Advances in the diagnosis and treatment of Cushing's syndrome.

Excess endogenous glucocorticoid production, whether ACTH-dependent or ACTH-independent, results in the classic clinical and biochemical picture of Cushing's syndrome. The diagnosis requires demonstration of an increased cortisol secretion rate, best achieved using determination of urinary free cortisol as an index. In mild cases, distinction from the hypercortisolism of pseudo-Cushing states may prove difficult. If the physician is in doubt, a dexamethasone/CRH test should be performed. Primary adrenal Cushing's syndrome can be diagnosed on the basis of undetectable plasma ACTH and the results of adrenal imaging procedures. ACTH-dependent Cushing's syndrome can be differentiated using an oCRH test and imaging procedures. In the presence of a discrete pituitary lesion on imaging, a standard oCRH test with results consistent with such a lesion is sufficient to proceed to transsphenoidal surgery. In the absence of such a lesion or if the oCRH test is equivocal, simultaneous BIPSS with oCRH administration should be performed to distinguish between a pituitary or ectopic source. Surgical ablation is the treatment of choice for all types of Cushing's syndrome. In the 5% of cases with Cushing's disease in whom transsphenoidal surgery fails and in the 5% of cases in whom the disease recurs, repeat transsphenoidal surgery or radiation therapy in association with mitotane treatment are reasonable alternatives. Bilateral adrenalectomy effectively cures hypercortisolism if resection of the ACTH-secreting tumour is unsuccessful and radiation/medical therapy fails.