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Szychlińska M, Baranowska-Jurkun A, Matuszewski W, Wołos-Kłosowicz K, Bandurska-Stankiewicz E. Markers of Subclinical Cardiovascular Disease in Patients with Adrenal Incidentaloma. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E69. [PMID: 32050625 PMCID: PMC7074127 DOI: 10.3390/medicina56020069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 01/19/2023]
Abstract
Due to the growing availability of imaging examinations the percentage of patients with incidentally diagnosed adrenal tumors has increased. The vast majority of these lesions are benign, non-functioning adenomas, although according to various estimates even up to 30%-50% of patients with adrenal incidentaloma may present biochemical hypercortisolemia, without typical clinical features of Cushing's syndrome. Adrenal adenomas secreting small amounts of glucocorticoids may cause morphological and functional changes in the myocardium and blood vessels. Early stages of cardiovascular remodeling may be observed among asymptomatic patients with adrenal adenoma. Vascular changes precede the development of cardiovascular diseases and can increase morbidity and mortality in patients with adrenal incidentaloma. This risk may result not only from the traditional risk factors. Seemingly hormonally inactive adrenal tumors can indeed produce small amounts of glucocorticoids that have metabolic implications. Therefore, evaluation of patients with incidental adrenal findings presenting with subclinical cardiovascular disease seems of particular importance.
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Affiliation(s)
- Magdalena Szychlińska
- Clinic of Endocrinology, Diabetology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-900 Olsztyn, Poland; (A.B.-J.); (W.M.); (K.W.-K.); (E.B.-S.)
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Li D, El Kawkgi OM, Henriquez AF, Bancos I. Cardiovascular risk and mortality in patients with active and treated hypercortisolism. Gland Surg 2020; 9:43-58. [PMID: 32206598 DOI: 10.21037/gs.2019.11.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with hypercortisolism demonstrate high cardiovascular morbidity and mortality, especially if diagnosis is delayed. Hypercortisolism-induced cardiovascular and metabolic comorbidities include hypertension, impaired glucose metabolism, dyslipidemia, and obesity. High prevalence of cardiovascular risk factors leads to increased rate of cardiovascular events and mortality. This risk is reduced, albeit not reversed even after successful treatment of hypercortisolism. In this review we will describe prevalence and mechanisms of cardiovascular comorbidities in patients with hypercortisolism. In addition, we will summarize the effect of therapy on cardiovascular risk factors, events, as well as mortality.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Omar M El Kawkgi
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Andres F Henriquez
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
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53
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Kelsall A, Iqbal A, Newell-Price J. Adrenal incidentaloma: cardiovascular and metabolic effects of mild cortisol excess. Gland Surg 2020; 9:94-104. [PMID: 32206602 DOI: 10.21037/gs.2019.11.19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the vast majority of cases adrenal incidentalomas (AI) are benign adrenocortical adenomas. They are present in up to 10% of the population over 70 years, with incidence increasing with age. Mild cortisol excess (MCE) in the context of AI is defined as autonomous cortisol secretion (ACS) in the absence of the classical clinical features of Cushing's syndrome. MCE has been reported in up to at least one third of patients with AI. Numerous studies have shown that MCE in AI is associated with increased cardiovascular events and mortality, likely to be consequent upon both hemodynamic changes and inflammatory pathways, and a worse metabolic phenotype characterized by: pancreatic β-cell dysfunction, insulin resistance, visceral obesity and dyslipidemia. There is currently no level 3 evidence from large intervention randomized controlled trials to guide management of MCE in AI, and there is a lack of predictive tools to allow stratification to intervention of only those patients who would benefit in terms of improved metabolic and cardiovascular end-points. Here, we describe the mal-effects of cortisol on cardiovascular and metabolic tissues and discuss management strategies based on current largely observational data.
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Affiliation(s)
- Alan Kelsall
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | - Ahmed Iqbal
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
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Chiodini I, Merlotti D, Falchetti A, Gennari L. Treatment options for glucocorticoid-induced osteoporosis. Expert Opin Pharmacother 2020; 21:721-732. [PMID: 32004105 DOI: 10.1080/14656566.2020.1721467] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Glucocorticoid (GC) induced osteoporosis (GIOP) is the most common form of secondary osteoporosis. It develops in a dose and time dependent manner, due to a rapid and transient increase in bone resorption, followed by the inhibition of bone formation. AREAS COVERED In this review, the authors summarize the pathophysiology of GIOP and give discussion to the clinical management of patients taking GCs, focusing on the currently available drugs that have antiresorptive or anabolic activity on bone. EXPERT OPINION Despite the widespread use of GCs and their well-established detrimental skeletal effects, GIOP remains an under-diagnosed and under-treated condition. Indeed, the clinical management of GIOP is still debated, so that the recent guidelines differ in their indications for pharmacological intervention. Either bone mineral density (BMD) or algorithms such as FRAX do not completely account for the remarkable and rapid increase in fracture risk of most GC-treated patients. Moreover, while oral bisphosphonates remain the most used and cost-effective option, the potential increased benefits of more potent antiresorptive agents (e.g. denosumab and zoledronate) or anabolic compounds (e.g. teriparatide) warrant further investigation. Despite the above limitations, the assessment of fracture risk is recommended for all individuals committed to receiving oral GCs for 3 months or longer.
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Affiliation(s)
- Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research , Milan, Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena , Italy
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research , Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena , Italy
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Liu C, Zhang H, Li X. ADRENAL ADENOMA WITH AUTONOMOUS CORTISOL SECRETION ACCOMPANIED BY HOMOLATERAL RENAL CELL CARCINOMA: A CASE REPORT. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2020; 16:97-102. [PMID: 32685047 PMCID: PMC7364015 DOI: 10.4183/aeb.2020.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CONTEXT Patients with renal malignancies present high risk of adrenal hyperplasia and adenoma, and part of these are primary lesions, mostly non-functional. Here we presented a case diagnosed as primary adrenal adenoma with autonomous cortisol secretion accompanied by homolateral renal cell carcinoma. CASE PRESENTATION A 79-year-old woman was referred for evaluation of a left adrenal mass, with a past medical history of severe hypertension, diabetes, and hyperlipidemia. On examination, no clinical signs of cushingoid features were found. Biochemical measurements showed plasma cortisol was 12.77 μg/dL and was not suppressed by 1 mg dexamethasone (DXM) overnight test (13.6 μg/dL). The contrast CT scan presented a 2.2 cm diameter adrenal mass and revealed, unfortunately, a hyperdense mass at the middle-upper pole of the left kidney. Laparoscopic nephrectomy with left adrenalectomy was performed and pathological examination indicated a final diagnosis of benign adrenocortical adenoma and renal clear cell carcinoma. At 2 months postoperatively, without replacement treatment of cortisol, a recovery of circadian rhythm of cortisol secretion was detected, indicated recovery of the hypothalamic-pituitary-adrenal axis. CONCLUSIONS Patients with renal cancer might be accompanied with functional adrenal adenoma. Therefore, screening for adrenal function should be recommended in patients with renal tumors and/or adrenal incidentaloma.
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Affiliation(s)
| | | | - X. Li
- Shanghai University of Traditional Chinese Medicine - Department of Endocrinology, Seventh People’s Hospital of Shanghai, Shanghai, China
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Araujo-Castro M, Robles Lázaro C, Parra Ramírez P, Cuesta Hernández M, Sampedro Núñez MA, Marazuela M. Cardiometabolic profile of non-functioning and autonomous cortisol-secreting adrenal incidentalomas. Is the cardiometabolic risk similar or are there differences? Endocrine 2019; 66:650-659. [PMID: 31473918 DOI: 10.1007/s12020-019-02066-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To study the differences in the cardiometabolic profile between patients with non-functioning adrenal incidentalomas (NFAI) and incidentalomas with autonomous cortisol secretion (ACS). METHODS A total of 149 patients with adrenal incidentalomas were retrospectively evaluated and followed-up for a mean time of 34.6 months at Departments of Endocrinology and Metabolic Diseases Units of four tertiary Spanish hospitals. Patients were grouped as NFAI or ACS adenomas based on two cutoffs in the dexamethasone suppression test (DST): 3.0 µg/dl (NFAIDST3 or ACSDST3) and 1.8 µg/dl (ACSDST1.8 and NFAIDST1.8). RESULTS The mean age of both groups was 62.0 (10.31) and was similar in ACS and NFAI. The prevalence of diabetes, high blood pressure, cardiovascular, and cerebrovascular disease was higher in ACS than in NFAI, but differences only reached statistical significance for cerebrovascular disease using the 3.0 µg/dl cutoff (15.8% vs 2.3%, p = 0.01) and for diabetes using the 1.8 µg/dl cutoff (38.0% vs 22.0%, p = 0.04). No differences were found in the prevalence of dyslipidemia. The prevalence of obesity was lower in patients with ACS than in NFAI 26.3% vs 39.2%, p = 0.18 (NFAIDST3 vs ACSDST3) and 32.1% vs 40.6%, p = 0.56 (ACSDST1.8 vs NFAIDST1.8), but the differences did not reach statistical significance. Maximum adenoma diameter (R-squared = 0.15, p < 0.001) and cerebrovascular disease (OR = 1.59, p = 0.04) were the only parameters that could be predicted by the DST. The DST was an inadequate predictor of clinical (systolic and diastolic blood pressure, body mass index), hormonal (DHEAS, ACTH, UFC, and basal serum cortisol), biochemical (glucose, cholesterol, LDL, HDL, and triglycerides), and other radiological (laterality, lipid content) parameters. Throughout the follow-up, patients did not develop overt Cushing's Syndrome; three NFAIDST3 developed ACSDST3, eight NFAIDST1.8 developed ACSDST1.8, and one NFAIDST1.8 progressed to ACSDST3. In both groups (NFAI and ACS) the metabolic profile remained stable. CONCLUSIONS Our data suggest higher prevalence of diabetes and cerebrovascular disease in ACS patients compared with NFAI. However, probably because of the small sample size, the differences only reached statistical significance using the cutoffs of 1.8 µg/dl for diabetes and 3.0 µg/dl for cerebrovascular disease. Patients with ACS and NFAI rarely progress to more aggressive forms of hypercortisolism, and the metabolic profile usually remains stable during the follow-up.
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Affiliation(s)
| | | | | | - Martín Cuesta Hernández
- Endocrinology Department, San Carlos Clinical University Hospital, Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | | | - Mónica Marazuela
- Endocrinology Department, Princesa University Hospital, Madrid, Spain
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Papakokkinou E, Jakobsson H, Sakinis A, Muth A, Wängberg B, Ehn O, Johannsson G, Ragnarsson O. Adrenal venous sampling in patients with ACTH-independent hypercortisolism. Endocrine 2019; 66:338-348. [PMID: 31440949 PMCID: PMC6838037 DOI: 10.1007/s12020-019-02038-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/26/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE To study the usefulness of adrenal venous sampling (AVS) in distinguishing unilateral from bilateral cortisol production in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions, or morphologically normal adrenal glands. METHODS A retrospective analysis of ten consecutive patients with ACTH-independent hypercortisolism who underwent AVS at our institution between 2009 and 2017. Unilateral dominant cortisol production was defined as a side-to-side cortisol/aldosterone lateralization ratio >2. RESULTS Four of ten patients had overt Cushing's syndrome. Of these, two had bilateral adrenal lesions on computed tomography and two had normal adrenal glands. One of the two patients with bilateral adrenal lesions had, based on the AVS, a unilateral dominant cortisol production. Following unilateral adrenalectomy the patient developed adrenal insufficiency. The other three patients were considered to have bilateral cortisol production and underwent bilateral adrenalectomy. Six patients had a mild autonomous cortisol secretion and bilateral adrenal lesions. Based on AVS, one patient was considered to have unilateral dominant cortisol production, underwent unilateral adrenalectomy and developed transient adrenal insufficiency postoperatively. CONCLUSIONS AVS may contribute to appropriate treatment in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions. In our series, AVS was helpful in the decision-making of two out of ten patients, avoiding chronic treatment with steroidogenesis inhibitors, or inappropriate bilateral adrenalectomy.
