Subscribe to RSS
DOI: 10.1055/a-2299-5065
Subtyping of Cushing’s Syndrome: A Step Ahead
Abstract
Cushing’s Syndrome (CS) is a rare disease due to chronic endogenous cortisol secretion. In recent years, new developments have broadened the spectrum of differential diagnosis, traditionally categorized as adrenocorticotropic hormone (ACTH)-dependent and ACTH-independent forms. Moreover, increased awareness of the detrimental effects of cortisol on cardiometabolic health and the risk of cardiovascular events lead to increased diagnosis of mild forms, especially in the context of adrenal incidentalomas.
This review provides an up-to-date narrative of the most recent literature regarding the challenges of CS diagnosis. After the description of the diagnostic tools available, the functional non-neoplastic hypercortisolism (formerly known as pseudo-Cushing state) is characterized, followed by the subtyping of the different conditions of hypercortisolism, including the differential diagnosis of ACTH-dependent forms and the management of adrenal hypercortisolism, with peculiar attention to the new genetic classification of adrenal CS, mild autonomous cortisol secretion, and bilateral adrenal adenomas.
Keywords
Cushing’s Syndrome - Cushing’s disease - ectopic ACTH secretion - diagnosis - non-neoplastic hypercortisolismPublication History
Received: 13 January 2024
Received: 26 March 2024
Accepted: 03 April 2024
Accepted Manuscript online:
04 April 2024
Article published online:
03 June 2024
© 2024. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
References
- 1 Nieman LK, Biller BMK, Findling JW. et al. The diagnosis of Cushing’s syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2008; 93: 1526-1540 DOI: 10.1210/jc.2008-0125.
- 2 Gadelha M, Gatto F, Wildemberg LE. et al. Cushing’s syndrome. Lancet 2023; 402: 2237-2252 DOI: 10.1016/S0140-6736(23)01961-X.
- 3 Reincke M, Fleseriu M. Cushing syndrome. JAMA 2023; 330: 170 DOI: 10.1001/jama.2023.11305.
- 4 Ceccato F, Boscaro M. Cushing’s syndrome: Screening and diagnosis. High Blood Press Cardiovasc Prev 2016; 23: 209-215 DOI: 10.1007/s40292-016-0153-4.
- 5 Louiset E, Duparc C, Young J. et al. Intraadrenal corticotropin in bilateral macronodular adrenal hyperplasia. N Engl J Med 2013; 369: 2115-2125 DOI: 10.1056/NEJMoa1215245.
- 6 Findling JW, Raff H. Recognition of nonneoplastic hypercortisolism in the evaluation of patients with Cushing syndrome. J Endocr Soc 2023; 7 DOI: 10.1210/jendso/bvad087.
- 7 Scaroni C, Albiger NM, Palmieri S. et al. Approach to patients with pseudo-Cushing’s states. Endocr Connect 2020; 9: R1-R13 DOI: 10.1530/EC-19-0435.
- 8 Galm BP, Qiao N, Klibanski A. et al. Accuracy of laboratory tests for the diagnosis of Cushing syndrome. J Clin Endocrinol Metab 2020; 105: 1-14 DOI: 10.1210/clinem/dgaa105.
- 9 Khalil RB, Baudry C, Guignat L. et al. Sequential hormonal changes in 21 patients with recurrent Cushing’s disease after successful pituitary surgery. Eur J Endocrinol 2011; 165: 729-737 DOI: 10.1530/EJE-11-0424.
- 10 Scaroni C, Mondin A, Ceccato F. How to rule out non-neoplastic hypercortisolemia (previously known as pseudo-Cushing. Pituitary 2022; 25: 701-704 DOI: 10.1007/s11102-022-01222-2.
- 11 Fleseriu M, Varlamov EV, Hinojosa-Amaya JM. et al. An individualized approach to the management of Cushing disease. Nat Rev Endocrinol 2023; 19: 581-599 DOI: 10.1038/s41574-023-00868-7.
