The Role of Non-Invasive Dynamic Tests in the Diagnosis of Cushing's Syndrome.

Objective : To evaluate the role of non-invasive dynamic tests in the diagnosis and differential diagnosis of Cushing’s syndrome (CS). Methods : We studied laboratory features of 74 patients with endogenous CS, subdivided as follows: 46 (62.1%) with Cushing’s disease (CD), 21 (28.3%) with an adrenal tumor, and 7 (9.5%) with ectopic ACTH syndrome (EAS). Results : In 100% of cases of CS we found serum cortisol levels greater than 1.8 μg/dl after low-dose dexamethasone suppression tests (LDDST), as well as elevation of midnight serum or salivary cortisol. However, urinary free cortisol was normal in 11.5% of patients. ACTH levels were suppressed in patients with adrenal tumors, normal or high in CD and invariably increased in EAS. After the 8-mg overnight dexamethasone suppression test (HDDST), serum cortisol suppression >50% was observed in 79.5% of cases of CD and in 28.6% of subjects with EAS, whereas cortisol suppression >80% was only found in CD. After stimulation with CRH or desmopressin an ACTH rise ≥ 35% occurred in 86.5% of individuals with CD and 14.3% of those with EAS, whereas an ACTH rise ≥ 50 achieved 100% specificity. Moreover, the combination of serum cortisol suppression >50% after HDDST and an ACTH increase ≥ 35% after the administration of CRH or desmopressin only occurred in CD. Conclusion : Our findings demonstrate that LDDST had 100% sensitivity for the diagnosis of CS and that HDDST and stimulation tests with CRH or desmopressin may be very useful for confirmation of CS etiology when analyzed together or when more stringent cutoffs are used.