Secretion of various endocrine substances by ACTH-secreting tumors--gastrin, melanotropin, norepinephrine, serotonin, parathormone, vasopressin, glucagon

Ectopic ACTH- and/or CRH-Producing Pheochromocytomas

CONTEXT

The characteristics of catecholamine-secreting pheochromocytomas have been well studied. However, less is known about the characteristics, management and outcome in patients with ectopic adrenocorticotropic hormone (ACTH) and/or corticotrophin-releasing hormone (CRH)-secreting pheochromocytomas.

OBJECTIVE

To review the characteristics and outcomes of ACTH- and/or CRH-secreting pheochromocytomas.

DATA SOURCE

A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 February 2020.

STUDY SELECTION

Original articles, including case reports and case series, reporting individual patient data from patients with ACTH- and/or CRH-secreting pheochromocytomas.

DATA EXTRACTION

Information on sex, age, symptoms at presentation, comorbidities, biochemistry, imaging, histopathology, and outcomes was extracted.

DATA SYNTHESIS

We identified 91 articles reporting on 99 cases of ACTH- and/or CRH-secreting pheochromocytomas (CRH-secreting n = 4). Median age at diagnosis was 49 years (interquartile range 38-59.5) with a 2:1 female to male ratio. Most patients presented with clinical Cushing syndrome (n = 79; 81%), hypertension (n = 87; 93%), and/or diabetes (n = 50; 54%). Blood pressure, glucose control, and biochemical parameters improved in the vast majority of patients postoperatively. Infections were the most common complication. Most cases (n = 70, 88%) with reported long-term outcome survived to publication (median follow-up 6 months).

CONCLUSION

Ectopic ACTH- and/or CRH-secreting pheochromocytoma should be considered in patients presenting with ACTH-dependent Cushing syndrome and adrenal mass. Despite the challenge in diagnosis, patient outcomes appear favorable.

Long-term Survival of a Patient with Small Cell Lung Cancer Secreting ADH and ACTH Simultaneously, Following the Prolonged Use of Amrubicin

Paraneoplastic syndromes are frequently observed in lung cancer, especially in small cell lung cancer (SCLC). Although there have been many reports on paraneoplastic syndromes, few reports have been published on SCLC that simultaneously produces antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH), and these reports described the prognosis of such cases as extremely poor. We herein present a rare case of a Japanese woman with SCLC accompanied by syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and Cushing's syndrome. The survival of the patient was prolonged by the long-term administration of amrubicin.

Beyond the Dual Paraneoplastic Syndromes of Small-Cell Lung Cancer with ADH and ACTH Secretion: A Case Report with Literature Review and Future Implications

We present a case of small-cell lung cancer (SCLC) with syndrome of inappropriate antidiuretic hormone secretion (SIADH) in which serum sodium gradually normalized with the onset of hypertension, refractory hypokalemia, and chloride-resistant metabolic alkalosis due to ectopic adrenocorticotrophic hormone (ACTH) secretion (EAS). In this case report, we discuss the diagnostic challenges of dual paraneoplastic syndromes with SIADH and EAS, management of SCLC with paraneoplastic endocrinopathies, and their prognostic impact on SCLC. In addition, we discuss neuroendocrine differentiation and ectopic hormone production in relation to intratumoral heterogeneity in SCLC and propose tumor microenvironment and hormonal and metabolic dependence as important determinants of tumor growth and survival.

Cushing’s syndrome due to ovarian serous adenocarcinoma secreting multiple endocrine substances: a case report and immunohistochemical analysis

BACKGROUND

Although Cushing's syndrome arises from various neuroendocrine tumors secreting adrenocorticotropin (ACTH) ectopically, ovarian carcinoma rarely causes this syndrome.