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Affiliation(s)
- Eleni Papakokkinou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Hugo Jakobsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Augustinas Sakinis
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bo Wängberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olof Ehn
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Olsen H, Kjellbom A, Löndahl M, Lindgren O. Response to Letter to the Editor: "Suppressed ACTH Is Frequently Unrelated to Autonomous Cortisol Secretion in Patients With Adrenal Incidentalomas". J Clin Endocrinol Metab 2019; 104:4628-4629. [PMID: 31220281 DOI: 10.1210/jc.2019-00669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/03/2019] [Indexed: 02/13/2023]
Affiliation(s)
- Henrik Olsen
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences in Lund, Lund University, Lund, Sweden
| | - Albin Kjellbom
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
| | - Magnus Löndahl
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences in Lund, Lund University, Lund, Sweden
| | - Ola Lindgren
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences in Lund, Lund University, Lund, Sweden
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Masjkur J, Gruber M, Peitzsch M, Kaden D, Di Dalmazi G, Bidlingmaier M, Zopp S, Langton K, Fazel J, Beuschlein F, Bornstein SR, Reincke M, Eisenhofer G. Plasma Steroid Profiles in Subclinical Compared With Overt Adrenal Cushing Syndrome. J Clin Endocrinol Metab 2019; 104:4331-4340. [PMID: 30977834 DOI: 10.1210/jc.2018-02349] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/05/2019] [Indexed: 12/26/2022]
Abstract
CONTEXT Diagnosis of subclinical adrenal hypercortisolism is based on several tests of the hypothalamic-pituitary-adrenal axis to establish mild alterations of cortisol secretion and dysregulated cortisol physiology. OBJECTIVE We assessed whether plasma steroid profiles might assist diagnosis of subclinical Cushing syndrome (SC). DESIGN Retrospective cross-sectional study. SETTING Two tertiary medical centers. PATIENTS Of 208 patients tested for hypercortisolism, disease was excluded in 152 and confirmed in 21 with overt adrenal Cushing syndrome (AC) compared to 35 with SC. Another 277 age- and sex-matched hypertensive and normotensive volunteers were included for reference. MAIN OUTCOME MEASURES A panel of 15 plasma steroids was measured by mass spectrometry, with classification by discriminant analysis. RESULTS Patients with SC had lower plasma concentrations of dehydroepiandrosterone and dehydroepiandrosterone-sulfate than subjects without SC (P < 0.05). The largest increases (P < 0.001) in plasma steroids among patients with SC were observed for 11-deoxycortisol and 11-deoxycorticosterone. Nevertheless, concentrations of 11-deoxycorticosterone, 11-deoxycortisol, and pregnenolone in patients with AC were higher (P < 0.05) than in those with SC. Patients with SC or AC could be distinguished from subjects without disease using this combination of steroids as precisely as with use of measurements of serum cortisol after administration of dexamethasone. The steroid combination provided superior diagnostic performance compared with each of the other routine biochemical tests. CONCLUSION Distinct plasma steroid profiles in patients with SC may provide a simple and reliable screening method for establishing the diagnosis.
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Affiliation(s)
- Jimmy Masjkur
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Matthias Gruber
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Denise Kaden
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Guido Di Dalmazi
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
- Endocrinology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Katharina Langton
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Julia Fazel
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
- Department of Endocrinology, Diabetology and Metabolism, Unviersitäts Spital Zürich, Zurich, Switzerland
| | - Stefan Richard Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Hsieh LB, Mackinney E, Wang TS. When to Intervene for Subclinical Cushing's Syndrome. Surg Clin North Am 2019; 99:747-758. [DOI: 10.1016/j.suc.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Hána V, Ježková J, Kosák M, Kršek M, Hána V, Hill M. Novel GC-MS/MS Technique Reveals a Complex Steroid Fingerprint of Subclinical Hypercortisolism in Adrenal Incidentalomas. J Clin Endocrinol Metab 2019; 104:3545-3556. [PMID: 30896752 DOI: 10.1210/jc.2018-01926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 03/15/2019] [Indexed: 02/02/2023]
Abstract
CONTEXT Improvement of imaging methods has led to more incidental adrenal tumor findings, especially adenomas. Routine hormonal evaluation uses only a few steroids to evaluate possible hormonal hypersecretion of these adenomas, but a wide spectrum of serum steroid hormone changes has not been published. OBJECTIVE To measure the serum levels of 83 steroids from patients with unilateral and bilateral adrenal incidentalomas to uncover full steroid profile changes in patients with subclinical hypercortisolism (SH). DESIGN Cross-sectional study. SETTING The study was conducted at a tertiary inpatient clinic. PATIENTS Fifty-two patients with adrenal incidentalomas (unilateral, n = 29; bilateral, n = 23), including nonfunctioning (n = 11) vs SH (n = 41), and 26 age- and sex-matched controls from the general population were included. MAIN OUTCOME MEASURES Eighty-three serum steroids were measured by gas chromatography-tandem mass spectrometry (GC-MS/MS) before and after 1 mg dexamethasone, ACTH, midnight serum cortisol, and urinary free cortisol/24 hour. RESULTS Of 83 measured steroids, 10 were significantly decreased in patients with SH, including dehydroepiandrosterone sulfate (DHEAS), androsterone sulfate, epiandrosterone sulfate, androstenediol sulfate, conjugated 5α-androstane-3β,17β-diol, and conjugated 5α-androstane-3α,17β-diol. This finding was observed even when unilateral, bilateral, male, and female subgroups were analyzed separately. When we compared routine clinical methods and GC-MS/MS‒measured steroids, the most discriminatory was DHEAS followed by midnight serum cortisol, epiandrosterone sulfate, androsterone sulfate, ACTH, and 16α-hydroxypregnenolone. CONCLUSIONS SH was associated with decreased levels of adrenal androgens, their metabolites, and pregnenolone metabolite. GC-MS/MS is a powerful tool for measuring serum levels of these undescribed changes in steroid metabolism, which are characteristic of SH in adrenal incidentalomas.
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Affiliation(s)
- Václav Hána
- 3rd Department of Internal Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jana Ježková
- 3rd Department of Internal Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Mikuláš Kosák
- 3rd Department of Internal Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Kršek
- 3rd Department of Internal Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Václav Hána
- 3rd Department of Internal Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Hill
- Steroid Hormone Unit, Institute of Endocrinology, Prague, Czech Republic
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Elhassan YS, Alahdab F, Prete A, Delivanis DA, Khanna A, Prokop L, Murad MH, O'Reilly MW, Arlt W, Bancos I. Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171:107-116. [PMID: 31234202 DOI: 10.7326/m18-3630] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Adrenal incidentalomas are mostly benign nonfunctioning adrenal tumors (NFATs) or adenomas causing mild autonomous cortisol excess (MACE), but their natural history is unclear. PURPOSE To summarize the follow-up data of adults with NFAT or MACE to determine the proportions of tumor growth, malignant transformation, and incident changes in hormone function; the prevalence of incident cardiometabolic comorbid conditions; and mortality. DATA SOURCES MEDLINE, Embase, Cochrane, and Scopus (January 1990 to February 2019) and bibliographies of identified articles, without language restriction. STUDY SELECTION Studies that included 20 or more conservatively managed patients with NFAT or MACE and reported outcomes at baseline and after at least 12 months of follow-up. DATA EXTRACTION Pairs of reviewers extracted outcomes and assessed methodological quality. DATA SYNTHESIS Thirty-two studies reported outcomes of 4121 patients with NFAT or MACE, 61.5% of whom were women; the mean age was 60.2 years, and mean follow-up was 50.2 months. Mean tumor growth was 2 mm over 52.8 months. Clinically significant tumor enlargement (≥10 mm) occurred in 2.5% of patients, and none developed adrenal cancer. Clinically overt hormone excess was unlikely to develop (<0.1%) in patients with NFAT or MACE. Only 4.3% of patients with NFAT developed MACE, and preexisting MACE was unlikely to resolve (<0.1%). Hypertension, obesity, dyslipidemia, and type 2 diabetes were highly prevalent (60.0%, 42.0%, 33.7%, and 18.1% of patients, respectively) and were more likely to develop and worsen in MACE than NFAT. New cardiovascular events were more prevalent in MACE (15.5%) than NFAT (6.4%). Mortality was 11.2% and was similar between NFAT and MACE. LIMITATION Evidence was scarce, and definitions of MACE and comorbid conditions were heterogeneous. CONCLUSION During follow-up, NFAT and MACE do not show clinically relevant changes in size or hormonal function, but they may carry an increased risk for cardiometabolic comorbid conditions. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Yasir S Elhassan
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Fares Alahdab
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Alessandro Prete
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Danae A Delivanis
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Aakanksha Khanna
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Larry Prokop
- Mayo Clinic, Rochester, Minnesota; Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota (L.P.)
| | - Mohammad H Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Michael W O'Reilly
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Wiebke Arlt
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Irina Bancos
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
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Ahn SH, Kim JH, Cho YY, Suh S, Kim BJ, Hong S, Lee SH, Koh JM, Song KH. The effects of cortisol and adrenal androgen on bone mass in Asians with and without subclinical hypercortisolism. Osteoporos Int 2019; 30:1059-1069. [PMID: 30719548 DOI: 10.1007/s00198-019-04871-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
Abstract
UNLABELLED Analyses using the largest Korean cohort of adrenal incidentaloma (AI) revealed that subtle cortisol excess in premenopausal women and reduced dehydroepiandrosterone-sulfate (DHEA-S) in postmenopausal women and men are associated with bone mineral density (BMD) reduction in Asian patients with subclinical hypercortisolism (SH). INTRODUCTION Few studies evaluated bone metabolism in Asians with SH. We investigated associations of cortisol and DHEA-S, an adrenal androgen, with BMD in Asians with AI, with or without SH. METHODS We used cross-sectional data of a prospective multicenter study from Korea. We measured BMD, bone turnover markers, cortisol levels after 1-mg dexamethasone suppression test (1-mg DST), DHEA-S, and baseline cortisol to DHEA-S ratio (cort/DHEA-S) in 109 AI patients with SH (18 premenopausal, 38 postmenopausal women, and 53 men) and 686 with non-functional AI (NFAI; 59 premenopausal, 199 postmenopausal women, and 428 men). RESULTS Pre- and postmenopausal women, but not men, with SH had lower BMDs at lumbar spine (LS) than those with NFAI (P = 0.008~0.016). Premenopausal women with SH also had lower BMDs at the hip than those with NFAI (P = 0.009~0.012). After adjusting for confounders, cortisol levels after 1-mg DST demonstrated inverse associations with BMDs at all skeletal sites only in premenopausal women (β = - 0.042~- 0.033, P = 0.019~0.040). DHEA-S had positive associations with LS BMD in postmenopausal women (β = 0.096, P = 0.001) and men (β = 0.029, P = 0.038). The cort/DHEA-S had inverse associations with LS BMD in postmenopausal women (β = - 0.081, P = 0.004) and men (β = - 0.029, P = 0.011). These inverse associations of cort/DHEA-S remained significant after adjusting for cortisol levels after 1-mg DST (β = - 0.079~- 0.026, P = 0.006~0.029). In postmenopausal women, the odds ratios of lower BMD by DHEA-S and cort/DHEA-S was 0.26 (95% CI, 0.08-0.82) and 3.40 (95% CI, 1.12-10.33), respectively. CONCLUSION Subtle cortisol excess in premenopausal women and reduced DHEA-S in postmenopausal women and men may contribute to BMD reduction in Asians with SH.