- 12 Young J, Haissaguerre M, Viera-Pinto O. et al. Cushing’s syndrome due to ectopic ACTH secretion: An expert operational opinion. Eur J Endocrinol 2020; 182: R29-R58 DOI: 10.1530/EJE-19-0877.
- 13 Boscaro M, Arnaldi G. Approach to the patient with possible Cushing’s syndrome. J Clin Endocrinol Metab 2009; 94: 3121-3131 DOI: 10.1210/jc.2009-0612.
- 14 Nowak E, Vogel F, Albani A. et al. Diagnostic challenges in cyclic Cushing’s syndrome: A systematic review. Lancet Diabetes Endocrinol 2023; 11: 593-606 DOI: 10.1016/S2213-8587(23)00150-X.
- 15 Pecori Giraldi F, Saccani A, Cavagnini F. et al. Assessment of ACTH assay variability: A multicenter study. Eur J Endocrinol 2011; 164: 505-512 DOI: 10.1530/EJE-10-0962.
- 16 Ceccato F, Tizianel I, Vedolin CK. Human corticotropin-releasing hormone tests: 10 years of real-life experience in pituitary and adrenal disease. J Clin Endocrinol Metab 2020; 105: e3938-e3949 DOI: 10.1210/clinem/dgaa564.
- 17 Pecori Giraldi F, Invitti C, Cavagnini F. Study group of the Italian Society of Endocrinology on the pathophysiology of the hypothalamic-pituitary-adrenal axis. The corticotropin-releasing hormone test in the diagnosis of ACTH-dependent Cushing’s syndrome: A reappraisal. Clin Endocrinol (Oxf) 2001; 54: 601-607 DOI: 10.1046/j.1365-2265.2001.01258.x.
- 18 Ceccato F, Di Dalmazi G. Shortage of hCRH for the diagnosis of endogenous CS: The end of an era or the beginning of a new journey?. J Endocrinol Invest 2023; 46: 2189-2191 DOI: 10.1007/s40618-023-02113-4.
- 19 Ritzel K, Beuschlein F, Berr C. et al. ACTH after 15 min distinguishes between Cushing’s disease and ectopic Cushing’s syndrome: A proposal for a short and simple CRH test. Eur J Endocrinol 2015; 173: 197-204 DOI: 10.1530/EJE-14-0912.
- 20 Detomas M, Ritzel K, Nasi-Kordhishti I. et al. Outcome of CRH stimulation test and overnight 8 mg dexamethasone suppression test in 469 patients with ACTH-dependent Cushing’s syndrome. Front Endocrinol (Lausanne) 2022; 13 DOI: 10.3389/fendo.2022.955945.
- 21 Barbot M, Albiger N, Koutroumpi S. et al. Predicting late recurrence in surgically treated patients with Cushing’s disease. Clin Endocrinol (Oxf) 2013; 79: 394-401 DOI: 10.1111/cen.12133.
- 22 Ceccato F, Barbot M, Mondin A. et al. Dynamic testing for differential diagnosis of ACTH-dependent Cushing syndrome: A systematic review and meta-analysis. J Clin Endocrinol Metab 2023; 108: e178-e188 DOI: 10.1210/clinem/dgac686.
- 23 Ceccato F, Artusi C, Barbot M. et al. Dexamethasone measurement during low-dose suppression test for suspected hypercortisolism: Threshold development with and validation. J Endocrinol Invest 2020; 43: 1105-1113 DOI: 10.1007/s40618-020-01197-6.
- 24 Nieman LK. Is it time for a new approach to the differential diagnosis of ACTH-dependent Cushing syndrome. J Clin Endocrinol Metab 2020; 105: e4964-e4966 DOI: 10.1210/clinem/dgaa493.
- 25 Loriaux DL. Diagnosis and differential diagnosis of Cushing’s syndrome. N Engl J Med 2017; 376: 1451-1459 DOI: 10.1056/NEJMra1505550.
