title: Transsphenoidal surgery for cushing disease after nondiagnostic inferior petrosal sinus sampling.
abstract: BACKGROUND
  Inferior petrosal sinus sampling (IPSS) is a useful technique for confirming a pituitary source of adrenocorticotropic hormone (ACTH) overproduction in Cushing disease. Uncertainty remains regarding the appropriate course of therapy when an ectopic tumor is predicted by IPSS but none can be found and in circumstances when the procedure cannot be successfully completed owing to technical or anatomic limitations.
  
  
  OBJECTIVE
  To determine an appropriate course of action after nondiagnostic IPSS.
  
  
  METHODS
  We reviewed 288 IPSS procedures in 283 patients between 1986 and 2010 at our center. An IPS:peripheral ACTH ratio ≥ 2 at baseline or ≥ 3 after corticotrophin-releasing hormone was considered predictive of a pituitary source of ACTH. A procedure was considered nondiagnostic if the procedure was successfully performed and the results predicted an ectopic source but none could be found despite extensive imaging or if the IPS could not be bilaterally cannulated because of technical difficulties or anatomic variants.
  
  
  RESULTS
  The sensitivity, specificity, positive predictive value, and negative predictive value of IPSS for detecting a pituitary source in Cushing disease were 94%, 50%, 98%, and 29%, respectively. We identified 3 categories of nondiagnostic IPSS comprising 44 of the total procedures. These patients underwent exploratory transsphenoidal surgery, and in 42 of these patients (95%), a pituitary source was surgically proven, with a remission rate of 83%.
  
  
  CONCLUSIONS
  Transsphenoidal surgery should be considered in cases of ACTH-dependent Cushing disease and noncentralized or technically unsuccessful IPSS without evidence of ectopic tumor.
authors.affiliation: Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA. sheth@post.harvard.edu
authors.forename: Sameer A
authors.initials: SA
authors.lastname: Sheth
authors.forename: Matthew K
authors.initials: MK
authors.lastname: Mian
authors.forename: Jonathan
authors.initials: J
authors.lastname: Neal
authors.forename: Nicholas A
authors.initials: NA
authors.lastname: Tritos
authors.forename: Lisa
authors.initials: L
authors.lastname: Nachtigall
authors.forename: Anne
authors.initials: A
authors.lastname: Klibanski
authors.forename: Beverly M K
authors.initials: BM
authors.lastname: Biller
authors.forename: Brooke
authors.initials: B
authors.lastname: Swearingen
mesh_terms: D000293:Adolescent; D000324:Adrenocorticotropic Hormone / Q000378:metabolism; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D003346:Corticotropin-Releasing Hormone / Q000378:metabolism; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D009666:Nose / Q000601:surgery*; D017591:Petrosal Sinus Sampling / Q000379:methods*; D047748:Pituitary ACTH Hypersecretion / Q000175:diagnosis* / Q000601:surgery*; D010902:Pituitary Gland / Q000601:surgery; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000324:Adrenocorticotropic Hormone; D003346:Corticotropin-Releasing Hormone; D006854:Hydrocortisone