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Affiliation(s)
- S H Ahn
- Division of Endocrinology and Metabolism, Department of Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea
| | - J H Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Y Y Cho
- Division of Endocrinology and Metabolism, Department of Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, South Korea
| | - S Suh
- Division of Endocrinology and Metabolism, Department of Medicine, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, South Korea
| | - B-J Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43 gil, Songpa-gu, Seoul, 05505, South Korea
| | - S Hong
- Division of Endocrinology and Metabolism, Department of Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea
| | - S H Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43 gil, Songpa-gu, Seoul, 05505, South Korea
| | - J-M Koh
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43 gil, Songpa-gu, Seoul, 05505, South Korea.
| | - K-H Song
- Division of Endocrinology and Metabolism, Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul, 05030, South Korea.
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64
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Chiodini I, Ramos-Rivera A, Marcus AO, Yau H. Adrenal Hypercortisolism: A Closer Look at Screening, Diagnosis, and Important Considerations of Different Testing Modalities. J Endocr Soc 2019; 3:1097-1109. [PMID: 31069279 PMCID: PMC6500795 DOI: 10.1210/js.2018-00382] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/05/2019] [Indexed: 11/19/2022] Open
Abstract
Although prolonged hypercortisolism is associated with increased mortality and substantial morbidity, the clinical signs and symptoms are wide ranging and often nonspecific, contributing to challenges in diagnosis, as well as treatment delays. Greater awareness is needed among clinicians to help identify which patients should undergo biochemical screening for excess cortisol. Several biochemical tests are available, each with important caveats that should be considered in the context of the individual patient. Cortisol secretion varies widely, further complicating the biochemical diagnosis of hypercortisolism, which relies on the use of definitive cutoff values. Patients with hypercortisolism resulting from adrenal adenomas, including those discovered incidentally, often do not present with overt Cushingoid features (plethora, striae, muscle weakness, moon facies, etc.). However, the consequences of prolonged exposure to even slight elevations in cortisol levels are profound, including increased risk of diabetes, hypertension, fractures, cardiovascular events, and mortality. Because most cases of hypercortisolism resulting from an adrenal adenoma can be managed, it is imperative to identify patients at risk and initiate testing early for the best outcomes. The aim of this report is to increase awareness of the indications for screening for hypercortisolism and to review the biochemical screening tests and diagnosis for hypercortisolism associated with adrenal adenomas.
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Affiliation(s)
- Iacopo Chiodini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Unit for Bone Metabolism Diseases and Diabetes and Laboratory of Endocrine and Metabolic Research, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Auxologico Italiano, Milan, Italy
| | - Arelys Ramos-Rivera
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Alan O Marcus
- South Orange County Endocrinology, Laguna Hills, California
| | - Hanford Yau
- Division of Endocrinology, University of California, San Francisco (UCSF Fresno), Fresno, California
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65
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Araujo-Castro M, Sampedro Núñez MA, Marazuela M. Autonomous cortisol secretion in adrenal incidentalomas. Endocrine 2019; 64:1-13. [PMID: 30847651 DOI: 10.1007/s12020-019-01888-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/28/2019] [Indexed: 02/06/2023]
Abstract
Adrenal incidentalomas (AI) are one of the most frequent reasons for consultation in Endocrinology, as they are present in 3-10% of the general population. Up to 20% of them may have autonomous cortisol secretion (ACS), a term that refers to AI carriers with biochemical evidence of excess cortisol, but without the "specific" clinical signs of Cushing's syndrome. As ACS is associated with an increased risk of diabetes, obesity, high blood pressure (HBP), osteoporosis, cardiovascular events, and global mortality; its correct identification is of great importance. There are different laboratory assays to detect ACS, but all of them have some limitations. The dexamethasone suppression test is the most accepted for screening. However, there is no consensus on the cutoff point that should be used. Low levels of ACTH and DHEA-S and high urinary free cortisol are also associated with ACS, but in isolation they are of little value to establish the diagnosis. Considering its clinical implications and the lack of consensus in the diagnosis and in which is the most appropriate management of these patients, this review offers a quick reference guide of ACS, presenting an exhaustive review of the topic: its definition, epidemiology, diagnosis, clinical implications, treatment, and follow-up.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Miguel Antonio Sampedro Núñez
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Mónica Marazuela
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
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Park J, De Luca A, Dutton H, Malcolm JC, Doyle MA. Cardiovascular Outcomes in Autonomous Cortisol Secretion and Nonfunctioning Adrenal Adenoma: A Systematic Review. J Endocr Soc 2019; 3:996-1008. [PMID: 31065617 PMCID: PMC6497919 DOI: 10.1210/js.2019-00090] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/15/2019] [Indexed: 01/06/2023] Open
Abstract
There is growing evidence that autonomous cortisol secretion (ACS), previously known as subclinical Cushing syndrome, is associated with greater prevalence of cardiovascular (CV) risk factors. However, it is unclear whether ACS is associated with greater prevalence of CV outcomes compared with nonfunctioning adrenal adenomas (NFAAs). The objective of this study is to evaluate CV outcomes and CV risk factors in patients with adrenal adenoma with ACS compared with NFAA. A literature review was performed in Embase, Medline, Cochrane Library, and reference lists within selected articles. The study protocol was registered with PROSPERO. A literature search yielded six studies that met the inclusion criteria. Studies varied in their definitions of ACS and CV outcomes. Two retrospective longitudinal studies further demonstrated higher incidence of new CV events (ACS 16.7% vs NFAA 6.7%, P = 0.04) and higher CV mortality in patients with ACS (ACS 22.6% vs 2.5%, P = 0.02). The prevalence of CV outcomes in ACS was more than three times greater than in patients with NFAA. Three of five studies found that ACS was associated with higher prevalence of diabetes and hypertension. There was no difference in dyslipidemia or body mass index demonstrated in any study. There is heterogeneity among the few studies evaluating the association between ACS and CV outcomes. Although these studies suggest a higher risk of CV outcomes in patients with ACS, many did not adjust for known confounders. Larger, high quality, prospective studies are needed to evaluate this association and to identify modifiable risk factors.
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Affiliation(s)
- Jane Park
- Western University, London, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada
| | | | - Heidi Dutton
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda
| | - Janine C Malcolm
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda
| | - Mary-Anne Doyle
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Chrisoulidou A, Rakitzi P, Boudina M, Apostolidou-Kiouti F, Poimenidou E, Papanikolaou A, Devlioti A, Rallis G, Pazaitou-Panayiotou K. Patients with extra-adrenal malignancies and adrenal lesions have similar rates of subclinical hypercortisolism compared with patients with true adrenal incidentalomas. Hormones (Athens) 2019; 18:85-89. [PMID: 30737657 DOI: 10.1007/s42000-019-00092-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/21/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE During follow-up in cancer patients, adrenal lesions are frequently found by computer tomography imaging. In these patients, the frequency of subclinical Cushing's syndrome (SCS) has not been fully explored. The aim of the present study was to investigate the presence of SCS in cancer patients with adrenal lesions in comparison to patients with true adrenal incidentalomas. DESIGN We studied 95 patients with adrenal lesions: 57 patients (group A, 20 males and 37 females) had a history of extra-adrenal malignancy and adrenal lesions were discovered during staging of the primary cancer, and 38 patients (group B, 6 males and 32 females) had adrenal incidentalomas. The two groups had similar BMI. All patients had unenhanced HU < 10 in computed tomography to ensure low risk of adrenal metastatic disease. Patients' morning plasma cortisol levels and ACTH were measured. An overnight 1 mg dexamethasone suppression test (ODST) was performed in all participants; in case of abnormal results, 24-h urine cortisol and the low-dose dexamethasone suppression test were additionally conducted. The cutoffs of morning cortisol values used for ODST were 1.8 and 5 μg/dl. RESULTS When the cutoff of 1.8 μg/dl for suppressed morning cortisol was used, 42.1% of group A and 39.5% of group B had abnormal results (p = 0.95). By using the threshold of 5 μg/dl after ODST, 5.3% of group A and 13.2% of group B did not have suppressed cortisol levels with the 1 mg ODST (p = 0.18). The main factors found to influence suppressed cortisol levels after ODST in both groups were BMI and size of the adrenal lesion. CONCLUSIONS Patients with extra-adrenal malignancies and adrenal lesions had similar rates of subclinical hypercortisolemia compared to patients with true adrenal incidentalomas.
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Affiliation(s)
- Alexandra Chrisoulidou
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
| | - Pantelitsa Rakitzi
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
| | - Maria Boudina
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
| | - Fani Apostolidou-Kiouti
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
| | - Eirini Poimenidou
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
| | - Achilleas Papanikolaou
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
| | - Anastasia Devlioti
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
| | - Grigorios Rallis
- Division of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007, Thessaloniki, Greece
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68
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Giorgi RB, Correa MV, Costa-Barbosa FA, Kater CE. Cyclic Subclinical Hypercortisolism: A Previously Unidentified Hypersecretory Form of Adrenal Incidentalomas. J Endocr Soc 2019; 3:678-686. [PMID: 30854503 PMCID: PMC6399707 DOI: 10.1210/js.2018-00385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/06/2019] [Indexed: 01/07/2023] Open
Abstract
Purpose Most adrenal incidentalomas (AIs) are nonfunctioning adenomas (NFAs), but up to 30% may secrete cortisol autonomously without clinical evidence of Cushing syndrome (CS), which nevertheless may increase cardiovascular mortality. This subclinical hypercortisolism (SCH) is confirmed by cortisol resistance to a dexamethasone suppression test (DST). Cyclic cortisol secretion occurs in classic CS but was not reported in SCH. Objective Investigate cyclic cortisol production/autonomy in AIs using sequential DSTs. Methods A total of 251 patients with AI underwent 487 DSTs over 12 years; patients with at least three DSTs were selected. DSTs were validated by measuring serum dexamethasone. Cyclic SCH was defined when at least two abnormal and two normal DSTs were documented. Results A total of 44 patients had three or more DSTs during follow-up: 9 of 44 patients (20.4%) had all negative test results (post-DST cortisol ≤1.8 μg/dL) and were classified as NFA; another nine patients had all positive results (cortisol >1.8 μg/dL) and were classified as sustained SCH. The remaining 26 (59.2%) had discordant responses: 8 of 44 (18.3%) had at least two positive and two negative tests, matching the criterion for cyclic SCH, whereas 18 of 44 (40.9%) had only one discordant test and were classified as possibly cyclic SCH. Eleven of 20 (55%) patients initially classified as NFA did not maintain their cortisol pattern. Conclusions Extended follow-up with repeated DSTs uncovered an unusual subset of AIs with cyclic SCH. Recurring production of cortisol may affect determination of AI subtypes if based on just one DST. Lack of recognition of this phenomenon makes follow-up of patients with AI misleading because even cyclic SCH may result in potential cardiovascular risk.
