Belaya Zh E, Golounina O O, Sitkin I I, Rozhinskaya L Ya, Degtyarev M V, Trukhina D A, Bondarenko E V, Lapshina A M, Mamedova E O, Przhiyalkovskaya E G, Vaks V V, Melnichenko G A, Mokrysheva N G, Dedov I I
The National Medical Research Center for Endocrinology.
Great Western Hospitals NHS Foundation Trust.
Probl Endokrinol (Mosk). 2024 Jan 24;69(6):4-16. doi: 10.14341/probl13299.
To analyze the diagnostic performance of bilateral inferior petrosal sinus sampling (BIPSS) with desmopressin as a stimulation agent and prolactin measurements to control catheter position with or without the ACTH/prolactin normalized ratio calculation in the differential diagnosis of ACTH-dependent endogenous hypercortisolism, and the diagnostics performance of ectopic ACTH-syndrome (EAS) visualization.
A single-center diagnostic study with a retrospective analysis of the data was carried out. The study included patients with ACTH-dependent endogenous hypercorticism with no visualization of pituitary adenoma on MRI or adenoma sizes less than 6 mm. All patients underwent BIPSS with and without calculation of the ACTH/prolactin normalized ratio. Visualization of an EAS included pituitary MRI (to exclude EAS), whole-body CT scan with contrast, and somatostatin receptor scintigraphy with 99mTc-Tectrotide and CT (99mTc-Tectrotide SPECT). The final verification was based on immunohistochemical confirmation of the tumor or stable remission of Cushing's disease (CD) after surgical treatment. Statistical data processing was carried out by using IBM SPSS Statistics 23. Confidence intervals were calculated using the JavaStat online calculator.
230 BIPSS were performed in 228 patients (166 women, 62 men), of which 178 patients were verified as CD and 50 cases were EAS of various localization. The effectiveness of catheterization of petrosal sinuses was 96.9%. The sensitivity of BIPSS without ACTH/prolactin ratio calculation (n=70) was 95.9% (95% CI 86.3-98.9), specificity was 92% (95% CI 75.0-97.8), for the BIPSS with additional determination of ACTH/prolactin-normalized ratio (n=51) - 97.3% (95% CI 86.2-99.5) and 93.8% (95% CI 71.7-98.9), respectively. The use of the MRI method for this sample of patients had a sensitivity of 60.2% (95% CI 52.6-67.5), specificity of 59.2% (95% CI 44.2-73.0), the total body CT with contrast has a sensitivity of 74% (95% CI 59.7-85.4), specificity of 100% (95% CI 97.95-100). The diagnostic accuracy for 99mTc-Tectrotide SPECT in NET visualization has a sensitivity of 73.3% (95% CI 44.9-92.2), specificity of 100% (95% CI 95.3-100).
BIPSS with desmopressin stimulation and prolactin measurements to control catheter position, as well as the additional calculation of the ACTH/prolactin-normalized ratio, is an optimal method for the differential diagnosis of EAS. Patients who are identified an EAS on BIPSS may be further referred for 99mTc-Tectrotide SPECT and CT for tumor visualization.
分析以去氨加压素作为刺激剂的双侧岩下窦采血（BIPSS）联合催乳素测量（无论是否计算促肾上腺皮质激素/催乳素标准化比值）在促肾上腺皮质激素（ACTH）依赖性内源性皮质醇增多症鉴别诊断中的诊断性能，以及异位ACTH综合征（EAS）可视化的诊断性能。
开展一项单中心诊断研究并对数据进行回顾性分析。该研究纳入了MRI未显示垂体腺瘤或腺瘤大小小于6mm的ACTH依赖性内源性皮质醇增多症患者。所有患者均接受了BIPSS，且部分患者计算了ACTH/催乳素标准化比值。EAS的可视化检查包括垂体MRI（以排除EAS）、增强全身CT扫描以及使用99m锝-替曲膦（99mTc-Tectrotide）和CT的生长抑素受体闪烁显像（99mTc-Tectrotide SPECT）。最终验证基于肿瘤的免疫组化确认或手术治疗后库欣病（CD）的稳定缓解。使用IBM SPSS Statistics 23进行统计数据处理。使用JavaStat在线计算器计算置信区间。
对228例患者（166例女性，62例男性）进行了230次BIPSS，其中178例患者被确诊为CD，50例为不同部位的EAS。岩下窦插管成功率为96.9%。未计算ACTH/催乳素比值的BIPSS（n=70）敏感性为95.9%（95%置信区间86.3-98.9），特异性为92%（95%置信区间75.0-97.8）；额外测定ACTH/催乳素标准化比值的BIPSS（n=51）敏感性分别为97.3%（95%置信区间86.2-99.5）和93.8%（95%置信区间71.7-98.9）。对于该组患者，MRI方法的敏感性为60.2%（95%置信区间52.6-67.5），特异性为59.2%（95%置信区间44.2-73.0）；增强全身CT的敏感性为74%（95%置信区间59.7-85.4），特异性为100%（95%置信区间97.95-100）。99mTc-Tectrotide SPECT在神经内分泌肿瘤（NET）可视化中的诊断准确性，敏感性为73.3%（95%置信区间44.9-92.2），特异性为100%（95%置信区间95.3-100）。
去氨加压素刺激联合催乳素测量以控制导管位置，并额外计算ACTH/催乳素标准化比值的BIPSS是EAS鉴别诊断的最佳方法。在BIPSS中确诊为EAS的患者可能需要进一步接受99mTc-Tectrotide SPECT和CT检查以实现肿瘤可视化。
