Algorithm for the Diagnosis, Localization, and Management of Endogenous Cushing Syndrome - Flowchart
Algorithm for the Diagnosis, Localization, and Management of Endogenous Cushing Syndrome - Flowchart Cushing Disease and Syndrome Cushing Disease and Syndrome
«Flowchart»

Biochemical diagnosis

24-hr urine free cortisol × 2

Biochemical diagnosis

24-hr urine free cortisol × 2

Biochemical diagnosis

24-hr urine free cortisol × 2

Normal

Normal

Normal

>3-fold elevation

>3-fold elevation

>3-fold elevation

<Next Node>

<Next Node>

<Next Node>

<Next Node>

Biochemical diagnosis

1-3 × normal

Biochemical diagnosis

1-3 × normal

Biochemical diagnosis

1-3 × normal

Biochemical diagnosis

Probable Cushing syndrome

Biochemical diagnosis

Probable Cushing syndrome

Biochemical diagnosis

Probable Cushing syndrome

Biochemical diagnosis

Cushing syndrome unlikely

Biochemical diagnosis

Cushing syndrome unlikely

Biochemical diagnosis

Cushing syndrome unlikely

Biochemical diagnosis

Late evening salivary cortisol × 2

Biochemical diagnosis

Late evening salivary cortisol × 2

Biochemical diagnosis

Late evening salivary cortisol × 2

<550 ng/dL

<550 ng/dL

<550 ng/dL

>550 ng/dL

>550 ng/dL

>550 ng/dL

End

End

End

Localization

ACTH-dependent disease

Localization

ACTH-dependent disease

Localization

ACTH-dependent disease

dependent

Localization

ACTH-independent disease

Localization

ACTH-independent disease

Localization

ACTH-independent disease

independent

Localization

ACTH

Localization

ACTH

Localization

ACTH

Undetectable

Undetectable

Undetectable

Detectable

Detectable

Detectable

Localization

CT of adrenals

Localization

CT of adrenals

Localization

CT of adrenals

Management

Adrenalectomy 90%+ effective

Management

Adrenalectomy 90%+ effective

Management

Adrenalectomy 90%+ effective

Management

Primary adrenal
Cushing syndrome (15%)

Management

Primary adrenal
Cushing syndrome (15%)

Management

Primary adrenal
Cushing syndrome (15%)


Management

Transsphenoidal pituitary microsurgery 75% effective

Management

Transsphenoidal pituitary microsurgery 75% effective

Management

Transsphenoidal pituitary microsurgery 75% effective

Localization

Pituitary MRI, high-dose dexamethasone suppression test

Localization

Pituitary MRI, high-dose dexamethasone suppression test

Localization

Pituitary MRI, high-dose dexamethasone suppression test

Mass >6 mm Suppression

Mass >6 mm Suppression

Mass >6 mm Suppression

No mass

No mass

No mass

Management

Failure

Management

Failure

Management

Failure

Management

Bilateral adrenalectomy

Management

Bilateral adrenalectomy

Management

Bilateral adrenalectomy

Management

Cushing disease (75%)

Management

Cushing disease (75%)

Management

Cushing disease (75%)

Localization

Chest/Abd CT, somatostatin receptor scintigraphy

Localization

Chest/Abd CT, somatostatin receptor scintigraphy

Localization

Chest/Abd CT, somatostatin receptor scintigraphy

Localization

Bilateral inferior petrosal sinus sampling

Localization

Bilateral inferior petrosal sinus sampling

Localization

Bilateral inferior petrosal sinus sampling

Gradient detected

Gradient detected

Gradient detected

No gradient

No gradient

No gradient

Management

Resection

Management

Resection

Management

Resection

Management

Ectopic ACTH (<10%)

Management

Ectopic ACTH (<10%)

Management

Ectopic ACTH (<10%)