CASE

A 66-year-old woman presented with facial swelling and skin pigmentation. She manifested hypercortisolemia, high plasma ACTH, and lack of dexamethasone suppression. MRI showed a solid ovarian tumor and resection of the tumor led to normalization of ACTH and cortisol levels. In addition, elevated serum vasopressin (ADH) and alpha-fetoprotein (AFP) were found, which were also normalized after removal of tumors. Pathological diagnosis was serous adenocarcinoma with neuroendocrine and hepatoid features. Immunohistochemistry detected immunoreactivity of chromogranin A, ACTH, ADH, and AFP in tumor cells.

CONCLUSION

This is a very rare case of successful treatment of Cushing's syndrome arising from an ovarian adenocarcinoma secreting multiple endocrine substances.

Cancer cachexia: its correlations and causes

Cancer cachexia involves the loss of weight, mainly in skeletal muscle and adipose tissue, that is not caused simply by anorexia. The syndrome includes anemia and immunosuppression along with a number of biochemical changes indicating systemic effects of the cancer. It is a major factor in morbidity and mortality from cancer. For 30 years beginning in 1948, a large number of studies reported isolation from many tumors of a heterogeneous group of small peptides, generally labeled toxohormone, that caused various correlates of cachexia shortly after injection into mice. Interest in toxohormone-like peptides then fell off for diverse reasons that had little to do with their clinical significance and was shifted to cytokines, ILs, and ectopic hormones with catabolic consequences that were sporadically found in tumors. At the same time, evidence was accumulating for an important role of pericellular proteases in driving progressive stages of neoplastic development. A central part of that evidence was the inhibition of transformation-related changes by protease inhibitors, particularly the combination present in fetal bovine serum, which fully suppressed the expression of the transformed phenotype in discrete foci of chicken embryo fibroblasts (CEF) infected by Rous sarcoma virus against a confluent background of uninfected CEF. In contrast, CEF cultures heavily infected with Rous sarcoma virus in the same medium underwent pervasive transformation, which was correlated with the release of low molecular weight cytotoxic substances. Reevaluation of all of the evidence supports a central role for proteolytically generated peptides derived from tumors in producing cancer cachexia.

Sporadic Zollinger-Ellison Syndrome With Ectopic Production Of Corticotropin: Surgical Management

OBJECTIVE

To describe two patients with concurrent Zollinger-Ellison syndrome and ectopic production of corticotropin in whom Cushing's syndrome was managed surgically.

METHODS

Two case vignettes are presented, and a general approach is discussed for determining a management strategy for optimal potential for survival.

RESULTS

The prognosis associated with medical management of patients with sporadic Zollinger-Ellison syndrome and Cushing's syndrome attributable to ectopic production of adrenocorticotropic hormone (corticotropin) is dismal. Two surgical options may yield improved outcomes. The first approach is bilateral adrenalectomy followed by replacement therapy with corticosteroids and mineralocorticoids. The second surgical approach consists of removal of the organ producing the corticotropin (the liver) and performance of hepatic transplantation. These two treatment strategies were used in our two patients, both of whom had widely metastatic disease at the time of initial assessment. The patient who underwent bilateral adrenalectomy continued to do well 4 years postoperatively.

CONCLUSION

Treatment of patients with Zollinger-Ellison syndrome and ectopic production of corticotropin presents a challenge. Because results with medical therapy have been suboptimal, aggressive surgical intervention seems warranted.

Genetic screening to identify the gene carrier in Italian and German kindreds affected by multiple endocrine neoplasia type 1 (MEN 1) syndrome

Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominantly inherited disorder characterized by parathyroid hyperplasia, anterior pituitary adenomas and neoplasms of the endocrine cells of the gastroenteric tract. It has been established that also other tissues exhibit excessive proliferation associated to the MEN 1 syndrome: carcinoids (bronchial and intestinal), lipomas (visceral and cutaneous), thyroid adenomas and goiter, and adrenal gland cortex adenomas. The men 1 gene has been mapped by genetic studies to the long arm of human chromosome 11, region q12-13. Genetic analysis of families and tumoral deletion mapping made possible to narrow the men 1 region to a 5 cM interval on chromosome 11q12-13. Thirteen marker complexes (17 DNA probes) were found to be linked to the men 1 gene and they span a 14% meiotic recombination with the men 1 locus in the middle. We report a genetic study on 103 subjects from 7 collected MEN 1-kindreds, six Italian and one German, including 30 affected individuals. By linkage analysis to 9 DNA markers (10 DNA probes) of the chromosome region where the men 1 gene maps (11q12-13), we identified 10 mutant gene carriers. The predicted MEN 1 diagnosis was clinically confirmed for 2 of these identified carriers. A predictive accuracy of this genetic test can reach up to 99.5% when it is possible to exclude meiotic crossing-over between the analyzed DNA markers and the disease locus.

A patient with malignant paraganglioma that simultaneously produces adrenocorticotropic hormone and interleukin-6

BACKGROUND

To the authors' knowledge, there have been no reports describing a case of malignant paraganglioma that produces both adrenocorticotropic hormone (ACTH) and interleukin-6 (IL-6).

METHODS

The clinical course and pathophysiology of a patient with Cushing's syndrome induced by ectopic ACTH syndrome caused by a cervical malignant paraganglioma with elevated plasma levels of IL-6 was investigated.

RESULTS

Ultrasonography, computed tomography, and magnetic resonance imaging of the neck revealed the presence of a tumor around the area from which the blood sample that showed the highest levels of ACTH and IL-6 was obtained by selective catheterization. Immunohistochemical staining of the removed tissue demonstrated the presence of ACTH and IL-6 proteins in the tumor cells. Reverse transcriptase-polymerase chain reaction also revealed the existence of IL-6 mRNA in those cells.

CONCLUSION

The malignant paraganglioma of ectopic ACTH syndrome may produce IL-6. The present investigation provides new observations concerning ectopic ACTH syndrome.

Immunohistological studies for gastrointestinal and other hormones in acth-secreting adenomas

Eighty-nine ACTH-secreting pituitary adenomas from patients with Cushing's disease or Nelson's syndrome were investigated by immunohistochemical methods for their content of gastrin, cholecystokinin (CCK), vasoactive intestinal peptide (VIP), bombesin, substance P, and ubiquitin as a marker for intercellular fibrils and hyalin and D11 as a marker for adrenocortical tissue. In contrast to in vitro studies reported in the relevant literature, we did not find significantly positive percentages (more than 10% of adenoma cells) for gastrin and CCK. VIP and bombesin were demonstrated in one adenoma. Among the adenomas examined, ubiquitin was found in 15% and D11 in 75%. ACTH was present in 99%, pro-γ-MSH in 21 %, β-endorphin in 13%, enkephalin in 4%, and α-subunit in 11.5%. The significance of the findings is discussed.

Colocalization of pancreatic polypeptide and insulin in secretory granules of a pancreatic endocrine neoplasm

A 45-year-old woman presented with clinical symptoms of hypoglycemia of 4 months duration. Laboratory testing confirmed hyperinsulinemia; mild hypercalcemia and hypergastrine-mia were also documented. At the time of operation, 3 pancreatic endocrine neoplasms were found, and a diagnosis of multiple endocrine neoplasia type I was made. Immunohistochem-istry and immunoelectron microscopy showed all the tumors to be plurihormonal, each containing three or more of the following: insulin, glucagon, somatostatin, pancreatic polypep-tide, gastrin, and serotonin. Electron microscopy of 2 tumors revealed numerous atypical granules. In 1 tumor, pancreatic polypeptide and insulin were colocalized in secretory granules by dual-staining immunoelectron microscopy. To our knowledge, this combination of hormones has not been described previously in pancreatic endocrine neoplasms and suggests that such neoplasms, like mature pancreatic endocrine cells, may originate from pluripotential common precursor cells.

