In more than one third of patients with
Cushing's disease, pituitary MRI does not identify a microadenoma. The diagnostic approach should be as rigorous as possible in patients with
ACTH-dependent
Cushing's syndrome, to obtain a definitive diagnosis. Improved pituitary MRI techniques, including dynamic sequences, optimal T1-weighted spin-echo MRI protocol, MRI technique of spoiled gradient recalled acquisition in the steady state, and using a 3-tesla magnet, improved the
tumor detection rate, parallel to the performance of endocrine dynamic tests (CRH stimulation,
desmopressin stimulation and high-dose
dexamethasone suppression tests). When a
pituitary tumor is not convincingly identified, inferior petrosal sinus sampling remains the gold standard for diagnosis, and recently, new approaches (simultaneous
prolactin measurement) could improve its sensitivity and specificity. Transsphenoidal surgery is the first-line treatment, with remission rates similar to those of patients with preoperative positive MRI. However, medical
therapies play an important role after surgical failure or in a search for the onset of a visible
tumor, especially with development of new drugs targeting the pituitary gland.