HV (1.6-91%), 32% in the S group (1.6-144%), and 51% (1.6-156%) in the CS group. Variability was higher in CS patients than those in the HV (P < 0.001) and S groups (P = 0.05). The AUC of LNSC1 was 0.945 (IC 95% 0.880-1.004); when considering the highest LNSC, the AUC was 0.980 (IC 95% 0.954-1.007) (P < 0.01). We found 23% of discordant LNSC in the S group and 11% in the CS group. Three patients with CS had only one elevated LNSC, all of them with mild CS. Our results suggest that LNSC is variable, and reproducibility is affected in both CS and S patients. We found significant improvements in the diagnostic accuracy of the LNSC measurement by obtaining two samples.
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Affiliation(s)
- C A Carrasco
- Facultad de Medicina, Department of Endocrinology, Pontificia Universidad Católica de Chile, Lira 85 piso 5, Santiago, Chile.
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Deutschbein T, Broecker-Preuss M, Flitsch J, Jaeger A, Althoff R, Walz MK, Mann K, Petersenn S. Salivary cortisol as a diagnostic tool for Cushing's syndrome and adrenal insufficiency: improved screening by an automatic immunoassay. Eur J Endocrinol 2012; 166:613-8. [PMID: 22214924 DOI: 10.1530/eje-11-0945] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Salivary cortisol is increasingly used to assess patients with suspected hypo- and hypercortisolism. This study established disease-specific reference ranges for an automated electrochemiluminescence immunoassay (ECLIA). METHODS Unstimulated saliva from 62 patients with hypothalamic-pituitary disease was collected at 0800 h. A peak serum cortisol level below 500 nmol/l during the insulin tolerance test (ITT) was used to identify hypocortisolism. Receiver-operating characteristic (ROC) analysis allowed establishment of lower and upper cutoffs with at least 95% specificity for adrenal insufficiency and adrenal sufficiency. Saliva from 40 patients with confirmed hypercortisolism, 45 patients with various adrenal masses, and 115 healthy subjects was sampled at 2300 h and after low-dose dexamethasone suppression at 0800 h . ROC analysis was used to calculate thresholds with at least 95% sensitivity for hypercortisolism. Salivary cortisol was measured with an automated ECLIA. RESULTS When screening for secondary adrenal insufficiency, a lower cutoff of 3.2 nmol/l and an upper cutoff of 13.2 nmol/l for unstimulated salivary cortisol allowed a highly specific diagnosis (i.e. similar to the ITT result) in 26% of patients. For identification of hypercortisolism, cutoffs of 6.1 nmol/l (sensitivity 95%, specificity 91%, area under the curve (AUC) 0.97) and 2.0 nmol/l (sensitivity 97%, specificity 86%, AUC 0.97) were established for salivary cortisol at 2300 h and for dexamethasone-suppressed salivary cortisol at 0800 h. CONCLUSIONS The newly established thresholds facilitated initial screening for secondary adrenal insufficiency and allowed excellent identification of hypercortisolism. Measurement by an automated immunoassay will allow broader use of salivary cortisol as a diagnostic tool.
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Affiliation(s)
- Timo Deutschbein
- Department of Endocrinology and Division of Laboratory Research, Medical Center, University Hospital of Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen, Germany
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Erickson D, Singh RJ, Sathananthan A, Vella A, Bryant SC. Late-night salivary cortisol for diagnosis of Cushing's syndrome by liquid chromatography/tandem mass spectrometry assay. Clin Endocrinol (Oxf) 2012; 76:467-72. [PMID: 21955126 DOI: 10.1111/j.1365-2265.2011.04239.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Late-night salivary cortisol (LNSC) measurements have been increasingly used by physicians as an initial diagnostic test for evaluation of patients with clinical suspicion of Cushing's syndrome (CS). Published studies include various numbers of cases, controls and importantly, various assay methods (vast majority various immunoassays), as well as various methods to generate cut-points. MATERIALS AND METHODS The retrospective study evaluated the diagnostic utility of LNSC measurements in 249 patients evaluated for possibility of CS because of various clinical conditions using liquid chromatography/tandem mass spectrometry method (LC-MS/MS). CS was confirmed in 47 patients (18·9%) and excluded in 202 (81·1%) patients at the time of analysis. RESULTS Late-night salivary cortisol was abnormal or >2·8 nmol/l in 35 of 47 patients with CS; sensitivity of 74·5% and elevated in 20 of 202 patients who were found not to have CS; specificity 90·1%. Using receiver-operator characteristic statistics for calculation of the most optimal sensitivity and specificity, the cut-off based on this data was LNSC > 2·1 nmol/l with sensitivity of 83·0% and specificity of 84·2%. CONCLUSION Analysis of data at one referral institution showed somewhat limited sensitivity of LNSC for diagnosis of CS using current reference ranges.
