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Perlman JE, Johnston PC, Hui F, Mulligan G, Weil RJ, Recinos PF, Yogi-Morren D, Salvatori R, Mukherjee D, Gallia G, Kennedy L, Hamrahian AH. Pitfalls in Performing and Interpreting Inferior Petrosal Sinus Sampling: Personal Experience and Literature Review. J Clin Endocrinol Metab 2021; 106:e1953-e1967. [PMID: 33421066 PMCID: PMC8599872 DOI: 10.1210/clinem/dgab012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Indexed: 02/13/2023]
Abstract
CONTEXT Inferior petrosal sinus sampling (IPSS) helps differentiate the source of ACTH-dependent hypercortisolism in patients with inconclusive biochemical testing and imaging, and is considered the gold standard for distinguishing Cushing disease (CD) from ectopic ACTH syndrome. We present a comprehensive approach to interpreting IPSS results by examining several real cases. EVIDENCE ACQUISITION We performed a comprehensive review of the IPSS literature using PubMed since IPSS was first described in 1977. EVIDENCE SYNTHESIS IPSS cannot be used to confirm the diagnosis of ACTH-dependent Cushing syndrome (CS). It is essential to establish ACTH-dependent hypercortisolism before the procedure. IPSS must be performed by an experienced interventional or neuroradiologist because successful sinus cannulation relies on operator experience. In patients with suspected cyclical CS, it is important to demonstrate the presence of hypercortisolism before IPSS. Concurrent measurement of IPS prolactin levels is useful to confirm adequate IPS venous efflux. This is essential in patients who lack an IPS-to-peripheral (IPS:P) ACTH gradient, suggesting an ectopic source. The prolactin-adjusted IPS:P ACTH ratio can improve differentiation between CD and ectopic ACTH syndrome when there is a lack of proper IPS venous efflux. In patients who have unilateral successful IPS cannulation, a contralateral source cannot be excluded. The value of the intersinus ACTH ratio to predict tumor lateralization may be improved using a prolactin-adjusted ACTH ratio, but this requires further evaluation. CONCLUSION A stepwise approach in performing and interpreting IPSS will provide clinicians with the best information from this important but delicate procedure.
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Affiliation(s)
- Jordan E Perlman
- Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, Baltimore, MD, USA
| | - Philip C Johnston
- Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - Ferdinand Hui
- Johns Hopkins University, Department of Radiology, Baltimore, MD, USA
| | - Guy Mulligan
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Pablo F Recinos
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Divya Yogi-Morren
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Roberto Salvatori
- Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, Baltimore, MD, USA
| | - Debraj Mukherjee
- Johns Hopkins University, Department of Neurosurgery, Baltimore, MD, USA
| | - Gary Gallia
- Johns Hopkins University, Department of Neurosurgery, Baltimore, MD, USA
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Amir H Hamrahian
- Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, Baltimore, MD, USA
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