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Affiliation(s)
- Rafael B Giorgi
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
| | - Marcelo V Correa
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
| | - Flávia A Costa-Barbosa
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
| | - Claudio E Kater
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
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69
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Olsen H, Kjellbom A, Löndahl M, Lindgren O. Suppressed ACTH Is Frequently Unrelated to Autonomous Cortisol Secretion in Patients With Adrenal Incidentalomas. J Clin Endocrinol Metab 2019; 104:506-512. [PMID: 30265354 DOI: 10.1210/jc.2018-01029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/24/2018] [Indexed: 02/13/2023]
Abstract
OBJECTIVE ACTH is considered a weak marker for autonomous cortisol secretion (ACS) in patients with adrenal incidentalomas (AIs). Our aim was to investigate suppressed basal ACTH as a marker of ACS and to elucidate why this criterion is of limited value. METHODS Basal ACTH and cortisol after overnight dexamethasone suppression test (cortisolONDST) were measured in 198 patients with unilateral AI and at 2-year follow-up. Basal ACTH was measured in 100 control subjects. RESULTS In patients with cortisolONDST <50 nmol/L (n = 145), ACTH was <2 pmol/L in 19%, compared with 4% in control subjects (P < 0.001). ACTH and size of AI correlated negatively (P = 0.002). Among patients with cortisolONDST ≥50 nmol/L, ACTH was <2 pmol/L in 53%. The patients were grouped according to whether cortisolONDST was <50 or ≥50 nmol/L and whether ACTH was <2.0 or ≥2.0 or pmol/L. At follow-up, these four groups were still separated with statistically significant differences in ACTH and cortisolONDST. CONCLUSIONS This study identifies a previously unrecognized group of patients defined by suppressed ACTH despite normal cortisolONDST. This suppression of ACTH by a factor other than ACS may explain the limitation of suppressed ACTH as a marker for ACS. We suggest increased cortisol secretion in response to ACTH by the AI to be an additional factor.
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Affiliation(s)
- Henrik Olsen
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences in Lund, Lund University, Lund, Sweden
| | - Albin Kjellbom
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
| | - Magnus Löndahl
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences in Lund, Lund University, Lund, Sweden
| | - Ola Lindgren
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences in Lund, Lund University, Lund, Sweden
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Khawandanah D, ElAsmar N, Arafah BM. Alterations in hypothalamic-pituitary-adrenal function immediately after resection of adrenal adenomas in patients with Cushing's syndrome and others with incidentalomas and subclinical hypercortisolism. Endocrine 2019; 63:140-148. [PMID: 30259310 DOI: 10.1007/s12020-018-1769-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with cortisol secreting adrenal adenomas present with Cushing's syndrome (CS), while 5-15% of subjects with adrenal incidentalomas have subclinical hypercortisolism (SH) as they have biochemical abnormalities suggesting autonomous cortisol secretion without associated clinical features of CS. GOALS Examine HPA function immediately after resection of either of these adenomas and utilize the data to decide on initiating glucocorticoid replacement. METHODS ACTH, cortisol, and DHEA-S levels were measured frequently for 8 h after adrenalectomy in 14 patients with CS and 19 others with incidentalomas + SH. Glucocorticoids were withheld before/during surgery and administered 6-8 h postoperatively to those who had cortisol levels of <3 ug/dL (83 nmol/L). RESULTS Preoperatively, incidentalomas + SH patients had larger tumors, higher ACTH, and DHEA-S but lower dexamethasone-suppressed serum cortisol levels than those with CS. Postoperatively, ACTH levels increased in both groups: (90.1 ± 31.6; 24.1 ± 14.4 ng/L, respectively; P < 0.001). Postoperative ACTH levels correlated negatively with preoperative Dexamethasone-suppressed cortisol concentrations in both groups. Patients with CS had steeper decline in cortisol concentrations than those with incidentalomas + SH. All patients with CS had hypocortisolemia requiring glucocorticoid therapy for several months, while only 5/19 with incidentalomas + SH had cortisol levels <3 ug/dL;(83 nmol/L) 6-8 h after adrenalectomy and received hydrocortisone replacement therapy for ≤4 weeks. CONCLUSIONS Surgical stress stimulates HPA function even in patients with hypercortisolemia. Patients with incidentalomas + SH have incomplete HPA suppression that allows more robust response to surgical stress than that observed in patients with CS. HPA assessment immediately after surgical resection of adrenal incidentalomas identified those requiring glucocorticoid replacement before discharge.
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Affiliation(s)
- Dena Khawandanah
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nadine ElAsmar
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Baha M Arafah
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.
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71
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Baba R, Oki K, Kobuke K, Itcho K, Okubo H, Ohno H, Yoneda M, Hattori N. Measurement of midnight ACTH levels is useful for the evaluation of midnight cortisol levels. Steroids 2018; 140:179-184. [PMID: 30414423 DOI: 10.1016/j.steroids.2018.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Elevated midnight cortisol levels induced by non-suppressed ACTH levels may lead to false-positive results for hypercortisolism in patients with adrenal incidentaloma. We investigated whether plasma ACTH-associated high midnight serum cortisol levels are correlated with other endocrinological findings with respect to hypothalamic-pituitaryadrenal function or hypercortisolism status. METHODS Two-hundred-forty-six patients with adrenocortical adenoma were evaluated via measurements of midnight ACTH and cortisol levels, a 1-mg dexamethasone suppression test (DST), and a cosyntropin-releasing hormone (CRH) stimulation test. Patients were divided into four groups according to their midnight plasma ACTH levels. RESULTS The groups with higher midnight ACTH levels had significantly higher basal ACTH levels. A positive relationship was observed between midnight serum cortisol and serum cortisol in the 1-mg DST for all groups; stronger associations were observed in the group with lower midnight ACTH. In the CRH test, peak, delta, and sigma ACTH had significant inverse relationships with midnight cortisol levels in the lowest and second lowest midnight ACTH groups. Patients with midnight cortisol levels >3.5 μg/dL were further divided into two groups according to whether their midnight plasma ACTH levels were below or above 10.0 pg/mL. There were significantly fewer patients with hypercortisolism in the higher ACTH group; midnight serum cortisol levels were associated with hypercortisolism only in the lower ACTH group. CONCLUSION We demonstrated that midnight ACTH-associated cortisol values were not correlated with other endocrinological findings or hypercortisolism state. Measurement of midnight ACTH levels is important, and careful evaluation is needed for patients with higher midnight ACTH levels.
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Affiliation(s)
- Ryuta Baba
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kenji Oki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Kazuhiro Kobuke
- Department of Preventive Medicine for Diabetes and Lifestyle-related Disease, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kiyotaka Itcho
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hirofumi Okubo
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Haruya Ohno
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masayasu Yoneda
- Department of Preventive Medicine for Diabetes and Lifestyle-related Disease, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Agarwal A, Gupta A. Commentary: Management of central serous chorioretinopathy: Looking beyond the eye. Indian J Ophthalmol 2018; 66:1714-1715. [PMID: 30451171 PMCID: PMC6256893 DOI: 10.4103/ijo.ijo_1412_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Aniruddha Agarwal
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amod Gupta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Bahadir CT, Ecemis GC, Atmaca H. Does IGF-1 play a role in the etiopathogenesis of non-functioning adrenocortical adenoma? J Endocrinol Invest 2018. [PMID: 29542030 DOI: 10.1007/s40618-018-0869-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE The aim of this study was to investigate the possible association of insulin-like growth factor-1 (IGF-1) with the pathogenesis of non-functioning adrenocortical adenomas (NFAs). METHODS This study included 50 female patients (mean age 54 years) with NFAs, 55 patients (mean age 48 years; 20 male, 35 female) with acromegaly and 38 female control subjects (mean age 58 years). Body mass index (BMI) and waist circumference (WC) of the subjects were recorded and blood samples for IGF-1 were taken. Insulin resistance was calculated using the homeostatic model assessment (HOMA) score. Since most of the acromegaly patients had been using medicine that could have effected insulin resistance, HOMA scores were calculated only in patients with NFAs and the controls. Computerized tomography or magnetic resonance imaging was taken of the acromegalics and controls to detect adrenal mass frequency. RESULTS The mean age was similar among the groups. As expected, the serum IGF-1 levels were significantly higher in patients with acromegaly than in patients with NFAs and the controls (p < 0.001). Although BMI, WC, and serum IGF-1 levels were significantly higher (p < 0.001) in patients with NFAs, the HOMA scores were similar between patients with NFAs and control groups. Although none of the control subjects had adrenal masses, NFAs were detected in 14 (25%) out of 55 acromegalic patients. CONCLUSIONS Higher serum IGF-1 levels in patients with NFAs compared to the control group and an increased prevalence of NFAs in acromegaly patients compared to control subjects and the general population suggest an association of IGF-1 with the etiopathogenesis of NFA.
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Affiliation(s)
- C T Bahadir
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ondokuz Mayis University, Kurupelit, 55139, Samsun, Turkey
| | - G C Ecemis
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ondokuz Mayis University, Kurupelit, 55139, Samsun, Turkey
| | - H Atmaca
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ondokuz Mayis University, Kurupelit, 55139, Samsun, Turkey.
- Endocrinology and Metabolism, Liv Hospital, Hançerli Mahallesi, F. Sultan Mehmet Cd. No:155, 55020, İlkadım/Samsun, Turkey.
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74
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[Adrenal incidentaloma : Diagnostic and therapeutic concept from an endocrinological perspective]. Chirurg 2018; 90:3-8. [PMID: 30353360 DOI: 10.1007/s00104-018-0739-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
An adrenal incidentaloma is an adrenal mass detected on imaging that was not performed for suspected adrenal disease. The prevalence is approximately 3% and increases up to 10% in older people. The risk of malignancy and a hormone excess have to be evaluated. Approximately 15% of incidentalomas harbor an overproduction of hormones, in particular primary aldosteronism (Conn's syndrome), hypercortisolism (Cushing's syndrome) and pheochromocytoma. Primary aldosteronism is the main cause of endocrine hypertension. It is characterized by an overproduction of aldosterone usually due to a unilateral adenoma or an idiopathic, often bilateral hyperplasia. The aldosterone to renin ratio is an established screening parameter for the diagnosis. If the ratio is elevated a confirmatory test, e. g. saline infusion test, should follow. Usually an adrenal venous catheter has to be used to discriminate between unilateral and bilateral aldosterone overproduction. In the case of unilateral overproduction an adrenalectomy is recommended, otherwise treatment is carried out with an aldosterone antagonist. For the diagnosis of an adrenal Cushing's syndrome a dexamethasone suppression test and a suppressed or in the lower limit of normal ACTH is required. The rare pheochromocytoma is a catecholamine-producing tumor. The diagnosis is carried out by determination of metanephrines in plasma or in 24 h urine samples. Unilateral adrenal tumors leading to clinically significant hormone excess or tumors with suspicion of malignancy should be surgically removed. A minimally invasive adrenalectomy is normally the method of choice in patients with a unilateral adrenal tumor <6 cm and without local tumor invasion. In unilateral, clearly benign, non-functioning, small adrenal tumors (<4 cm) surgery is not required.
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75
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Huayllas MKP, Netzel BC, Singh RJ, Kater CE. Serum Cortisol Levels via Radioimmunoassay vs Liquid Chromatography Mass Spectrophotometry in Healthy Control Subjects and Patients With Adrenal Incidentalomas. Lab Med 2018; 49:259-267. [PMID: 29608696 DOI: 10.1093/labmed/lmy005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Adrenal incidentalomas (AIs) are present in 4% of adults. As many as 30% may secrete cortisol autonomously in the absence of specific signs of overt hypercortisolism, in a phenomenon called subclinical hypercortisolism (SH). Diagnosis of SH is established by serum cortisol resistance to dexamethasone suppression. Methods We compared serum cortisol concentrations, as determined by radioimmunoassay (RIA) and liquid chromatography/tandem mass spectronomy (LC/MS-MS), in 73 patients with AI group (52 with unilateral AI) and 34 control subjects in 3 scenarios: basal; after 1-mg dexamethasone suppression; and after 0.25-mg stimulation with cosyntropin, a synthetic derivative of adrenocorticotropic hormone (ACTH). To bolster evidence for the diagnosis of SH, we also measured salivary cortisol levels at 11 PM and after DST, as well as plasma ACTH and serum dehydroepiandrosterone sulfate (DHEA-S) levels. Results We observed significant positive correlation (r = 0.9345, P <.001) for all 318 pairs of serum cortisol values, as measured by both methods. Conclusions Serum cortisol concentrations in patients with AI and in control subjects were very similar, as measured by RIA and LC/MS-MS.