- 26 Fleseriu M, Auchus R, Bancos I. et al. Consensus on diagnosis and management of Cushing’s disease: A guideline update. Lancet Diabetes Endocrinol 2021; 9: 847-875 DOI: 10.1016/S2213-8587(21)00235-7.
- 27 Webb KL, Hinkle ML, Walsh MT. et al. Inferior petrosal sinus sampling tumor lateralization and the surgical treatment of Cushing disease: A meta-analysis and systematic review. World Neurosurg 2024; 182: e712-e720 DOI: 10.1016/j.wneu.2023.12.024.
- 28 Wang H, Ba Y, Xing Q. et al. Differential diagnostic value of bilateral inferior petrosal sinus sampling (BIPSS) in ACTH-dependent Cushing syndrome: A systematic review and meta-analysis. BMC Endocr Disord 2020; 20: 143 DOI: 10.1186/s12902-020-00623-3.
- 29 Pecori Giraldi F, Cavallo LM, Tortora F. et al. The role of inferior petrosal sinus sampling in ACTH-dependent Cushing’s syndrome: Review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology. Neurosurg Focus 2015; 38: E5 DOI: 10.3171/2014.11.FOCUS14766.
- 30 Perlman JE, Johnston PC, Hui F. et al. Pitfalls in Performing and interpreting inferior petrosal sinus sampling: Personal experience and literature review. J Clin Endocrinol Metab 2021; 106: e1953-e1967 DOI: 10.1210/clinem/dgab012.
- 31 Almeida de TS, Rodrigues T, da C Costenaro F. et al. Enhancing Cushing’s disease diagnosis: Exploring the impact of desmopressin on ACTH gradient during BIPSS. Front Endocrinol (Lausanne) 2023; 14 DOI: 10.3389/fendo.2023.1224001.
- 32 Chen S, Chen K, Wang S. et al. The optimal cut-off of BIPSS in differential diagnosis of ACTH-dependent Cushing’s syndrome: Is stimulation necessary?. J Clin Endocrinol Metab 2020; 105 DOI: 10.1210/clinem/dgz194.
- 33 Pecori Giraldi F, Federici AB, Cavagnini F. Caution during use of desmopressin in IPSS. J Neurointerv Surg 2013; 5: e27 DOI: 10.1136/neurintsurg-2012-010580.
- 34 Detomas M, Ritzel K, Nasi-Kordhishti I. et al. Bilateral inferior petrosal sinus sampling with human CRH stimulation in ACTH-dependent Cushing’s syndrome: Results from a retrospective multicenter study. Eur J Endocrinol 2023; 188: 448-456 DOI: 10.1093/ejendo/lvad050.
- 35 Frete C, Corcuff J-B, Kuhn E. et al. Non-invasive diagnostic strategy in ACTH-dependent Cushing’s syndrome. J Clin Endocrinol Metab 2020; 105: 3273-3284 DOI: 10.1210/clinem/dgaa409.
- 36 Ferrante E, Barbot M, Serban AL. et al. Indication to dynamic and invasive testing in Cushing’s disease according to different neuroradiological findings. J Endocrinol Invest 2022; 45: 629-637 DOI: 10.1007/s40618-021-01695-1.
- 37 Isidori AM, Kaltsas GA, Pozza C. et al. The ectopic adrenocorticotropin syndrome: Clinical features, diagnosis, management, and long-term follow-up. J Clin Endocrinol Metab 2006; 91: 371-377 DOI: 10.1210/jc.2005-1542.
- 38 Davi’ MV, Cosaro E, Piacentini S. et al. Prognostic factors in ectopic Cushing’s syndrome due to neuroendocrine tumors: A multicenter study. Eur J Endocrinol 2017; 176: 453-461 DOI: 10.1530/EJE-16-0809.
- 39 Ragnarsson O, Juhlin CC, Torpy DJ. et al. A clinical perspective on ectopic Cushing’s syndrome. Trends Endocrinol Metab 2024; 35: 347-360 DOI: 10.1016/j.tem.2023.12.003.