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Affiliation(s)
- Dana Erickson
- Division of Endocrinology, Metabolism and Nutrition, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
This short review summarizes the use of late-night salivary cortisol measurement in the diagnosis of Cushing's syndrome, in the evaluation of patients with adrenal incidentalomas, and in monitoring of post-operative patients, with a focus on the different assay methodologies currently in common use. The focus is on recent studies identified by literature searches using Ovid Medline and Google Scholar as well as analysis of several recent review articles on the topic. Measurement of late night salivary cortisol (LNSC) has an excellent sensitivity and specificity for the diagnosis of Cushing's syndrome regardless of the assay methodology used. Immunoassays have the advantage of simplicity, low cost, and small sample volume requirement, while liquid chromatography-tandem mass spectrometry has the advantage of a high specificity for cortisol and the ability to measure cortisone. The overnight dexamethasone suppression test appears to be superior to LNSC measurement in the evaluation of patients with adrenal incidentalomas. LNSC measurement is an excellent approach to monitor post-operative Cushing's disease patients for surgical failure or recurrence. Salivary cortisol is most useful as the initial test when Cushing's syndrome is suspected and for periodic patient monitoring after pituitary surgery for Cushing's disease.
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Affiliation(s)
- Hershel Raff
- Endocrine Research Laboratory, Endocrine-Diabetes Center, Aurora St. Luke's Medical Center, Milwaukee, WI 53215, USA.
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Alexandraki KI, Grossman AB. Is urinary free cortisol of value in the diagnosis of Cushing's syndrome? Curr Opin Endocrinol Diabetes Obes 2011; 18:259-63. [PMID: 21681089 DOI: 10.1097/med.0b013e3283487193] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Cushing's syndrome results from prolonged and inappropriately high exposure of tissues to glucocorticoids. Biochemical tests are always needed to confirm the clinical suspicion: these include measurement of excess total endogenous cortisol secretion assessed by 24-h urinary free cortisol (UFC), loss of the normal feedback of the hypothalamo-pituitary-adrenal axis assessed by suppressibility after dexamethasone testing, and disturbance of the normal circadian rhythm of cortisol secretion assessed by midnight serum or salivary cortisol. This review focuses on recent data emerging on the value of UFC as a screening test for Cushing's syndrome. RECENT FINDINGS Considerable evidence has emerged regarding the utility of UFC in the diagnosis of Cushing's syndrome because of its long-term use in clinical practice. Despite the fact that UFC assesses the active (free) component of cortisol, the methodological difficulties in 24-h urine collection and in assay precision have rendered this screening technique increasingly unpopular. Furthermore, the increased prevalence of mild, preclinical or cyclic Cushing's syndrome along with the fact that cortisol is not uniformly secreted during the day do not support its use as a screening test, although strikingly high levels can be useful. SUMMARY Since the sensitivity and specificity of UFC are less than ideal when compared with other diagnostic modalities, we suggest the use of other more novel tests as first-step diagnostic tests to screen for hypercortisolaemia.
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Affiliation(s)
- Krystallenia I Alexandraki
- Centre for Endocrinology, William Harvey Research Institute, Barts and London School of Medicine, Queen Mary University of London, London, UK
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Carrozza C, Corsello SM, Paragliola RM, Ingraudo F, Palumbo S, Locantore P, Sferrazza A, Pontecorvi A, Zuppi C. Clinical accuracy of midnight salivary cortisol measured by automated electrochemiluminescence immunoassay method in Cushing's syndrome. Ann Clin Biochem 2010; 47:228-32. [PMID: 20406774 DOI: 10.1258/acb.2010.010020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The diagnosis of Cushing's syndrome (CS) represents a challenge for endocrinologists. Several screening tests are used, but none of them seems to be the gold standard for the diagnosis. The aim of this study was to confirm the diagnostic value of salivary cortisol (SC) as a first-level screening test and to evaluate the clinical performance of a electrochemiluminescence immunoassay (ECLIA) method. METHODS In 33 patients with a strong clinical suspicion of CS, we evaluated urinary free cortisol, circadian rhythm plasma cortisol (PC) and morning PC after low-dose dexamethasone suppression test (LDDST). At the same sampling times, we evaluated SC analysed by the same automated method. Correlation studies were evaluated by Spearman index (significance P < 0.05). RESULTS On the basis of biochemical results CS was confirmed in 21/33. SC was significantly correlated to PC at 12:00 and 23:00. Thus, we chose 8.3 nmol/L as midnight SC cut-off value with 100% sensitivity and 97.4% specificity. The cut-off chosen after LDDST was 1.7 nmol/L (100% sensitivity and 72% specificity). CONCLUSION SC assay showed a good clinical accuracy and the ECLIA method can be used in clinical routine to obtain fast results easily.