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Affiliation(s)
- Martha K P Huayllas
- Steroids Laboratory, Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP).,Department of Neuroendocrinology, Hospital Brigadeiro, São Paulo, Brazil
| | - Brian C Netzel
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Claudio E Kater
- Steroids Laboratory, Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP)
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Affiliation(s)
- Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville
- Knowledge and Evaluation Research Unit (KER-ENDO), Mayo Clinic, Rochester, Minnesota
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hans K Ghayee
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville
- Malcom Randall VA Medical Center, Gainesville, Florida
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Kim BJ, Kwak MK, Ahn SH, Kim JS, Lee SH, Koh JM. The association of cortisol and adrenal androgen with trabecular bone score in patients with adrenal incidentaloma with and without autonomous cortisol secretion. Osteoporos Int 2018; 29:2299-2307. [PMID: 29971455 DOI: 10.1007/s00198-018-4608-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/15/2018] [Indexed: 12/22/2022]
Abstract
UNLABELLED Despite ethnic differences in cortisol sensitivity, only one study in Caucasians has assessed trabecular bone score (TBS) in patients with subclinical hypercortisolism (SH). We showed that both subtle cortisol excess and reduced adrenal androgen may contribute to impaired bone quality in Asian women with SH. INTRODUCTION One study in Caucasians has assessed trabecular bone score (TBS), an index of bone microstructure, in adrenal incidentaloma (AI) patients with subclinical hypercortisolism (SH). There are ethnic differences in cortisol sensitivities between Caucasian and Asian populations. We investigated the associations of cortisol and the adrenal androgen dehydroepiandrosterone-sulfate (DHEA-S) with TBS in AI patients with SH, adrenal Cushing's syndrome (CS), and nonfunctional AI (NFAI). METHODS We measured TBS, cortisol levels after the overnight 1 mg dexamethasone suppression test (1 mg DST), and cortisol/DHEA-S in 61 patients with SH (30 men; 31 women), 19 with adrenal CS (4 men; 15 women), and 355 with NFAI (213 men; 142 women). RESULTS After adjusting for confounders, the serum cortisol level after 1 mg DST was inversely correlated with TBS in men (β = -0.133, P = 0.045) and women (β = - 0.140, P = 0.048). Higher cortisol/DHEA-S ratio was associated with lower TBS in women (β = - 0.252, P < 0.001), but not men. This inverse association of cortisol/DHEA-S ratio in women remained statistically significant after adjusting for the serum cortisol level after 1 mg DST (β = - 0.221, P = 0.008). Compared with women with NFAI, women with SH had 2.2% lower TBS (P = 0.040). Deteriorated bone microstructure (TBS < 1.230) was associated with the serum cortisol level after 1 mg DST (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.04-4.53) and cortisol/DHEA-S ratio (OR, 2.05; 95% CI, 1.03-4.08). CONCLUSIONS Subtle cortisol excess in both genders and reduced DHEA-S, especially in women, may contribute to impaired bone quality in Asian patients with SH.
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Affiliation(s)
- B-J Kim
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - M K Kwak
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - S H Ahn
- Department of Endocrinology, Inha University School of Medicine, Incheon, 22332, South Korea
| | - J S Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - S H Lee
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea.
| | - J-M Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea.
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Abe I, Sugimoto K, Miyajima T, Ide T, Minezaki M, Takeshita K, Takahara S, Nakagawa M, Fujimura Y, Kudo T, Miyajima S, Taira H, Ohe K, Ishii T, Yanase T, Kobayashi K. Clinical Investigation of Adrenal Incidentalomas in Japanese Patients of the Fukuoka Region with Updated Diagnostic Criteria for Sub-clinical Cushing's Syndrome. Intern Med 2018; 57:2467-2472. [PMID: 29709936 PMCID: PMC6172556 DOI: 10.2169/internalmedicine.0550-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives We retrospectively investigated the clinical and endocrinological characteristics of adrenal incidentalomas. Methods We studied 61 patients who had been diagnosed with adrenal incidentalomas and had undergone detailed clinical and endocrinological evaluations while hospitalized. We used common criteria to diagnose the functional tumors, but for sub-clinical Cushing's syndrome, we used an updated set of diagnosis criteria: serum cortisol ≥1.8 μg/dL after a positive response to a 1-mg dexamethasone suppression test if the patient has a low morning adrenocorticotropic hormone (ACTH) level (<10 pg/mL) and a loss of the diurnal serum cortisol rhythm. Results Of the 61 patients, none (0%) had malignant tumors, 8 (13.1%) had pheochromocytoma, and 15 (24.6%) had primary aldosteronism; when diagnosed by our revised criteria, 13 (21.3%) had cortisol-secreting adenomas (Cushing's syndrome and sub-clinical Cushing's syndrome), and 25 (41.0%) had non-functional tumors. Compared with the non-functional tumor group, the primary aldosteronism group and the cortisol-secreting adenoma group were significantly younger and had significantly higher rates of hypokalemia, whereas the pheochromocytoma group had significantly larger tumors and a significantly lower body mass index. Conclusion Our study found a larger percentage of functional tumors among adrenal incidentalomas than past reports, partly because we used a lower serum cortisol level after a dexamethasone suppression test to diagnose sub-clinical Cushing's syndrome and because all of the patients were hospitalized and could therefore receive more detailed examinations. Young patients with hypokalemia or lean patients with large adrenal tumors warrant particularly careful investigation.
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Affiliation(s)
- Ichiro Abe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Kaoru Sugimoto
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | | | - Tomoko Ide
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Midori Minezaki
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Kaori Takeshita
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Saori Takahara
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Midori Nakagawa
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Yuki Fujimura
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Tadachika Kudo
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Shigero Miyajima
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Hiroshi Taira
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Kenji Ohe
- Department of Pharmacotherapeutics, Faculty of Pharmaceutical Sciences, Fukuoka University, Japan
| | - Tatsu Ishii
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Japan
| | - Kunihisa Kobayashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
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Inoue K, Yamazaki Y, Kitamoto T, Hirose R, Saito J, Omura M, Sasano H, Nishikawa T. Aldosterone Suppression by Dexamethasone in Patients With KCNJ5-Mutated Aldosterone-Producing Adenoma. J Clin Endocrinol Metab 2018; 103:3477-3485. [PMID: 30020487 DOI: 10.1210/jc.2018-00738] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/12/2018] [Indexed: 01/08/2023]
Abstract
CONTEXT Aldosterone biosynthesis is regulated principally by ACTH and gene mutations as well as by angiotensin II and serum potassium. In addition, previous studies have reported the potential effects of KCNJ5 mutations in aldosterone-producing adenoma (APA) on cardiovascular diseases. However, responsiveness to ACTH in APAs according to potassium inwardly rectifying channel, subfamily J, member 5 (KCNJ5) mutations remains unknown. OBJECTIVE To investigate KCNJ5 genotype-specific differences in aldosterone biosynthesis in response to ACTH stimulation. DESIGN AND SETTING A cross-sectional study through retrieval of clinical records. PARTICIPANTS One hundred forty-one patients aged ≥20 years with APA were examined. MAIN OUTCOME MEASURES Associations between KCNJ5 mutations and clinical parameters reflecting the renin-angiotensin system [saline infusion test (SIT)] and ACTH pathways [dexamethasone suppression test (DST)]. RESULTS KCNJ5 mutations were detected in 107 cases. In the crude comparison, patients with mutations in KCNJ5 had higher plasma aldosterone concentrations (PACs) both at baseline and after the SIT. PAC after the DST showed a significant inverse association with KCNJ5 genotypes after controlling for age, sex, tumor size, and PAC after the SIT. Immunohistochemical analysis of 101 cases revealed more abundant immunoreactivity of CYP11B1 and CYP17 in the KCNJ5-mutated group than in the KCNJ5 wild-type group. CONCLUSION This report of marked suppression of PAC by dexamethasone in patients with KCNJ5-mutated APAs indicates that such APAs respond to endogenous ACTH more readily than APAs in nonmutated cases. Further molecular and epidemiologic studies are required to validate our results and clarify the clinical effectiveness of the DST for predicting KCNJ5 mutations before adrenalectomy.
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Affiliation(s)
- Kosuke Inoue
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takumi Kitamoto
- Division of Endocrinology, Department of Medicine, Columbia University, New York, New York
- Department of Medical Physiology, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Rei Hirose
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Masao Omura
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
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Bourdeau I, El Ghorayeb N, Gagnon N, Lacroix A. MANAGEMENT OF ENDOCRINE DISEASE: Differential diagnosis, investigation and therapy of bilateral adrenal incidentalomas. Eur J Endocrinol 2018; 179:R57-R67. [PMID: 29748231 DOI: 10.1530/eje-18-0296] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/10/2018] [Indexed: 01/11/2023]
Abstract
The investigation and management of unilateral adrenal incidentalomas have been extensively considered in the last decades. While bilateral adrenal incidentalomas represent about 15% of adrenal incidentalomas (AIs), they have been less frequently discussed. The differential diagnosis of bilateral incidentalomas includes metastasis, primary bilateral macronodular adrenal hyperplasia and bilateral cortical adenomas. Less frequent etiologies are bilateral pheochromocytomas, congenital adrenal hyperplasia (CAH), Cushing's disease or ectopic ACTH secretion with secondary bilateral adrenal hyperplasia, primary malignancies, myelolipomas, infections or hemorrhage. The investigation of bilateral incidentalomas includes the same hormonal evaluation to exclude excess hormone secretion as recommended in unilateral AI, but diagnosis of CAH and adrenal insufficiency should also be excluded. This review is focused on the differential diagnosis, investigation and treatment of bilateral AIs.
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Affiliation(s)
- Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - Nada El Ghorayeb
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - Nadia Gagnon
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
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Kim JH, Kwak MK, Ahn SH, Kim H, Cho YY, Suh S, Kim BJ, Song KH, Lee SH, Koh JM. Alteration in skeletal muscle mass in women with subclinical hypercortisolism. Endocrine 2018; 61:134-143. [PMID: 29717464 DOI: 10.1007/s12020-018-1598-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/09/2018] [Indexed: 01/06/2023]
Abstract
PURPOSE Despite the well-known deleterious effects of cortisol on skeletal muscle, whether subtle cortisol excess in subclinical hypercortisolism (SH) affects skeletal muscle mass is unknown. Our objective was to understand the effects of the cortisol level on skeletal muscle mass in patients with SH. METHODS We compared skeletal muscle mass and fat mass (FM) between 21 patients with SH (12 women and 9 men) and 224 controls (67 women and 157 men) with nonfunctioning adrenal incidentaloma (NFAI). Medical records were reviewed, and we measured body composition parameters using bioelectrical impedance analysis and serum cortisol levels after the overnight 1-mg dexamethasone suppression test (DST). RESULTS After adjusting for confounding factors, 1-mg DST levels were inversely correlated with appendicular skeletal muscle mass (ASM) (γ = -0.245, P = 0.040), lower limb ASM (γ = -0.244, P = 0.040), and appendicular skeletal muscle index (ASMI; height-adjusted ASM) (γ = -0.229, P = 0.048) in all women, but not men. ASM and ASMI were significantly lower by 6.2% (P = 0.033) and 5.9% (P = 0.046), respectively, in women with SH compared with those with NFAI, but not men. Conversely, FM and percent fat mass were similar between the two groups. Compared with women with NFAI, among those with SH, lower limb, but not upper limb, ASM was lower by 6.8% (P = 0.020). CONCLUSIONS This study showed that women with SH had lower skeletal muscle mass, especially of the lower limb, and suggested that subtle cortisol excess also has adverse effects on skeletal muscle metabolism.