- 40 Isidori AM, Sbardella E, Zatelli MC. et al. Conventional and nuclear medicine imaging in ectopic Cushing’s syndrome: A systematic review. J Clin Endocrinol Metab 2015; 100: 3231-3244 DOI: 10.1210/JC.2015-1589.
- 41 Goroshi MR, Jadhav SS, Lila AR. et al. Comparison of 68Ga-DOTANOC PET/CT and contrast-enhanced CT in localisation of tumours in ectopic ACTH syndrome. Endocr Connect 2016; 5: 83-91 DOI: 10.1530/EC-16-0010.
- 42 Wannachalee T, Turcu AF, Bancos I. et al. The clinical impact of [68Ga]-DOTATATE PET/CT for the diagnosis and management of ectopic adrenocorticotropic hormone – secreting tumours. Clin Endocrinol (Oxf) 2019; 91: 288-294 DOI: 10.1111/cen.14008.
- 43 Ceccato F, Cecchin D, Gregianin M. et al. The role of68ga-dota derivatives PET-CT in patients with ectopic ACTH syndrome. Endocr Connect 2020; 9: 337-345 DOI: 10.1530/EC-20-0089.
- 44 de Bruin C, Feelders RA, Waaijers AM. et al. Differential regulation of human dopamine D2 and somatostatin receptor subtype expression by glucocorticoids in vitro. J Mol Endocrinol 2009; 42: 47-56 DOI: 10.1677/JME-08-0110.
- 45 Davi’ MV, Salgarello M, Francia G. Positive 68Ga-DOTATOC-PET/CT after cortisol level control during ketoconazole treatment in a patient with liver metastases from a pancreatic neuroendocrine tumor and ectopic Cushing syndrome. Endocrine 2015; 49: 566-567 DOI: 10.1007/s12020-014-0391-y.
- 46 Deutschbein T, Reimondo G, Di Dalmazi G. et al. Age-dependent and sex-dependent disparity in mortality in patients with adrenal incidentalomas and autonomous cortisol secretion: An international, retrospective, cohort study. Lancet Diabetes Endocrinol 2022; 10: 499-508 DOI: 10.1016/S2213-8587(22)00100-0.
- 47 Toini A, Dolci A, Ferrante E. et al. Screening for ACTH-dependent hypercortisolism in patients affected with pituitary incidentaloma. Eur J Endocrinol 2015; 172: 363-369 DOI: 10.1530/EJE-14-0599.
- 48 Misra M, Klibanski A. Endocrine consequences of anorexia nervosa. Lancet Diabetes Endocrinol 2014; 2: 581-592 DOI: 10.1016/S2213-8587(13)70180-3.
- 49 Schorr M, Miller KK. The endocrine manifestations of anorexia nervosa: Mechanisms and management. Nat Rev Endocrinol 2017; 13: 174-186 DOI: 10.1038/nrendo.2016.175.
- 50 Badrick E, Bobak M, Britton A. et al. The relationship between alcohol consumption and cortisol secretion in an aging cohort. J Clin Endocrinol Metab 2008; 93: 750-757 DOI: 10.1210/jc.2007-0737.
- 51 Mondin A, Barbot M, Voltan G. et al. Second-line tests in the differential diagnosis of neoplastic and non-neoplastic hypercortisolism: A systematic review and meta-analysis. J Endocrinol Invest 2023; 46: 1947-1959 DOI: 10.1007/s40618-023-02099-z.
- 52 Woo YS, Isidori AM, Wat WZ. et al. Clinical and biochemical characteristics of adrenocorticotropin-secreting macroadenomas. J Clin Endocrinol Metab 2005; 90: 4963-4969 DOI: 10.1210/jc.2005-0070.
- 53 Toivanen S, Leijon H, Arola A. et al. Characteristics and outcomes of the Finnish ectopic ACTH syndrome cohort. Endocrine 2021; 74: 387-395 DOI: 10.1007/s12020-021-02768-0.