Small cell carcinoma with two paraendocrine syndromes

Simultaneous elevated levels of ectopic arginine vasopressin (AVP) and ectopic adrenocorticotropin (ACTH) were found in a patient with small cell carcinoma (SCC). The finding of one of these paraendocrine syndromes at the time of diagnosis is common; however, the simultaneous presence of both syndromes has been reported in the literature only on four occasions in the past 25 years. This is the only report in which elevated plasma levels of both hormones are documented in a patient who simultaneously fulfills the criteria for the syndrome associated with each ectopically produced peptide. In the English-language literature, this is the first case that demonstrates by immunohistochemical staining the presence of both of these hormones in the patient's neoplasm. In addition to the use of radiographs, the presence of paraendocrine disorders can provide a method of monitoring the patient's response to therapy. The levels of ACTH and AVP were assayed during this patient's course and correlated with disease refractory to therapy, resulting in poor survival.

Endocrine neoplasms of the pancreas: a clinicopathologic study of 24 cases and immunohistochemical remarks

A total of 24 patients with endocrine neoplasms of the pancreas were clinicopathologically and immunohistochemically studied. They consisted of 18 patients with adenoma and 6 with carcinoma. Of the 24 patients, 13 developed attacks of hypoglycemia due to hyperinsulinemia, and 1 developed an uncontrollable duodenal ulcer caused by the hypersecretion of gastrin, however, the remaining 10 were asymptomatic. No prediction could be made as to the site of origin of the tumors. A clear difference was seen between adenoma and carcinoma in the size of the mass, the mean greatest diameter of the 18 adenoma cases being 1.7 cm, while that of the 6 carcinoma cases was 7.3 cm. One of the 13 insulinomas and a gastrinoma was malignant, while all 24 tumors were positive for neuron-specific enolase. The 13 insulinomas were diffusely positive for insulin and 5 were also shown to be focally immunoreactive for gastrin, with 3 also being immunoreactive for somatostatin and 2 for pancreatic polypeptide. The gastrinoma showed immunoreactivity for somatostatin, insulin, pancreatic polypeptide, and glucagon in addition to a positivity to gastrin. The above findings thus indicate the multiple hormone synthesis of endocrine neoplasms of the pancreas.

Endocrine neoplasms (non-gastrin) of the pancreas

Although neoplasms that produce gut regulatory peptides and amines can be found throughout the gastroenteropancreatic axis (excluding carcinoids), the vast majority of these lesions are found within the pancreas. Recognition of the various clinical syndromes produced by the secretions of these tumors, the development of sensitive and specific radioimmunoassays for the elaborated peptides, and development of more effective localization techniques have contributed to earlier diagnosis and marked improvement in patient care. Treatment is directed toward medical management to correct the metabolic disturbances produced by the excessive amounts of gut regulatory peptides, followed by localization and extirpation of tumor. In the presence of unresectable tumor or metastases, palliative treatment directed at reducing peptide secretion or preventing its effects by surgery, chemotherapy, hormonal therapy, and hepatic-artery embolization can produce long-term remission of symptoms. Because the majority of these tumors are malignant, the ultimate goal in successful patient management is the early detection and surgical excision of the islet cell tumor before metastases occur.

Current diagnosis and management of Zollinger-Ellison syndrome

The treatment of patients with Zollinger-Ellison syndrome (ZES) has undergone dramatic evolution during the past decade. Although initially regarded as an incurable tumor, resection of gastrinoma for potential cure has been reported in 30% to 40% of selected patients in recent series. Conversely, although definitive control of acid hypersecretion is achieved by total gastrectomy, histamine (H2)-receptor antagonists and the newly introduced agents omeprazole and somatostatin analogues allow effective medical therapy of gastric acid overproduction. Confirmation of the diagnosis is best achieved with the I.V. secretin stimulation test, and tumor localization techniques are mandatory to identify candidates for operative tumor resection. Intraoperative sonography and careful exploration are required for tumor removal; successful tumor resection is associated with prolonged survival. The majority of patients (60%) are still found to have malignant disease at the time of diagnosis, but 10-year overall survival commonly exceeds 40%. The presence of multiple endocrine neoplasia type I (MEN-I) is seen in 10% to 25% of patients; correction of hypercalcemia alone may have therapeutic benefit in some ZES patients, and while gastrinoma resection is rarely possible, MEN-I patients demonstrate prolonged survival. The choice of medical rather than surgical therapy for acid hypersecretion depends on the suitability of each patient for careful and repeated endoscopic and chemical studies, versus the likelihood of a successful postoperative outcome. Socioeconomic, geographic, and related medical factors in each case may dictate the form of long-term antisecretory therapy. Exploration for possible tumor resection is indicated for virtually all patients who have no documented metastatic disease.

