[促肾上腺皮质激素释放激素（CRH）试验在库欣综合征鉴别诊断中的价值]

[The value of corticotropin-releasing hormone (CRH) test for differential diagnosis of Cushing's syndrome].

作者信息

Penezić Zorana, Zarković Milos, Vujović Svetlana, Ivović Miomira, Beleslin Biljana, Ciric Jasmina, Drezgić Milka

出版信息

Srp Arh Celok Lek. 2007 Jan-Feb;135(1-2):31-7. doi: 10.2298/sarh0702031p.

DOI:10.2298/sarh0702031p

PMID:17503565

Abstract

INTRODUCTION

Diagnosis and differential diagnosis of Cushing's syndrome (CS) remain considerable challenge in endocrinology. For more than 20 years, CRH has been widely used as differential diagnostic test. Following the CRH administration, the majority of patients with ACTH secreting pituitary adenoma show a significant rise of plasma cortisol and ACTH, whereas those with ectopic ACTH secretion characteristically do not.

OBJECTIVE

The aim of our study was to assess the value of CRF test for differential diagnosis of CS using the ROC (receiver operating characteristic) curve method.

METHOD

A total of 30 patients with CS verified by pathological examination and postoperative testing were evaluated. CRH test was performed within diagnostic procedures. ACTH secreting pituitary adenoma was found in 18, ectopic ACTH secretion in 3 and cortisol secreting adrenal adenoma in 9 of all patients with CS. Cortisol and ACTH were determined -15.0, 15, 30, 45, 60, 90 and 120 min. after i.v. administration of 100 microg of ovine CRH. Cortisol and ACTH were determined by commercial RIA. Statistical data processing was done by ROC curve analysis. Due to small number, the patients with ectopic ACTH secretion were excluded from test evaluation by ROC curve method.

RESULTS

In evaluated subgroups, basal cortisol was (1147.3 +/- 464.3 vs. 1589.8 +/- 296.3 vs. 839.2 +/- 405.6 nmol/L); maximal stimulated cortisol (1680.3 +/- 735.5 vs. 1749.0 +/- 386.6 vs. 906.1 +/- 335.0 nmol/L); and maximal increase as a percent of basal cortisol (49.1 +/- 36.9 vs. 9.0 +/- 7.6 vs. 16.7 +/- 37.3%). Consequently, basal ACTH was (100.9 +/- 85.0 vs. 138.0 +/- 123.7 vs. 4.8 +/- 4.3 pg/mL) and maximal stimulated ACTH (203.8 +/- 160.1 vs. 288.0 +/- 189.5 vs. 7.4 +/- 9.2 pg/mL). For cortisol, determination area under ROC curve was 0.815 +/- 0.083 (CI 95% 0.652-0.978). For cortisol increase cut-off level of 20%, test sensitivity was 83%, with specificity of 78%. For ACTH, determination area under ROC curve was 0.637 +/- 0.142 (CI 95% 0.359-0.916). For ACTH increase cut-off level of 30%, test sensitivity was 70%, with specificity of 57%.

CONCLUSION

Determination of cortisol and ACTH levels in CRH test remains reliable tool in differential diagnosis of Cushing's syndrome.

摘要

引言

库欣综合征（CS）的诊断和鉴别诊断仍是内分泌学领域面临的重大挑战。20多年来，促肾上腺皮质激素释放激素（CRH）一直被广泛用作鉴别诊断试验。静脉注射CRH后，大多数分泌促肾上腺皮质激素（ACTH）的垂体腺瘤患者血浆皮质醇和ACTH显著升高，而异位ACTH分泌患者通常无此表现。

目的

本研究旨在采用ROC（受试者工作特征）曲线法评估CRF试验对CS鉴别诊断的价值。

方法

对30例经病理检查和术后检测确诊的CS患者进行评估。在诊断过程中进行CRH试验。所有CS患者中，18例为分泌ACTH的垂体腺瘤，3例为异位ACTH分泌，9例为分泌皮质醇的肾上腺腺瘤。静脉注射100μg羊CRH后，分别于-15.0、15、30、45、60、90和120分钟测定皮质醇和ACTH。采用商业放射免疫分析法（RIA）测定皮质醇和ACTH。通过ROC曲线分析进行统计数据处理。由于病例数较少，异位ACTH分泌患者被排除在ROC曲线法的试验评估之外。

结果

在评估的亚组中，基础皮质醇水平分别为（1147.3±464.3 vs. 1589.8±296.3 vs. 839.2±405.6 nmol/L）；最大刺激后皮质醇水平分别为（1680.3±735.5 vs. 1749.0±386.6 vs. 906.1±335.0 nmol/L）；最大升高幅度占基础皮质醇的百分比分别为（49.1±36.9 vs. 9.0±7.6 vs. 16.7±37.3%）。相应地，基础ACTH水平分别为（100.9±85.0 vs. 138.0±123.7 vs. 4.8±4.3 pg/mL），最大刺激后ACTH水平分别为（203.8±160.1 vs. 288.0±189.5 vs. 7.4±9.2 pg/mL）。对于皮质醇，ROC曲线下面积为0.815±0.083（95%可信区间0.652 - 0.978）。当皮质醇升高截断水平为20%时，试验敏感性为83%，特异性为78%。对于ACTH，ROC曲线下面积为0.637±0.142（95%可信区间0.359 - 0.916）。当ACTH升高截断水平为30%时，试验敏感性为70%，特异性为57%。