- 54 Ceccato F, Trementino L, Barbot M. et al. Diagnostic accuracy of increased urinary cortisol/cortisone ratio to differentiate ACTH-dependent Cushing’s syndrome. Clin Endocrinol (Oxf) 2017; 87: 500-507 DOI: 10.1111/cen.13391.
- 55 Yogi-Morren D, Habra MA, Faiman C. et al. Pituitary MRI findings in patients with pituitary and ectopic ACTH-dependent Cushing syndrome: Does a 6-mm pituitary tumor size cut-off value exclude ectopic ACTH syndrome. Endocr Pract 2015; 21: 1098-1103 DOI: 10.4158/EP15662.OR.
- 56 Vilar L, Freitas MC, Naves LA. et al. The role of non-invasive dynamic tests in the diagnosis of Cushing’s syndrome. J Endocrinol Invest 2008; 31: 1008-1013 DOI: 10.1007/BF03345640.
- 57 Barbot M, Trementino L, Zilio M. et al. Second-line tests in the differential diagnosis of ACTH-dependent Cushing’s syndrome. Pituitary 2016; 19: 488-495 DOI: 10.1007/s11102-016-0729-y.
- 58 Elenius H, McGlotten R, Nieman LK. Ovine CRH stimulation and 8 mg dexamethasone suppression tests in 323 patients with ACTH-dependent Cushing’s syndrome. J Clin Endocrinol Metab 2023; 109: e182-e189 DOI: 10.1210/clinem/dgad454.
- 59 Bashari WA, Gillett D, MacFarlane J. et al. Modern imaging in Cushing’s disease. Pituitary 2022; 25: 709-712 DOI: 10.1007/s11102-022-01236-w.
- 60 Kasaliwal R, Sankhe SS, Lila AR. et al. Volume interpolated 3D-spoiled gradient echo sequence is better than dynamic contrast spin echo sequence for MRI detection of corticotropin secreting pituitary microadenomas. Clin Endocrinol (Oxf) 2013; 78: 825-830 DOI: 10.1111/cen.12069.
- 61 Grober Y, Grober H, Wintermark M. et al. Comparison of MRI techniques for detecting microadenomas in Cushing’s disease. J Neurosurg 2018; 128: 1051-1057 DOI: 10.3171/2017.3.JNS163122.
- 62 Gillett D, MacFarlane J, Bashari W. et al. Molecular imaging of pituitary tumors. Semin Nucl Med 2023; 53: 530-538 DOI: 10.1053/j.semnuclmed.2023.02.005.
- 63 Koulouri O, Steuwe A, Gillett D. et al. A role for 11C-methionine PET imaging in ACTH-dependent Cushing’s syndrome. Eur J Endocrinol 2015; 173: M107-M120 DOI: 10.1530/EJE-15-0616.
- 64 Berkmann S, Roethlisberger M, Mueller B. et al. Selective resection of Cushing microadenoma guided by preoperative hybrid 18-fluoroethyl-L-tyrosine and 11-C-methionine PET/MRI. Pituitary 2021; 24: 878-886 DOI: 10.1007/s11102-021-01160-5.
- 65 Walia R, Gupta R, Bhansali A. et al. Molecular imaging targeting corticotropin-releasing hormone receptor for corticotropinoma: A changing paradigm. J Clin Endocrinol Metab 2021; 106: 1816-1826 DOI: 10.1210/clinem/dgaa755.
- 66 Fassnacht M, Tsagarakis S, Terzolo M. et al. European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2023; 189: G1-G42 DOI: 10.1093/ejendo/lvad066.
- 67 Pelsma ICM, Fassnacht M, Tsagarakis S. et al. Comorbidities in mild autonomous cortisol secretion and the effect of treatment: Systematic review and meta-analysis. Eur J Endocrinol 2023; 189: S88-S101 DOI: 10.1093/ejendo/lvad134.
