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Jugular Venous Sampling: An Alternative to Petrosal Sinus Sampling for the Diagnostic Evaluation of Adrenocorticotropic Hormone-Dependent Cushing’s Syndrome

Pediatric and Reproductive Endocrinology Branch (I.I., K.P., L.K.N.), National Institute of Child Health and Human Development; Department of Radiology (R.C., J.D.) and Biostatistics and Clinical Epidemiology Service (R.W.), Warren Grant Magnuson Clinical Center; and Surgical Neurology Branch (E.H.O.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892

Address all correspondence and requests for reprints to: Lynnette K. Nieman, M.D., Building 10, Room 9D42 MSC 1583, 10 Center Drive, Bethesda, Maryland 20892-1583. E-mail: NiemanL{at}nih.gov.

Bilateral sampling of the inferior petrosal sinuses (IPSS) to distinguish Cushing’s disease from the ectopic ACTH syndrome is accurate but risky and technically difficult. Bilateral sampling of the internal jugular vein (JVS) is simpler and presumably safer. To compare jugular and petrosal sinus venous sampling for distinguishing Cushing’s disease from ectopic ACTH syndrome, we studied 74 patients with surgically proven Cushing’s disease, 11 with surgically confirmed, and three with occult ectopic ACTH secretion. Patients underwent JVS and IPSS with administration of CRH on separate days. Ratios of central-to-peripheral ACTH in venous samples were calculated. At 100% specificity, IPSS correctly identified 61 of 65 patients with Cushing’s disease [sensitivity, 94%; confidence interval (CI), 84–98%]. When patients with abnormal venous drainage were excluded, sensitivity was 98% (CI, 90–100%). JVS had a sensitivity of 83% (CI, 71–91%) at 100% specificity. Receiver operated characteristics plot areas under the curve were similar (0.968 ± 0.020 and 0.974 ± 0.016, area under the curve ± SE, JVS vs. IPSS). Although petrosal sampling had better diagnostic accuracy, CIs overlapped (95% CI, 90–100% vs. 86% CI, 78–94%). Centers with limited sampling experience may choose to use the simpler JVS and refer patients for IPSS when the results are negative.

This work was supported by the intramural division of the National Institutes of Health (Bethesda, MD).

This work was presented in part at The Endocrine Society’s 85th Annual Meeting, June 19–22, 2003, in Philadelphia, Pennsylvania.

Abbreviations: AUC, Area under the curve; CI, confidence interval; C/P, central-to-peripheral; IPSS, inferior petrosal sinus sampling; JVS, internal jugular vein sampling; LR, likelihood ratio; MRI, magnetic resonance imaging; ROC, receiver operated characteristics.

¹ Deceased.

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