Cushing's Syndrome
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This pathway provides guidance on the imaging of adult patients with Cushing's syndrome.
Date reviewed: August 2017
Date of next review: June 2023
Published: April 2018
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page |
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| 1a |  |
Cushing's Disease Image 1a and b (Magnetic Resonance Imaging): There is a right sided pituitary adenoma (arrows) measuring up to 14mm with deviation of the stalk to the left. Slight suprasellar extension is noted without impingement of the chiasm or optic nerves. |
| 1b |  |
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| 2a |  |
Pituitary Macroadenoma Image 2a and 2b: Post-mortem specimens showing a circumcribed nodular tumour arising from the anterior pituitary consistent with a macroadenoma. |
| 2b |  |
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| 2c |  |
Image 2c (H&E, x2.5) and 2d (H&E, x20): Histological sections demonstrating a circumscribed lesion composed of sheets of uniform polygonal cells with centrally placed nuclei and amphophilic cytoplasm. The features are consistent with a pituitary adenoma. |
| 2d |  |
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Teaching Points
Teaching Points
- A thorough clinical assessment and biochemical analysis along with imaging studies are required in the work up of Cushing’s Syndrome
- Once Cushing's Syndrome is confirmed biochemically, further imaging is dictated by the ACTH
- ACTH suppressed – Likely primary adrenocortical lesion and CT scan of the adrenals is required
- ACTH normal or high – Either pituitary disease or ectopic source of ACTH. Further biochemical testing with dexamethasone suppression may help differentiate the two causes prior to imaging
References
References
Date of literature search: July 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Sahdev A, Reznek RH, Evanson J, Grossman AB. Imaging in Cushing's syndrome. Arq Bras Endocrinol Metabol. 2007;51(8):1319-28. (Review Article). View the reference
- Mengden T, Hubmann P, Muller J, Greminger P, Vetter W. Urinary free cortisol versus 17-hydroxycorticosteroids: a comparative study of their diagnostic value in Cushing's syndrome. Clin Investig. 1992;70(7):545-8. (Level III evidence). View the reference
- Wagner-Bartak NA, Baiomy A, Habra MA, Mukhi SV, Morani AC, Korivi BR, et al. Cushing Syndrome: Diagnostic Workup and Imaging Features, With Clinical and Pathologic Correlation. AJR Am J Roentgenol. 2017;209(1):19-32. (Review article). View the reference
- Goldfarb DA. Contemporary evaluation and management of Cushing's syndrome. World J Urol. 1999;17(1):22-5. (Review article). View the reference
- Boscaro M, Barzon L, Fallo F, Sonino N. Cushing's syndrome. Lancet. 2001;357(9258):783-91. (Review article). View the reference
- Newell-Price J, Trainer P, Besser M, Grossman A. The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's states. Endocr Rev. 1998;19(5):647-72. (Review article). View the reference
- Kaye TB, Crapo L. The Cushing syndrome: an update on diagnostic tests. Ann Intern Med. 1990;112(6):434-44. (Level II evidence). View the reference
- Buchfelder M, Nistor R, Fahlbusch R, Huk WJ. The accuracy of CT and MR evaluation of the sella turcica for detection of adrenocorticotropic hormone-secreting adenomas in Cushing disease. AJNR Am J Neuroradiol. 1993;14(5):1183-90. (Level III evidence). View the reference
- Colombo N, Loli P, Vignati F, Scialfa G. MR of corticotropin-secreting pituitary microadenomas. AJNR Am J Neuroradiol. 1994;15(8):1591-5. (Level IV evidence). View the reference
- de Herder WW, Uitterlinden P, Pieterman H, Tanghe HL, Kwekkeboom DJ, Pols HA, et al. Pituitary tumour localization in patients with Cushing's disease by magnetic resonance imaging. Is there a place for petrosal sinus sampling? Clin Endocrinol (Oxf). 1994;40(1):87-92. (Level III evidence). View the reference
- Doppman JL, Frank JA, Dwyer AJ, Oldfield EH, Miller DL, Nieman LK, et al. Gadolinium DTPA enhanced MR imaging of ACTH-secreting microadenomas of the pituitary gland. J Comput Assist Tomogr. 1988;12(5):728-35. (Level IV evidence). View the reference
- Zampetti B, Grossrubatscher E, Dalino Ciaramella P, Boccardi E, Loli P. Bilateral inferior petrosal sinus sampling. Endocr Connect. 2016;5(4):R12-25. (Review article). View the reference
- Oldfield EH, Doppman JL, Nieman LK, Chrousos GP, Miller DL, Katz DA, et al. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome. N Engl J Med. 1991;325(13):897-905. (Level III evidence). View the reference
- Findling JW, Raff H. Cushing's Syndrome: important issues in diagnosis and management. J Clin Endocrinol Metab. 2006;91(10):3746-53. (Review article). View the reference
- Guo Q, Young WF, Erickson D, Erickson B. Usefulness of dynamic MRI enhancement measures for the diagnosis of ACTH-producing pituitary adenomas. Clin Endocrinol (Oxf). 2015;82(2):267-73. (Level III evidence). View the reference
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Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy |
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