Symptomatic secondary hormone syndromes in patients with established malignant pancreatic endocrine tumors

Over a five-year period, we measured concentrations of gut hormones in plasma samples from 353 patients in whom diagnoses of pancreatic endocrine tumors were subsequently confirmed. A median of 19 months (range, 7 to 120) after the initial diagnosis, 24 of these patients (6.8 percent) had elevated concentrations of other hormones in association with new clinical symptoms. In 13 of these patients (8 with glucagonomas, 3 with tumors secreting vasoactive intestinal polypeptide, and 2 with insulinomas), hypergastrinemia developed along with the clinical features of a gastrinoma; 5 patients died of gastrointestinal perforation or bleeding, apparently caused by this second tumor. We conclude that patients with pancreatic endocrine tumors, regardless of their initial clinical picture, require continued surveillance for new elevations of hormones.

A case of ACTH-producing pheochromocytoma

A woman with sustained hypertension, facial roundness, hirsutism, marked sweating, and generalized tremor was found to have a right adrenal pheochromocytoma. Elevated levels of serum cortisol, plasma ACTH, and serum catecholamines returned to normal after the tumor was removed. It was confirmed that enzymatically dispersed tumor cells produced ACTH and catecholamines concomitantly during in vitro incubation.

Metastatic islet cell tumor with ACTH, gastrin, and glucagon secretion. Clinical and pathologic studies with multiple therapies

A patient with metastatic islet cell carcinoma demonstrated multiple clinical syndromes simultaneously with secretion of ACTH, gastrin, glucagon, and serotonin. Hepatic arterial embolization resulted in an initial decrease in all secretory products, which was sustained for glucagon and serotonin. Recrudescence of the Cushings and Zollinger-Ellison syndrome was managed by surgical extirpation of the primary tumor and regional metastases as well as bilateral adrenalectomy. Electron microscopy and immunocytochemistry of the primary tumor and the metastatic lesions revealed the presence of multiple types of granules within single cells and, different patterns of secretory profiles in different tumor sites.

Cushing's syndrome in patients with the Zollinger-Ellison syndrome

Reports of Cushing's syndrome in patients with the Zollinger-Ellison syndrome are rare, although up to 30 percent of gastrinomas contain ACTH-like immunoreactivity. We prospectively examined 75 patients with the Zollinger-Ellison syndrome for Cushing's syndrome. Three of 59 patients (5 percent) with the sporadic form of the Zollinger-Ellison syndrome had Cushing's syndrome, with severe symptoms due to ectopic production of ACTH. Each of these patients had metastatic gastrinoma, responded poorly to chemotherapy, and died within three years of the diagnosis of both syndromes. Three of 16 patients (19 percent) with the Zollinger-Ellison syndrome and multiple endocrine neoplasia type 1 had Cushing's syndrome due to pituitary production of ACTH, and their symptoms were mild. The gastrinoma in these patients was localized, and the prognosis was excellent. Thus, Cushing's syndrome is more common in patients with the Zollinger-Ellison syndrome than was previously reported, occurring in 8 percent of all cases. Furthermore, Cushing's syndrome in patients with sporadic Zollinger-Ellison syndrome and in those with multiple endocrine neoplasia type 1 differ in incidence, cause, clinical severity, extent of gastrinoma, the need for therapy, and prognosis. All patients with the Zollinger-Ellison syndrome and all patients with multiple endocrine neoplasia type 1 should be screened for Cushing's syndrome.