- 68 Ceccato F, Antonelli G, Frigo AC. et al. First-line screening tests for Cushing’s syndrome in patients with adrenal incidentaloma: The role of urinary free cortisol measured by LC-MS/MS. J Endocrinol Invest 2017; 40: 753-760 DOI: 10.1007/s40618-017-0644-8.
- 69 Di Dalmazi G, Altieri B, Scholz C. et al. RNA sequencing and somatic mutation status of adrenocortical tumors: Novel pathogenetic insights. J Clin Endocrinol Metab 2020; 105: dgaa616 DOI: 10.1210/clinem/dgaa616.
- 70 Araujo-Castro M, Marazuela M. Cushing´s syndrome due to bilateral adrenal cortical disease: Bilateral macronodular adrenal cortical disease and bilateral micronodular adrenal cortical disease. Front Endocrinol (Lausanne) 2022; 13: 913253 DOI: 10.3389/fendo.2022.913253.
- 71 Ceccato F, Barbot M, Scaroni C. et al. Frequently asked questions and answers (if any) in patients with adrenal incidentaloma. J Endocrinol Invest 2021; 44: 2749-2763 DOI: 10.1007/s40618-021-01615-3.
- 72 Cavalcante IP, Berthon A, Fragoso MC. et al. Primary bilateral macronodular adrenal hyperplasia: Definitely a genetic disease. Nat Rev Endocrinol 2022; 18: 699-711 DOI: 10.1038/s41574-022-00718-y.
- 73 Espiard S, Drougat L, Libé R. et al. ARMC5 mutations in a large cohort of primary macronodular adrenal hyperplasia: Clinical and functional consequences. J Clin Endocrinol Metab 2015; 100: E926-E935 DOI: 10.1210/jc.2014-4204.
- 74 Albiger NM, Regazzo D, Rubin B. et al. A multicenter experience on the prevalence of ARMC5 mutations in patients with primary bilateral macronodular adrenal hyperplasia: From genetic characterization to clinical phenotype. Endocrine 2017; 55: 959-968 DOI: 10.1007/s12020-016-0956-z.
- 75 Jojima T, Kogai T, Iijima T. et al. Genetic alteration of ARMC5 in a patient diagnosed with meningioma and primary macronodular adrenal hyperplasia: A case report. Eur J Endocrinol 2020; 183: K7-K12 DOI: 10.1530/EJE-20-0014.
- 76 Chasseloup F, Bourdeau I, Tabarin A. et al. Loss of KDM1A in GIP-dependent primary bilateral macronodular adrenal hyperplasia with Cushing’s syndrome: A multicentre, retrospective, cohort study. Lancet Diabetes Endocrinol 2021; 9: 813-824 DOI: 10.1016/S2213-8587(21)00236-9.
- 77 Vaczlavik A, Bouys L, Violon F. et al. KDM1A inactivation causes hereditary food-dependent Cushing syndrome. Genet Med 2022; 24: 374-383 DOI: 10.1016/j.gim.2021.09.018.
- 78 Kamilaris C, Faucz F, Voutetakis A. et al. Carney complex. Exp Clin Endocrinol Diabetes 2019; 127: 156-164 DOI: 10.1055/a-0753-4943.
- 79 Kirschner LS, Carney JA, Pack SD. et al. Mutations of the gene encoding the protein kinase A type I-α regulatory subunit in patients with the Carney complex. Nat Genet 2000; 26: 89-92 DOI: 10.1038/79238.
- 80 Bertherat J, Groussin L, Sandrini F. et al. Molecular and functional analysis of PRKAR1A and its locus (17q22-24) in sporadic adrenocortical tumors: 17q losses, somatic mutations, and protein kinase A expression and activity. Cancer Res 2003; 63: 5308-5319 http://www.ncbi.nlm.nih.gov/pubmed/14500362
- 81 Stratakis CA, Sarlis N, Kirschner LS. et al. Paradoxical response to dexamethasone in the diagnosis of primary pigmented nodular adrenocortical disease. Ann Intern Med 1999; 131: 585 DOI: 10.7326/0003-4819-131-8-199910190-00006.
