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Limited Invasive Protocol: Optimizing Diagnostic Modalities in Corticotropin Mediated Cushing Syndrome.

Rahul Gupta1, Rama Walia1, Chirag Ahuja2

  • 1Department of Endocrinology, Diabetes and Metabolism, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

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Summary

Limited invasive protocols (LIPs) offer a less invasive and more cost-effective alternative to conventional invasive strategies for distinguishing Cushing disease (CD) from ectopic Cushing syndrome (ECS). These strategies maintain high diagnostic accuracy, potentially reducing the need for bilateral inferior petrosal sinus sampling (BIPSS).

Keywords:
BIPSSCushing diseasediagnosisectopic Cushing syndromenoninvasive

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Area of Science:

  • Endocrinology
  • Diagnostic Imaging
  • Minimally Invasive Procedures

Background:

  • Distinguishing Cushing disease (CD) from ectopic Cushing syndrome (ECS) often relies on bilateral inferior petrosal sinus sampling (BIPSS).
  • A noninvasive approach combining biochemical testing and radiological imaging has been proposed as an alternative to conventional invasive strategies (CIS).
  • Further validation is needed for noninvasive strategies to limit the role of BIPSS.

Purpose of the Study:

  • To evaluate two limited invasive protocols (LIP-1 and LIP-2) as alternatives to CIS.
  • To assess the ability of LIPs to reduce the need for BIPSS while maintaining diagnostic accuracy.
  • To compare the cost-effectiveness of LIPs versus CIS.

Main Methods:

  • A single-center study involving patients with corticotropin-dependent Cushing syndrome.
  • LIPs involved high-dose dexamethasone suppression tests (cutoff >50% for LIP-1, >80% for LIP-2) and sella MRI.
  • Selective computed tomography of the chest and abdomen was used before BIPSS in the LIPs.

Main Results:

  • BIPSS could have been avoided in 62.3% (LIP-1) and 35.9% (LIP-2) of eligible patients, compared to 25.4% with CIS.
  • Positive predictive values for CD were high: 98.9% for LIP-1 and 100% for LIP-2.
  • Cost per patient was lower for LIP-1 ($602.21) and LIP-2 ($966.81) compared to CIS ($1107.78).

Conclusions:

  • Limited invasive protocols (LIPs) are equally accurate alternatives to CIS for differentiating CD and ECS.
  • LIPs offer a less invasive approach, reducing the reliance on BIPSS.
  • The evaluated LIPs are more cost-effective than the conventional invasive strategy.