Cushing's Disease: Its Roentgenographic Findings

Abstract

Cushing's disease, an unusual and complex endocrine disturbance, has been recognized in the past twenty years with increasing frequency. This increase in incidence, or in recognition, as well as the iatrogenic occurrence of the disease, warrants knowledge of its roentgenographic appearance. Relatively little, however, has appeared in the radiologic literature. The main roentgen features described are osteoporosis and associated fractures. Eisenhardt and Thompson (7), in a study of 61 patients, found the bones to be normal in only 3, the remainder showing definite to questionable osteoporosis. Sosman (8) reported 7 cases investigated from the diagnostic and therapeutic aspects, but critical appraisal of roentgenographic findings was not attempted. Sussman and Copleman (9) described osteoporosis in 6 of 7 cases reviewed, involving the skull, spine, and ribs, and in 1 instance the long bones. They emphasized, as “almost pathognomonic” for Cushing's disease, a peculiar, sharply defined, localized expansion of the lower ribs to about twice their normal diameter just lateral to the costochondral junction. This callus-like abnormality was indistinguishable either roentgenographically or histologically from callus resulting from fracture. This bizarre and as yet poorly understood entity is of complicated etiological background, but is said to be due to hyperadrenocorticism resulting from pituitary basophilism, adrenal cortical hyperplasia, adenoma, or carcinoma. It is believed that the changes in bone are the result of a disturbance of protein metabolism leading to insufficient tissue repair and to lack of bony matrix formation and calcium deposition, resulting in osteoporosis (1, 3). A typical full-blown case of Cushing's disease is easily recognized (2). It is characterized clinically by unusual deposition of fat chiefly limited to the face, neck, and trunk, producing the appearances commonly described as “moon face” and “buffalo hump.” In contrast, the extremities are thin and wasted. The patients tend to have acne and atrophy of the skin with purplish striae of the abdominal wall, and to bruise easily. There are also undue fatigability, susceptibility to infection, hirsutism without virilism, amenorrhea, gonadal suppression, hypertension, and osteoporosis. The laboratory findings include glycosuria, a decreased sugar tolerance, slight polycythemia, and mild leukocytosis with lymphopenia and eosinopenia. The serum calcium and phosphorus are normal. The present study is based on a review of the roentgenograms of 38 patients with Cushing's disease. The first diagnosis of this condition was made at the Massachusetts General Hospital in 1935, and in the subsequent twenty years 49 patients with the disease were admitted. For 38, roentgenograms are available and the findings are herewith presented.