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Affiliation(s)
- Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Mi Kyung Kwak
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, Korea
| | - Seong Hee Ahn
- Department of Endocrinology, Inha University School of Medicine, Incheon, 22332, Korea
| | - Hyeonmok Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Medical Center, Seoul, Korea
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Department of Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sunghwan Suh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Beom-Jun Kim
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, Korea
| | - Kee-Ho Song
- Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, Korea.
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, Korea
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Javanmard P, Duan D, Geer EB. Mortality in Patients with Endogenous Cushing's Syndrome. Endocrinol Metab Clin North Am 2018; 47:313-333. [PMID: 29754634 DOI: 10.1016/j.ecl.2018.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cushing's syndrome is associated with increased morbidity and mortality. Cardiovascular events, sepsis, and thromboembolism are the leading causes of mortality. Patient's with Cushing's due to a pituitary adenoma and those with Cushing's due to benign adrenal adenoma have relatively good survival outcomes often mirroring that of the general population. Persistent or recurrent disease is associated with high mortality risk. Ectopic Cushing's syndrome and Cushing's due to adrenocortical carcinoma confer the highest mortality risk among Cushing's etiologies. Prompt diagnosis and treatment, and specific monitoring for and treatment of associated comorbidities are essential to decrease the burden of mortality from Cushing's.
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Affiliation(s)
- Pedram Javanmard
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine, The Mount Sinai Hospital, 1 Gustave L Levy Place, Box 1055, New York, NY 10029, USA
| | - Daisy Duan
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine, The Mount Sinai Hospital, 1 Gustave L Levy Place, Box 1055, New York, NY 10029, USA
| | - Eliza B Geer
- Division of Endocrinology, Department of Medicine, Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 419, New York, NY 10065, USA.
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Abstract
During the last 20 years, a significant body of literature has accumulated regarding subclinical hypercortisolism in patients with adrenal incidentalomas. Retrospective studies have indicated these patients have an increase in cardiovascular events and mortality. Current recommendations for patients with adrenal incidentalomas include an overnight low-dose dexamethasone suppression test and a thorough evaluation of cardiovascular and metabolic risk factors. Further hormonal testing and close monitoring are necessary in patients with incomplete suppression. Unilateral adrenalectomy may be beneficial in cases with abnormal suppression and comorbidities related to hypercortisolemia. Prospective studies are need for a better risk stratification and tailored therapy.
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Affiliation(s)
- Guido Zavatta
- Division of Endocrinology, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy.
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Ahn SH, Kim JH, Baek SH, Kim H, Cho YY, Suh S, Kim BJ, Hong S, Koh JM, Lee SH, Song KH. Characteristics of Adrenal Incidentalomas in a Large, Prospective Computed Tomography-Based Multicenter Study: The COAR Study in Korea. Yonsei Med J 2018; 59:501-510. [PMID: 29749133 PMCID: PMC5949292 DOI: 10.3349/ymj.2018.59.4.501] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 02/28/2018] [Accepted: 03/13/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Previous studies on adrenal incidentalomas (AIs) are limited by their retrospective design, small numbers of patients, Western populations, or use of an outdated imaging technique. We investigated the characteristics of AIs in Korean patients and compared them with those reported in the largest retrospective study in Italy to discover the effects of improved imaging techniques and ethnicity differences. MATERIALS AND METHODS This was a prospective, multicenter, cross-sectional observational study including 1005 Korean patients. Levels of plasma adrenocorticotrophic hormone, 24-h urinary free cortisol (UFC), serum cortisol after a 1 mg-dexamethasone suppression test, 24-h urinary fractionated metanephrine, and plasma aldosterone and plasma renin activity were measured. All AIs were characterized using computed tomography (CT). RESULTS Compared with the results of the Italian study, AIs in Korean patients were observed more frequently in men and predominantly on the left side. Korean patients with AIs were slightly younger, and fewer patients underwent surgery. Most AIs were nonfunctional in both studies, while fewer subclinical hypercortisolism and more primary aldosteronism (PA) cases were detected in Korean patients. In our study, high UFC levels showed very low sensitivity, compared to those in the Italian study. In pheochromocytoma or PA cases, there were no hormonal differences between the studies. AIs in Korean patients were smaller, such that a lower cutoff size for detecting adrenocortical carcinoma (ACC) could be warranted. CONCLUSION Recent advances in CT technology were leveraged to provide accurate characteristics of AIs and to detect smaller ACCs.
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Affiliation(s)
- Seong Hee Ahn
- Division of Endocrinology and Metabolism, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hee Baek
- Division of Clinical Epidemiology and Biostatics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeonmok Kim
- Division of Endocrinology and Metabolism, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sunghwan Suh
- Division of Endocrinology and Metabolism, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Beom Jun Kim
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seongbin Hong
- Division of Endocrinology and Metabolism, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jung Min Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Kee Ho Song
- Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.
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85
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Morelli V, Palmieri S. Adrenal incidentaloma: differential diagnosis and management strategies. MINERVA ENDOCRINOL 2018; 44:4-18. [PMID: 29808642 DOI: 10.23736/s0391-1977.18.02868-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adrenal incidentaloma is a frequent clinical finding. Once an adrenal mass is detected, is mandatory to determine whether the lesion is malignant or benign and whether it is hormonally active or non-functioning, to estabilish an adequate treatement or follow-up. The European Society of Endocrinology and ENSAT Guideline recently provided the best recommendation based on the available literature. However, due to the retrospective design of the majority of the studies, the small number of patients included and the inadequate follow-up, some issues are still unresolved. In particular, there is a general consensus about the need of adrenalectomy in the presence of unilateral adrenal mass and clinically relevant hormone excess or radiological findings suspected for malignancy. On the other side, how to manage adrenal masses with indeterminate characteristics or subtle cortisol secretion, and how long the radiological and functional follow-up of benign adrenal mass should last in non-operated patients, are still open questions. Therefore, high-quality research for establish the adequate management of these patients and randomized clinical trials are needed to avoid unnecessary investigations and invasive procedures and ensure a clinically effective work-up.
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Affiliation(s)
- Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy -
| | - Serena Palmieri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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The difficulties of pseudo-Cushing's syndrome (or "non-neoplastic hypercortisolism"). ANNALES D'ENDOCRINOLOGIE 2018; 79:138-145. [PMID: 29716734 DOI: 10.1016/j.ando.2018.04.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pseudo-Cushing's syndrome covers different pathological conditions responsible for mild-to-moderate ACTH-dependent hypercortisolism, related not to an ACTH-secreting tumor but rather to CRH and/or AVP hypothalamic secretion through activation of various neural pathways, in patients generally displaying excess central adiposity. It is better termed "non-neoplastic hypercortisolism" (NNH). The main conditions implicated in NNH comprise: neuropsychiatric disorder, alcohol abuse, insulin-resistant obesity, polycystic ovary syndrome, and end-stage kidney disease. Glucocorticoid resistance is one differential diagnosis, as are some cases of primary adrenal disease with incompletely suppressed ACTH. Differentiating between NNH and mild-to-moderate Cushing's disease can be a real challenge. Clinical analysis, based on thorough history taking and screening for catabolic signs is essential; useful explorations include midnight serum or salivary cortisol and Dex/CRH and ddAVP stimulation response. Pituitary MRI suffers from limitations regarding both sensitivity and specificity, while bilateral inferior petrosal sinus sampling cannot distinguish between pituitary ACTH secretion by a tumor or by normal cells stimulated by endogenous CRH. Definitive diagnosis of functional etiology requires demonstrating that treatment of the underlying condition restores normal secretion of ACTH and cortisol, but this is not always possible. Lingering diagnostic uncertainty has to be accepted in certain patients, who will have to be followed up for some time before diagnosis can be considered more or less definitive.
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87
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Tabarin A. Do the diagnostic criteria for subclinical hypercortisolism exist? ANNALES D'ENDOCRINOLOGIE 2018; 79:146-148. [PMID: 29661471 DOI: 10.1016/j.ando.2018.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
"Subclinical hypercortisolism" (SH) refers to a condition associated with a mild chronic increase in cortisol secretion. By definition, patients with SH do not exhibit specific symptoms of overt Cushing's syndrome (such as purple striae, easy bruising, proximal muscle weakness), SH has been preferred to "subclinical Cushing's syndrome", a semantic ambiguity since Cushing's syndrome is, by definition, a set of symptoms; and to the term "preclinical Cushing syndrome" because the progression toward overt clinical hypercortisolism is very rare. However, SH still is misnomer as a number of studies suggest that this condition may induce long-term non-specific adverse conditions related to the mild cortisol excess (i.e. diabetes, hypertension, obesity, and osteoporosis). Various attempts have been made to define SH that remains a matter of controversies and uncertainties.
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Affiliation(s)
- Antoine Tabarin
- Department of endocrinology, diabetes and nutrition, CHU de Bordeaux, hopital Haut-Lévêque, 33604 Pessac, France.
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88
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Marina LV, Ivović M, Tančić-Gajić M, Arizanović Z, Raković D, Milin-Lazović J, Kendereški A, Micić D, Vujović S. Luteinizing hormone and insulin resistance in menopausal patients with adrenal incidentalomas: The cause-effect relationship? Clin Endocrinol (Oxf) 2018; 88:541-548. [PMID: 29288564 DOI: 10.1111/cen.13541] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/13/2017] [Accepted: 12/21/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE A high prevalence of insulin resistance (IR) has proven to manifest in patients with adrenal incidentalomas (AI). It has been demonstrated that an increase in IR is related to the size of tumourous masses; additionally, luteinizing hormone (LH)-dependent adrenal pathologies are well documented in patients with LH-responsive adrenal tumours occurring under conditions of physiologically elevated LH. We hypothesized that an association between LH and insulin might play a role in adrenal tumourigenesis and steroidogenesis. DESIGN The aim of our study was to investigate the association between LH and IR; adrenal tumour size (ATS) and IR; LH and cortisol after the 1 mg overnight dexamethasone test (1 mg DST); and ATS and 1 mg DST cortisol in AI patients. This was a case-control study conducted in the Clinic for Endocrinology, Diabetes and Metabolic Diseases in Belgrade, Serbia. The total study group consisted of 105 menopausal women: 75 AI patients [27 with nonfunctional AI (NAI) and 48 with (possible) autonomous cortisol secretion ((P)ACS)] and 30 age-, BMI-, LH- and menopause duration-matched healthy control (HC) women. To estimate IR, we used homeostasis model assessment (HOMA-IR). RESULTS Luteinizing hormone and ATS are in a significant positive correlation with HOMA-IR and 1 mg DST cortisol in menopausal patients with AI and (P)ACS. CONCLUSIONS Our data point to a possible cause-effect relationship between LH and insulin in patients with AI and (P)ACS adding to the body of evidence of their involvement in adrenal tumourigenesis and steroidogenesis.