An adrenocorticotropic hormone-producing pheochromocytoma: diagnostic and immunohistochemical studies

A patient is described with Cushing's syndrome owing to a pheochromocytoma that was producing adrenocorticotropic hormone. Preoperative diagnosis was suggested by finding bilateral adrenocortical hyperplasia plus a separate unilateral adrenal medullary mass and was confirmed laboratory studies. Proper preoperative preparation was followed by a unilateral adrenalectomy and a clinical cure of both conditions. Immunohistochemical studies confirmed the ectopic production of adrenocorticotropic hormone and its related peptides more thoroughly than previous reports. The hormone production appeared clinically and immunocytochemically to resemble pituitary Cushing's disease more closely than ectopic production of adrenocorticotropic hormone by other tumors. The clinical aspects of this case illustrate the importance of proper preoperative recognition to reduce the high known percentage of morbidity and mortality.

Insulinoma. An immunocytochemical and morphologic analysis of 95 cases

One hundred twenty-seven insulinomas from 95 cases (1 malignant and 94 benign) were studied pathologically. Thirty-six tumors (35 cases) were examined by electron microscopy. Typical beta-cell secretory granules of crystalloid-form cores and/or atypical secretory granules were discerned in all tumors examined. A new type of secretory granule, with high electron-dense crystalloid-form cores and moderate electron-dense granular substance filling the space between the core and the limiting membrane, were observed in two cases. Among 68 insulinomas (67 cases) subjected to immunocytochemical investigations with ten peptide hormones (insulin, glucagon, somatostatin, pancreatic polypeptide (PP), gastrin, motilin, secretin, vasoactive intestinal polypeptide (VIP), gastric inhibitory polypeptide (GIP), and neurotensin), 42 were found to be multihormonal, varying from two to four peptides secreted. The hormones contained were insulin, glucagon, PP, somatostatin, and gastrin in different combinations. One patient had hyperinsulinemia and hypergastrinemia concurrently, and two islet tumors were excised at an interval of 10 months. Both electron microscopy and immunocytochemistry confirmed the presence of beta- and alpha-cells in the first tumor, whereas the second tumor revealed only G-cells by electron microscopy, and G- and beta-cells on immunocytochemical staining. The morphologic and immunocytochemical characteristics of the insulinomas in this series are discussed.

What's new in endocrine factors of tumor growth?

In this review some aspects of endocrinological factors in cancer are discussed. The first part addresses the determination of steroid hormone receptors in cancer of the breast. The importance of steroid hormone receptor determination for the clinical management of breast cancer patients is emphasized. Current methods for receptor measurement are critically evaluated and it is concluded that rigorous standardization of tissue handling procedures and of radiochemical methodology is mandatory to improve the reliability of the presently available methods. The development of new techniques for receptor determination has been met with high expectations. Monoclonal antireceptor antibodies in principle allow the development of a radioimmunoassay but are not widely available as yet. Histochemical methods for receptor localization have so far failed to meet accepted criteria of specificity. Therefore radiochemical determination at present remains the only reliable method. The second part addresses the production of peptide hormones by endocrine tumours of the gastroenteropancreatic (GEP) system and by non-neuroendocrine neoplasms. In the endocrine tumours of the GEP system a wide range of peptide hormones can be detected by immunocytochemistry, but most frequently the pattern of hormone production is comparable with that in the normal organ of origin. Clinical symptoms of excess hormone production occur much less frequently than hormone production is found by immunological methods and is usually caused by one hormone. It is proposed that these neoplasms are classified according to the hormone which causes the leading clinical symptoms and/or the hormone with the highest serum level. Peptide hormone producing cells in classical carcinoma are an intriguing phenomenon which has shed some new light on the embryological origin of neuroendocrine cells in the relevant organs and also on the histogenesis of neuroendocrine as well as non-neuroendocrine neoplasms.