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Affiliation(s)
- Cinzia Carrozza
- Institute of Biochemistry and Clinical Biochemistry, Catholic University School of Medicine, Rome, Italy. ccarrozza@ rm.unicatt.it
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Thomas MV, Branscum A, Miller CS, Ebersole J, Al-Sabbagh M, Schuster JL. Within-subject variability in repeated measures of salivary analytes in healthy adults. J Periodontol 2009; 80:1146-53. [PMID: 19563296 DOI: 10.1902/jop.2009.080654] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Saliva contains a large number of biomolecules, some of which have putative diagnostic usefulness. A potential problem with the use of biomolecules in diagnosis is day-to-day fluctuation due to within-subject variability. This study evaluated the intraindividual variability of six salivary analytes in healthy adults and determined their normal range. METHODS Unstimulated whole saliva (5 ml) was collected every 2 to 3 days on six occasions from 30 subjects in good oral and systemic health. Four of the samples were collected in the clinic, and two were collected by the subject at home. The concentration ranges of interleukin (IL)-1beta, IL-6, matrix metalloproteinase-8, prostaglandin E(2), tumor necrosis factor-alpha, interferon-alpha, and albumin were examined. Descriptive statistics were computed, and a one-way random-effects model was used to quantify within- and between-subject components of variability. Intraclass correlation coefficients (ICCs) were calculated for each subject/analyte combination. RESULTS Within-subject coefficients of variation for these analytes ranged from 67.6% to 172.1% for the in-clinic samples and from 111.9% to 201.0% for the at-home samples. The ICC for the various analytes ranged from 41% to 61% for the in-clinic samples. The at-home samples exhibited significantly more variability than did those obtained in the clinic under supervision. CONCLUSIONS There was marked within-subject variation in the salivary concentrations of these analytes. With increased interest in salivary diagnostics, the within-subject variability, normal range, and threshold levels for abnormal levels of individual salivary analytes need to be determined if these diagnostics tests are to have clinical usefulness.
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Affiliation(s)
- Mark V Thomas
- Division of Periodontology, Department of Oral Health Practice, University of Kentucky College of Dentistry, Lexington, KY, USA.
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Raff H. Utility of salivary cortisol measurements in Cushing's syndrome and adrenal insufficiency. J Clin Endocrinol Metab 2009; 94:3647-55. [PMID: 19602555 DOI: 10.1210/jc.2009-1166] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The measurement of cortisol in saliva is a simple, reproducible, and reliable test to evaluate the normal and disordered control of the hypothalamic-pituitary-adrenal (HPA) axis. There are a variety of simple methods to obtain saliva samples without stress, making this a robust test applicable to many different experimental and clinical situations. EVIDENCE ACQUISITION Ovid Medline and PubMed from 1950 to present were searched using the following strategies: [<saliva or salivary>and<cortisol or hydrocortisone>and<Cushing or Cushing's>] and [<saliva or salivary>and<cortisol or hydrocortisone>and<adrenal insufficiency or hypoadrenalism or hypopituitarism or Addison's disease>]. The bibliographies of all relevant citations were evaluated for any additional appropriate citations. EVIDENCE SYNTHESIS Measurement of an elevated late-night (2300 to 2400 h) salivary cortisol has a greater than 90% sensitivity and specificity for the diagnosis of endogenous Cushing's syndrome. Late-night salivary cortisol measurements are also useful to monitor patients for remission and/or recurrence after pituitary surgery for Cushing's disease. Because it is a surrogate for plasma free cortisol, the measurement of salivary cortisol may be useful during an ACTH stimulation test in patients with increased plasma binding protein concentrations due to increased estrogen, or decreased plasma binding protein concentrations during critical illness. Most reference laboratories now offer salivary cortisol testing. CONCLUSIONS It is expected that the use of the measurement of salivary cortisol will become routine in the evaluation of patients with disorders of the HPA axis.
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Affiliation(s)
- Hershel Raff
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin 53215, USA.
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