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Affiliation(s)
- Ljiljana V Marina
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miomira Ivović
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milina Tančić-Gajić
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zorana Arizanović
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragana Raković
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Aleksandra Kendereški
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragan Micić
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Svetlana Vujović
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Morelli V, Minelli L, Eller-Vainicher C, Palmieri S, Cairoli E, Spada A, Arosio M, Chiodini I. Predictability of hypoadrenalism occurrence and duration after adrenalectomy for ACTH-independent hypercortisolism. J Endocrinol Invest 2018; 41:485-493. [PMID: 29151238 DOI: 10.1007/s40618-017-0788-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/29/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate if the parameters of hypothalamic-pituitary-adrenal (HPA) axis activity could predict the occurrence and duration of post-surgical hypocortisolism (PSH) in patients with Cushing's syndrome (CS) and with adrenal incidentaloma (AI). METHODS We studied 80 patients (54 females, age 53.3 ± 11 years), who underwent adrenalectomy for CS (17 patients) or for AI (53 patients). Before surgery, we measured adrenocorticotroph hormone (ACTH), urinary free cortisol (UFC) and serum cortisol after 1 mg dexamethasone suppression test (1 mg-DST) levels. After surgery, all patients were given a steroid replacement therapy, and PSH was searched after 2 months by a low-dose (1 µg, iv) corticotropin stimulation test, that was repeated every 6 months in PSH patients for at least 4 years. RESULTS The PSH occurred in 82.4 and 46% of CS and AI patients, respectively. In the whole sample and in AI patients separately considered, the PSH was independently predicted by the preoperative cortisol levels after 1 mg-DST, however, with a low (< 70%) accuracy. In AI patients the PSH occurrence was not ruled out even by the cortisol levels after 1 mg-DST lower than 1.8 μg/dL (50 nmol/L). In the 50% of CS patients and in 31% of AI patients the PSH lasted more than 18 months and in 35.7% of CS patients it persisted for more than 36 months. In AI patients, the PSH duration was not predictable by any parameter. However, a PSH duration of at least 12 months was significantly predicted before adrenalectomy (sensitivity 91.7%, specificity 41.2%, positive predictive value 52.4%, negative predictive value 87.5%, p = 0.05) by the presence of at least 2 out of low ACTH levels, increased UFC levels and cortisol levels after 1 mg-DST ≥ 3.0 µg/dL (83 nmol/L). CONCLUSION The PSH occurrence and its duration are hardly predictable before surgery. All patients undergoing unilateral adrenalectomy should receive a steroid substitutive therapy.
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Affiliation(s)
- V Morelli
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - L Minelli
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Eller-Vainicher
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Pad. Granelli, Via F. Sforza 35, 20122, Milan, Italy
| | - S Palmieri
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Cairoli
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - A Spada
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Arosio
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Pad. Granelli, Via F. Sforza 35, 20122, Milan, Italy
| | - I Chiodini
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Pad. Granelli, Via F. Sforza 35, 20122, Milan, Italy.
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90
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Morelli V, Arosio M, Chiodini I. Cardiovascular mortality in patients with subclinical Cushing. ANNALES D'ENDOCRINOLOGIE 2018; 79:149-152. [PMID: 29606280 DOI: 10.1016/j.ando.2018.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patients with adrenal incidentaloma (AI) and subclinical hypercortisolism (SH) show a high prevalence of cardiovascular risk factors and an increased prevalence and incidence of cardiovascular events. Furthermore, some recent data suggest that in these patients, the cardiovascular mortality is also increased. Unfortunately, to date, the diagnosis of SH is still a matter of debate, and, therefore, it is still not possible to address the treatment of choice (i.e. surgical or conservative approach) in many AI patients. Overall, the available data show that in AI patients with established SH the surgical removal of the adrenal mass causing SH can lead to the improvement of hypertension and diabetes, but in many patients with possible SH the effect of surgery is still largely unknown. Finally, no data are available on the effect of the recovery from SH on the cardiovascular events. Therefore, randomized studies are needed to investigate the possibility of predicting the usefulness of surgery by using the available indexes of cortisol secretion in the individual AI patient. Finally, the development of safe and well-tolerated drugs aimed to control cortisol secretion will be among the goals of the future research.
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Affiliation(s)
- Valentina Morelli
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Padiglione Granelli, via F. Sforza 35, 20122 Milano, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Padiglione Granelli, via F. Sforza 35, 20122 Milano, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Iacopo Chiodini
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Padiglione Granelli, via F. Sforza 35, 20122 Milano, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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91
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Kosteria I, Kanaka-Gantenbein C, Anagnostopoulos AK, Chrousos GP, Tsangaris GT. Pediatric endocrine and metabolic diseases and proteomics. J Proteomics 2018; 188:46-58. [PMID: 29563068 DOI: 10.1016/j.jprot.2018.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/05/2018] [Accepted: 03/16/2018] [Indexed: 12/11/2022]
Abstract
The principles of Predictive, Preventive and Personalized Medicine (PPPM) dictate the need to recognize individual susceptibility to disease in a timely fashion and to offer targeted preventive interventions and treatments. Proteomics is a state-of-the art technology- driven science aiming at expanding our understanding of the pathophysiologic mechanisms that underlie disease, but also at identifying accurate predictive, diagnostic and therapeutic biomarkers, that will eventually promote the implementation of PPPM. In this review, we summarize the wide spectrum of the applications of Mass Spectrometry-based proteomics in the various fields of Pediatric Endocrinology, including Inborn Errors of Metabolism, type 1 diabetes, Adrenal Disease, Metabolic Syndrome and Thyroid disease, ranging from neonatal screening to early recognition of specific at-risk populations for disease manifestations or complications in adult life and to monitoring of disease progression and response to treatment. SIGNIFICANCE Proteomics is a state-of-the art technology- driven science aiming at expanding our understanding of the pathophysiologic mechanisms that underlie disease, but also at identifying accurate predictive, diagnostic and therapeutic biomarkers that will eventually lead to successful, targeted, patient-centric, individualized approach of each patient, as dictated by the principles of Predictive, Preventive and Personalized Medicine. In this review, we summarize the wide spectrum of the applications of Mass Spectrometry-based proteomics in the various fields of Pediatric Endocrinology, including Inborn Errors of Metabolism, type 1 diabetes, Adrenal Disease, Metabolic Syndrome and Thyroid disease, ranging from neonatal screening, accurate diagnosis, early recognition of specific at-risk populations for the prevention of disease manifestation or future complications.
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Affiliation(s)
- Ioanna Kosteria
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece.
| | - Christina Kanaka-Gantenbein
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece.
| | | | - George P Chrousos
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece
| | - George Th Tsangaris
- Proteomics Research Unit, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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92
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Moraitis AG. Nonfunctional Adrenal Adenomas: Truth or Myth? Presentation and Treatment of 2 Patients. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171897.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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93
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Effects of Mifepristone on Nonalcoholic Fatty Liver Disease in a Patient with a Cortisol-Secreting Adrenal Adenoma. Case Rep Endocrinol 2017; 2017:6161348. [PMID: 29348947 PMCID: PMC5733994 DOI: 10.1155/2017/6161348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/23/2017] [Indexed: 12/14/2022] Open
Abstract
Cushing syndrome (CS), a complex, multisystemic condition resulting from prolonged exposure to cortisol, is frequently associated with nonalcoholic fatty liver disease (NAFLD). In patients with adrenal adenoma(s) and NAFLD, it is essential to rule out coexisting endocrine disorders like CS, so that the underlying condition can be properly addressed. We report a case of a 49-year-old woman with a history of hypertension, prediabetes, dyslipidemia, biopsy-confirmed steatohepatitis, and benign adrenal adenoma, who was referred for endocrine work-up for persistent weight gain. Overt Cushing features were absent. Biochemical evaluation revealed nonsuppressed cortisol on multiple 1-mg dexamethasone suppression tests, suppressed adrenocorticotropic hormone, and low dehydroepiandrosterone sulfate. The patient initially declined surgery and was treated with mifepristone, a competitive glucocorticoid receptor antagonist. In addition to improvements in weight and hypertension, substantial reductions in her liver enzymes were noted, with complete normalization by 20 weeks of therapy. This case suggests that autonomous cortisol secretion from adrenal adenoma(s) could contribute to the metabolic and liver abnormalities in patients with NAFLD. In conclusion, successful management of CS with mifepristone led to marked improvement in the liver enzymes of a patient with long-standing NAFLD.
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Abstract
The daily rhythm of the hypothalamo-pituitary-adrenal (HPA) axis is regulated by the central clock in the suprachiasmatic nucleus. Cortisol, a glucocorticoid, acts as a secondary messenger between the central clock and the peripheral tissues. Changes in clock time, as seen in shift workers, alters the HPA axis and results in metabolic disturbances associated with ill health. Depression, anorexia nervosa and obstructive sleep apnoea, are associated with cortisol rhythm phase shifts and increased cortisol exposure. Higher nocturnal cortisol exposure is observed in patients with Cushing's syndrome and adrenal incidentalomas with autonomous cortisol secretion and is associated with insulin resistance, and increased cardiovascular risk and mortality. A decrease in cortisol rhythm amplitude is seen in adrenal insufficiency, and despite replacement, patients have an impaired quality of life and increased mortality. Research on cortisol replacement has focused on replacing the cortisol daily rhythm by subcutaneous hydrocortisone infusions and oral modified release hydrocortisone formulations with the aim of improving disease control and quality of life.
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Affiliation(s)
| | - Richard Ross
- Oncology and Metabolism, University of Sheffield, Sheffield, S10 2RX, UK.
| | - Miguel Debono
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield, UK.
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Debono M, Harrison RF, Chadarevian R, Gueroult C, Abitbol JL, Newell-Price J. Resetting the Abnormal Circadian Cortisol Rhythm in Adrenal Incidentaloma Patients With Mild Autonomous Cortisol Secretion. J Clin Endocrinol Metab 2017; 102:3461-3469. [PMID: 28911138 PMCID: PMC5587065 DOI: 10.1210/jc.2017-00823] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/27/2017] [Indexed: 12/24/2022]
Abstract
CONTEXT Adrenal incidentalomas (AIs) are found commonly on axial imaging. Around 30% exhibit autonomous cortisol secretion (ACS) associated with increased cardiovascular events and death. OBJECTIVE We hypothesized that AI/ACS patients have an abnormal cortisol rhythm that could be reversed by use of carefully timed short-acting cortisol synthesis blockade, with improvement in cardiovascular disease markers. DESIGN, SETTING, AND PARTICIPANTS In a phase 1/2a, prospective study (Eudract no. 2012-002586-35), we recruited six patients with AI/ACS and two control groups of six sex-, age-, and body mass index-matched individuals: (1) patients with AI and no ACS (AI/NoACS) and (2) healthy volunteers with no AI [healthy controls (HC)]. Twenty-four-hour circadian cortisol analysis was performed to determine any differences between groups and timing of intervention for cortisol lowering using the 11β-hydroxylase inhibitor metyrapone. Circadian profiles of serum interleukin-6 (IL-6) were assessed. RESULTS Serum cortisol levels in group AI/ACS were significantly higher than both group AI/NoACS and group HC from 6 pm to 10 pm [area under the curve (AUC) difference: 0.81 nmol/L/h; P = 0.01] and from 10 pm to 2 am (AUC difference: 0.86 nmol/L/h; P < 0.001). In light of these findings, patients with ACS received metyrapone 500 mg at 6 pm and 250 mg at 10 pm, and cortisol rhythms were reassessed. Postintervention evening serum cortisol was lowered, similar to controls [6 pm to 10 pm (AUC difference: -0.06 nmol/L/h; P = 0.85); 10 pm to 2 am (AUC difference: 0.10 nmol/L/h; P = 0.76)]. Salivary cortisone showed analogous changes. IL-6 levels were elevated before treatment [10 pm to 2 pm (AUC difference: 0.42 pg/mL/h; P = 0.01)] and normalized post treatment. CONCLUSIONS In AI/ACS, the evening and nocturnal cortisol exposure is increased. Use of timed evening doses of metyrapone resets the cortisol rhythm to normal. This unique treatment paradigm is associated with a reduction in the cardiovascular risk marker IL-6.
