title: Cushing's Syndrome: important issues in diagnosis and management.
abstract: BACKGROUND
  The diagnosis, differential diagnosis, and treatment of Cushing's syndrome are challenging problems in clinical endocrinology. We focus on critical questions addressing screening for Cushing's syndrome, differentiation of Cushing's subtypes, and treatment options.
  
  
  METHODS
  Ovid's MEDLINE (1996 through April 2006) was used to search the general literature. We also relied on previously published reviews and a recent monograph and cite a mix of primary articles and recent reviews.
  
  
  RESULTS
  Although this article represents our opinion, it draws heavily on a recent consensus statement from experts in the field and a recent monograph on Cushing's syndrome.
  
  
  CONCLUSIONS
  We concluded that: 1) measurement of late-night or bedtime salivary cortisol is a useful approach to screen for Cushing's syndrome; 2) measurement of suppressed plasma ACTH by immunometric assay is useful to differentiate ACTH-dependent and -independent Cushing's syndrome; 3) inferior petrosal sinus sampling for ACTH should be performed in patients with ACTH-dependent hypercortisolism in whom a pituitary magnetic resonance imaging is normal or equivocal (in the absence of a pituitary ACTH gradient, prolactin levels should be measured to confirm the integrity of venous sampling); 4) computed tomography of the chest and abdomen and somatostatin receptor scintigraphy should be performed in patients with the occult ectopic ACTH syndrome; and 5) patients with Cushing's disease should be referred to a neurosurgeon with extensive experience operating on corticotroph microadenomas. Bilateral laparoscopic adrenalectomy should be considered in patients with Cushing's disease who fail therapies directed at the pituitary.
authors.affiliation: Endocrime-Diabetes Center, St. Luke's Physician's Office Building, 2801 West KK River Parkway, Suite 245, Milwaukee, WI 53215, USA.
authors.forename: James W
authors.initials: JW
authors.lastname: Findling
authors.forename: Hershel
authors.initials: H
authors.lastname: Raff
mesh_terms: D000324:Adrenocorticotropic Hormone / Q000097:blood / Q000378:metabolism; D003480:Cushing Syndrome / Q000175:diagnosis* / Q000628:therapy; D003907:Dexamethasone / Q000494:pharmacology; D006801:Humans; D006854:Hydrocortisone / Q000032:analysis / Q000097:blood / Q000652:urine; D010902:Pituitary Gland / Q000601:surgery; D012469:Salivary Glands / Q000737:chemistry
chemical_list: D003907:Dexamethasone; D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone