Findling James W, Raff Hershel
Endocrime-Diabetes Center, St. Luke's Physician's Office Building, 2801 West KK River Parkway, Suite 245, Milwaukee, WI 53215, USA.
J Clin Endocrinol Metab. 2006 Oct;91(10):3746-53. doi: 10.1210/jc.2006-0997. Epub 2006 Jul 25.
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.
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.
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.
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.
库欣综合征的诊断、鉴别诊断及治疗是临床内分泌学中具有挑战性的问题。我们关注有关库欣综合征筛查、亚型鉴别及治疗选择的关键问题。
使用Ovid的MEDLINE（1996年至2006年4月）检索一般文献。我们还参考了先前发表的综述和近期的专著，并引用了一系列原始文章和近期综述。
尽管本文代表我们的观点，但它大量借鉴了该领域专家最近的共识声明以及关于库欣综合征的近期专著。
我们得出以下结论：1）测定午夜或睡前唾液皮质醇是筛查库欣综合征的有用方法；2）通过免疫测定法测定抑制状态下的血浆促肾上腺皮质激素（ACTH）有助于鉴别ACTH依赖性和非依赖性库欣综合征；3）对于垂体磁共振成像正常或不明确的ACTH依赖性皮质醇增多症患者，应进行岩下窦取血测定ACTH（在没有垂体ACTH梯度的情况下，应测量催乳素水平以确认静脉取血的完整性）；4）对于隐匿性异位ACTH综合征患者，应进行胸部和腹部计算机断层扫描及生长抑素受体闪烁显像；5）库欣病患者应转诊至有丰富垂体微腺瘤手术经验的神经外科医生处。对于垂体治疗无效的库欣病患者，应考虑双侧腹腔镜肾上腺切除术。