Neuroendocrine islet cell tumour producing gastrin and ACTH in a patient with calcifying chronic pancreatitis

A patient with a calcifying chronic pancreatitis was found to have a neuroendocrine islet cell tumour (a previously unreported association). The tumour secreted both gastrin and ACTH leading to clinical manifestations of both the Zollinger-Ellison syndrome and Cushing's syndrome.

Ectopic ACTH syndrome. Diagnostic and therapeutic aspects

Twenty-five patients were identified with non-pituitary, nonadrenal ACTH-secreting tumors (bronchial carcinoid, bronchial small cell carcinoma, pancreatic islet cell carcinoma, medullary thyroid carcinoma, thymic carcinoids, metastatic adenocarcinoma, and pancreatic cystadenoma). Clinical features were weakness, hypertension, cushingoid appearance, peripheral edema, personality disorders, and hyperpigmentation. Biochemical features were a markedly increased urinary free cortisol level (all patients), hypokalemia (71 percent of patients), and an elevated ACTH level (72 percent of patients). Surgical therapy consisted of bilateral total adrenalectomy (56 percent of patients). Twelve percent underwent transsphenoidal hypophysectomy and 36 percent had excision of their tumor. No surgical therapy was undertaken in 28 percent. Bilateral total adrenalectomy in patients with a slow-growing malignancy or an unknown tumor secreting ACTH is beneficial in relieving symptoms and prolonging life. Excision of nonmalignant ACTH-producing tumors yields an excellent long-term prognosis.

Pancreatic islet cell carcinoma with hypercalcemia. Primary hyperparathyroidism or humoral hypercalcemia of malignancy

A 60-year-old woman presented with hypercalcemia and was found to have metastatic pancreatic islet cell carcinoma. Although clinical features were very suggestive of hyperparathyroidism, her parathyroid hormone levels were not elevated and no abnormal parathyroid tissue was detected by thallium-technetium or computed tomographic scanning techniques. Her hypercalcemia appeared to be due to a humoral factor--distinct from parathyroid hormone--that mimics the action of parathyroid hormone almost exactly. The various tools that may be used to differentiate primary hyperparathyroidism from the humoral hypercalcemia of malignancy are reviewed.

Report of a case of pheochromocytoma producing immunoreactive ACTH and beta-endorphin

A 47-year old woman is presented who had a left adrenal pheochromocytoma with manifestations also indicative of ectopic ACTH syndrome. The excised adrenal gland showed both an adrenal medullary tumor and adrenal cortical hyperplasia. Immunostaining also showed the presence in the tumor of ACTH and beta endorphins. The immediate post-adrenalectomy decline of catecholamines, ACTH, cortisol and beta endorphins indicate that the adrenal itself was the source of these hormones. This patient, the thirteenth now reported in the literature, represents one form of ectopic ACTH syndrome in which the lesion is benign, and in which a successful outcome can be anticipated.

Concurrent Cushing's and Zollinger-Ellison syndromes in a patient with islet cell carcinoma. Case report and review of the literature

This report documents the simultaneous occurrence of Cushing's and Zollinger-Ellison syndromes in a patient with islet cell carcinoma. The clinical concurrence of these two syndromes has been recorded in only three previous case studies, while three other case reports record evidence suggesting the presence of both gastrin and ACTH within the tumor but without clinical sequelae. In the present report, evidence based on multiple clinical and biochemical data supports the concept that both syndromes are a result of "ectopic" hormone production by the tumor.