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Affiliation(s)
- Miguel Debono
- Academic Unit of Endocrinology, University of Sheffield, Sheffield S10 2TN, United Kingdom
| | - Robert F. Harrison
- Department of Automatic Control and Systems Engineering, University of Sheffield S10 2TN, Sheffield, United Kingdom
| | | | - Carole Gueroult
- HRA Pharma, 14/16 rue des Petits Hôtels 75 010 Paris, France
| | | | - John Newell-Price
- Academic Unit of Endocrinology, University of Sheffield, Sheffield S10 2TN, United Kingdom
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96
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Yang J, Shen J, Fuller PJ. Diagnosing endocrine hypertension: a practical approach. Nephrology (Carlton) 2017; 22:663-677. [DOI: 10.1111/nep.13078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/10/2017] [Accepted: 05/24/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Jun Yang
- Centre for Endocrinology and Metabolism; Hudson Institute of Medical Research; Melbourne Victoria Australia
- Department of Endocrinology; Monash Health; Melbourne Victoria Australia
| | - Jimmy Shen
- Centre for Endocrinology and Metabolism; Hudson Institute of Medical Research; Melbourne Victoria Australia
- Department of Endocrinology; Monash Health; Melbourne Victoria Australia
| | - Peter J. Fuller
- Centre for Endocrinology and Metabolism; Hudson Institute of Medical Research; Melbourne Victoria Australia
- Department of Endocrinology; Monash Health; Melbourne Victoria Australia
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97
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Peverelli E, Catalano R, Giardino E, Treppiedi D, Morelli V, Ronchi CL, Vaczlavik A, Fusco N, Ferrero S, Bertherat J, Beuschlein F, Chiodini I, Arosio M, Spada A, Mantovani G. Cofilin is a cAMP effector in mediating actin cytoskeleton reorganization and steroidogenesis in mouse and human adrenocortical tumor cells. Cancer Lett 2017; 406:54-63. [PMID: 28826686 DOI: 10.1016/j.canlet.2017.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/20/2017] [Accepted: 07/27/2017] [Indexed: 11/17/2022]
Abstract
cAMP pathway plays a major role in the pathogenesis of cortisol-producing adrenocortical adenomas (CPA). cAMP-induced steroidogenesis is preceded by actin cytoskeleton reorganization, a process regulated by cofilin activity. In this study we investigated cofilin role in mediating cAMP effects on cell morphology and steroidogenesis in adrenocortical tumor cells. We demonstrated that forskolin induced cell rounding and strongly reduced phosphorylated (P)-cofilin/total cofilin ratio in Y1 (-52 ± 16%, p < 0.001) and human CPA cells (-53 ± 18%, p < 0.05). Cofilin silencing significantly reduced both forskolin-induced morphological changes and progesterone production (1.3-fold vs 1.8-fold in controls, p < 0.05), whereas transfection of wild-type or S3A (active), but not S3D (inactive) cofilin, potentiated forskolin effects on cell rounding and increased 3-fold progesterone synthesis with respect to control (p < 0.05). Furthermore, cofilin dephosphorylation by a ROCK inhibitor potentiated forskolin-induced cell rounding and steroidogenesis (2-fold increase vs forskolin alone). Finally, we found a reduced P-cofilin/total cofilin ratio and increased cofilin expression in CPA vs endocrine inactive adenomas by western blot and immunohistochemistry. Overall, these results identified cofilin as a mediator of cAMP effects on both morphological changes and steroidogenesis in mouse and human adrenocortical tumor cells.
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Affiliation(s)
- E Peverelli
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - R Catalano
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Giardino
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - D Treppiedi
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - V Morelli
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C L Ronchi
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - A Vaczlavik
- Institut Cochin, Inserm U1016, CNRS UMR8104, Descartes University, Paris, France; Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France
| | - N Fusco
- Division of Pathology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan Medical School, Milan, Italy
| | - S Ferrero
- Division of Pathology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan Medical School, Milan, Italy
| | - J Bertherat
- Institut Cochin, Inserm U1016, CNRS UMR8104, Descartes University, Paris, France; Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France
| | - F Beuschlein
- Medizinische Klinik und Poliklinik IV, Endocrine Research Unit, Klinikum der Universität München, LMU, Munich, Germany
| | - I Chiodini
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Arosio
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - A Spada
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - G Mantovani
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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98
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Morelli V, Palmieri S, Lania A, Tresoldi A, Corbetta S, Cairoli E, Eller-Vainicher C, Arosio M, Copetti M, Grossi E, Chiodini I. Cardiovascular events in patients with mild autonomous cortisol secretion: analysis with artificial neural networks. Eur J Endocrinol 2017; 177:73-83. [PMID: 28468767 DOI: 10.1530/eje-17-0047] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/18/2017] [Accepted: 05/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The independent role of mild autonomous cortisol secretion (ACS) in influencing the cardiovascular event (CVE) occurrence is a topic of interest. We investigated the role of mild ACS in the CVE occurrence in patients with adrenal incidentaloma (AI) by standard statistics and artificial neural networks (ANNs). METHODS We analyzed a retrospective record of 518 AI patients. Data regarding cortisol levels after 1 mg dexamethasone suppression (1 mg DST) and the presence of obesity (OB), hypertension (AH), type-2 diabetes (T2DM), dyslipidemia (DL), familial CVE history, smoking habit and CVE were collected. RESULTS The receiver-operating characteristic curve analysis suggested that 1 mg DST, at a cut-off of 1.8 µg/dL, had the best accuracy for detecting patients with increased CVE risk. In patients with 1 mg-DST ≥1.8 µg/dL (DST+, n = 223), age and prevalence of AH, T2DM, DL and CVE (66 years, 74.5, 25.9, 41.4 and 26.8% respectively) were higher than that of patients with 1 mg-DST ≤1.8 µg/dL (61.9 years, 60.7, 18.5, 32.9 and 10%, respectively, P < 0.05 for all). The CVE were associated with DST+ (OR: 2.46, 95% CI: 1.5-4.1, P = 0.01), regardless of T2DM, AH, DL, smoking habit, gender, observation period and age. The presence of at least two among AH, T2DM, DL and OB plus DST+ had 61.1% sensitivity in detecting patients with CVE. By using the variables selected by ANNs (familial CVE history, age, T2DM, AH, DL and DST+) 78.7% sensitivity was reached. CONCLUSIONS Cortisol after 1 mg-DST is independently associated with the CVE occurrence. The ANNs might help for assessing the CVE risk in AI patients.
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Affiliation(s)
- Valentina Morelli
- Department of Medical Sciences and Community HealthUniversity of Milan, Milan, Italy
- Unit of Endocrinology and Metabolic DiseasesIRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena Palmieri
- Department of Medical Sciences and Community HealthUniversity of Milan, Milan, Italy
- Unit of Endocrinology and Metabolic DiseasesIRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Lania
- Endocrine UnitIRCCS Humanitas Clinical Institute, Humanitas University, Rozzano, Milan, Italy
| | - Alberto Tresoldi
- Department of Medical Sciences and Community HealthUniversity of Milan, Milan, Italy
- Endocrine UnitIRCCS Humanitas Clinical Institute, Humanitas University, Rozzano, Milan, Italy
| | - Sabrina Corbetta
- Department of Biomedical SciencesUnit of Endocrinology, University of Milan, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Elisa Cairoli
- Department of Medical Sciences and Community HealthUniversity of Milan, Milan, Italy
- Unit of Endocrinology and Metabolic DiseasesIRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Eller-Vainicher
- Unit of Endocrinology and Metabolic DiseasesIRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Department of Medical Sciences and Community HealthUniversity of Milan, Milan, Italy
- Unit of Endocrinology and Metabolic DiseasesIRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Unit of Endocrine Diseases and DiabetologyOspedale San Giuseppe, Gruppo Multimedica, Milan, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics 'Casa Sollievo della Sofferenza'IRCCS, San Giovanni Rotondo, Foggia, Italy
| | | | - Iacopo Chiodini
- Department of Medical Sciences and Community HealthUniversity of Milan, Milan, Italy
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99
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Notarianni E. Cortisol: Mediator of association between Alzheimer's disease and diabetes mellitus? Psychoneuroendocrinology 2017; 81:129-137. [PMID: 28458232 DOI: 10.1016/j.psyneuen.2017.04.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 04/17/2017] [Accepted: 04/17/2017] [Indexed: 01/21/2023]
Abstract
Numerous epidemiologic studies have identified an independent association between Alzheimer's disease (AD) and diabetes mellitus (DM), which remains unexplained. This review contends that the association is mediated by mild hypercortisolemia that is manifested in AD by early stages, as empirical evidence indicates that hypercortisolemia is diabetogenic even at subclinical levels. Subclinical Cushing's syndrome is discussed as the paradigm. It is proposed that hypercortisolemia increases the risk of pre-diabetes and DM during early AD and the preceding decades. That hypercortisolemia is exhibited during the AD prodromal stage has yet to be determined, but may be inferred from concurrent metabolic parameters as documented in the literature. Studies refuting association between AD and DM also are evaluated, and the relationship between AD and DM is deduced to be more complex than directly causal, with DM of longstanding duration having a protective role. Association between DM and AD may require reappraisal by APOE ε4 carrier status, in view of newly identified roles of APOE ε4 in pre-diabetes. That association of APOE ε4 with DM in AD may have been underestimated in epidemiologic studies also is highlighted. At the core of arguments and mechanisms presented in this review is the circadian rhythm of cortisol secretion, which is the main determinant of glycemic control in humans. Alterations to that rhythm and to the hypothalamic-pituitary-adrenal axis occurring in AD are examined. Consequently the cause of hypercortisolemia in AD, and therefore of association between AD and DM, is proposed to be adrenal hyper-responsiveness to adrenocorticotropic hormone.
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Affiliation(s)
- Elena Notarianni
- St Hilda's College, University of Oxford, Cowley Place, Oxford OX4 1DY, UK; Department of Biosciences, Durham University, South Road, Durham DH1 3LE, UK.
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100
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Scaroni C, Zilio M, Foti M, Boscaro M. Glucose Metabolism Abnormalities in Cushing Syndrome: From Molecular Basis to Clinical Management. Endocr Rev 2017; 38:189-219. [PMID: 28368467 DOI: 10.1210/er.2016-1105] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 03/15/2017] [Indexed: 12/13/2022]
Abstract
An impaired glucose metabolism, which often leads to the onset of diabetes mellitus (DM), is a common complication of chronic exposure to exogenous and endogenous glucocorticoid (GC) excess and plays an important part in contributing to morbidity and mortality in patients with Cushing syndrome (CS). This article reviews the pathogenesis, epidemiology, diagnosis, and management of changes in glucose metabolism associated with hypercortisolism, addressing both the pathophysiological aspects and the clinical and therapeutic implications. Chronic hypercortisolism may have pleiotropic effects on all major peripheral tissues governing glucose homeostasis. Adding further complexity, both genomic and nongenomic mechanisms are directly induced by GCs in a context-specific and cell-/organ-dependent manner. In this paper, the discussion focuses on established and potential pathologic molecular mechanisms that are induced by chronically excessive circulating levels of GCs and affect glucose homeostasis in various tissues. The management of patients with CS and DM includes treating their hyperglycemia and correcting their GC excess. The effects on glycemic control of various medical therapies for CS are reviewed in this paper. The association between DM and subclinical CS and the role of screening for CS in diabetic patients are also discussed.
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Affiliation(s)
- Carla Scaroni
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
| | - Michelangelo Foti
- Department of Cell Physiology & Metabolism, Centre Médical Universitaire, 1 Rue Michel Servet, 1211 Genèva, Switzerland
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
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