- 82 Albiger NM, Occhi G, Sanguin F. et al. Adrenal nodules in patients with Cushing’s disease: Prevalence, clinical significance and follow-up. J Endocrinol Invest 2011; 34: 1-20 DOI: 10.3275/7349.
- 83 Di Dalmazi G, Timmers HJLM, Arnaldi G. et al. Somatic PRKACA mutations: Association with transition from pituitary-dependent to adrenal-dependent Cushing syndrome. J Clin Endocrinol Metab 2019; 104: 5651-5657 DOI: 10.1210/jc.2018-02209.
- 84 Tizianel I, Detomas M, Deutschbein T. et al. Corticotropin-releasing hormone test predicts the outcome of unilateral adrenalectomy in primary bilateral macronodular adrenal hyperplasia. J Endocrinol Invest 2024; 47: 749-756 DOI: 10.1007/s40618-023-02204-2.
- 85 Albiger NM, Ceccato F, Zilio M. et al. An analysis of different therapeutic options in patients with Cushing’s syndrome due to bilateral macronodular adrenal hyperplasia: A single-centre experience. Clin Endocrinol (Oxf) 2015; 82 DOI: 10.1111/cen.12763.
- 86 Katabathina VS, Flaherty E, Kaza R. et al. Adrenal collision tumors and their mimics: Multimodality imaging findings. Cancer Imaging 2013; 13: 602-610 DOI: 10.1102/1470-7330.2013.0053.
- 87 Barat M, Cottereau A-S, Gaujoux S. et al. Adrenal mass characterization in the era of quantitative imaging: State of the art. Cancers (Basel) 2022; 14: 569 DOI: 10.3390/cancers14030569.
- 88 Boland GW, Lee MJ, Gazelle GS. et al. Characterization of adrenal masses using unenhanced CT: An analysis of the CT literature. Am J Roentgenol 1998; 171: 201-204 DOI: 10.2214/ajr.171.1.9648789.
- 89 Ceccato F, Tizianel I, Voltan G. et al. Attenuation value in adrenal incidentalomas: A longitudinal study. Front Endocrinol (Lausanne) 2021; 12: 1-9 DOI: 10.3389/fendo.2021.794197.
- 90 Nandra G, Duxbury O, Patel P. et al. Technical and interpretive pitfalls in adrenal imaging. RadioGraphics 2020; 40: 1041-1060 DOI: 10.1148/rg.2020190080.
- 91 Boland GWL, Dwamena BA, Jagtiani Sangwaiya M. et al. Characterization of adrenal masses by using FDG PET: A systematic review and meta-analysis of diagnostic test performance. Radiology 2011; 259: 117-126 DOI: 10.1148/radiol.11100569.
- 92 Kim SJ, Lee SW, Pak K. et al. Diagnostic accuracy of 18F-FDG PET or PET/CT for the characterization of adrenal masses: A systematic review and meta-analysis. Br J Radiol 2018; 91: 20170520 DOI: 10.1259/bjr.20170520.
- 93 Patel D, Gara SK, Ellis RJ. et al. FDG PET/CT scan and functional adrenal tumors: A pilot study for lateralization. World J Surg 2016; 40: 683-689 DOI: 10.1007/s00268-015-3242-y.
- 94 Acharya R, Dhir M, Bandi R. et al. Outcomes of adrenal venous sampling in patients with bilateral adrenal masses and ACTH-independent Cushing’s syndrome. World J Surg 2019; 43: 527-533 DOI: 10.1007/s00268-018-4788-2.
- 95 Rubinstein G, Osswald A, Braun LT. et al. The role of adrenal venous sampling (AVS) in primary bilateral macronodular adrenocortical hyperplasia (PBMAH): A study of 16 patients. Endocrine 2022; 76: 434-445 DOI: 10.1007/s12020-022-03020-z.