Surgical management of the ectopic ACTH syndrome

Most patients with extra-pituitary ACTH-secreting tumors die from carcinoma, but a few can benefit from operation. Of 96 patients with Cushing's syndrome, 11 probably had such tumors. There were three modes of presentation: (1) three had malignant tumors with visceral metastases initially. One (bronchial carcinoid) died without operation. Two with carcinoma (thyroid medullary and islet-cell) underwent adrenalectomy with remission, but died soon. (2) three had apparently benign tumors initially. One (appendicular carcinoid) underwent appendectomy and one (bronchial carcinoid with hilar node metastases) underwent lobectomy. Both had rapid remissions. The third (pheochromocytoma) died after resection of the tumor. (3) five patients had no obvious tumors and underwent adrenalectomy with remission. In one a benign bronchial carcinoid was removed later. Four others remain well, but without localizing signs of tumor. The main biochemical features in all were hypokalemic alkalosis and very high urinary excretion of free cortisol. Seven of the eight patients without visceral metastases are in remission from one to 15 years after operation.

Immunoreactive somatostatin in catecholamine-producing extra-adrenal paraganglioma

A patient with catecholamine-producing extra-adrenal paraganglioma was found to have a high concentration of immunoreactive somatostatin (IR-SRIF) in the peripheral blood plasma (47.0 pg/ml, normal; 13.3 +/- 5.3 pg/ml, mean +/- SD). After removal of the tumor, the plasma SRIF level fell within normal range (8.7 pg/ml). In the resected tumor, a considerable amount of IR-SRIF (71.0 ng/g wet weight)( was also detected and SRIF-positive tumor cells were demonstrated by the immunoperoxidase technique. Chromatographic analysis of an extract of the tumor showed the presence of two IR-SRIF components of large molecular size besides a component consistent with authentic tetradecapeptide SRIF (SRIF 14), and one of these had the same molecular size as octacosapeptide SRIF (SRIF 28). This seems to be the first report of a catecholamine-producing extra-adrenal paraganglioma that produces IR-SRIF with molecular heterogeneity.

Cushing's syndrome due to ectopic ACTH production by a nasal paraganglioma

A patient is described with Cushingoid features and a tumor of the paranasal sinuses. Laboratory studies revealed hyperglycemia, hypokalemia, alkalosis, hypercortisolemia, and elevated serum ACTH levels. The cortisol level increased briskly in response to parenteral ACTH, but was only partially suppressed by dexamethasone. Microscopically, the tumor was found to be a paraganglioma containing many neurosecretory granules.. Treatment with methyrapone, o,p'DDD, and irradiation of the tumor resulted in a lasting remission. It is concluded that this unique patient suffered from Cushing's syndrome due to ectopic ACTH production by a paraganglioma of the paranasal sinuses.

CT localization of occult secretory tumors in children

Three seemingly occult secretory tumors in children (pheochromocytoma, ganglioneuroblastoma and islet cell carcinoma) were localized within the abdomen by computed tomography after other diagnostic imaging procedures had failed. The superb density resolution and tomographic formating of CT images make CT uniquely suited for the demonstration of small abdominal lesions. CT is recommended as a primary imaging modality for secretory tumors in children.

Ectopic hormone production by endocrine tumors: localization of hormones at the cellular level by immunocytochemistry

Clinical and laboratory data, histologic, electron microscopic and immunocytochemical findings of the tumors of eight patients suffering from Cushing's syndrome and of one patient with hypercalcemia are described. The unlabeled antibody enzyme method was used for the detection of insulin, glucagon, somatostatin, pancreatic polypeptide, corticotropin, beta-lipotropin, calcitonin, parathyroid hormone, and gastrin. Ectopic Cushing's syndrome was caused by pancreatic endocrine tumors, medullary thyroid carcinoma, a bronchial, a gastric and a thymic carcinoid, and a carcinoid of the mediastinum. Hypercalcemia in one patient was related to a pancreatic endocrine tumor. After surgery the clinical symptoms disappeared in two patients, but persisted or relapsed in five patients. ACTH-immunoreactivity could be demonstrated in six of eight tumors; calcitonin-immunoreactivity was found in the tumor of the patient suffering from hypercalcemia. ACTH-immunoreactivity could be localized to secretory granules by immunoelectron microscopy, and the presence of ACTH and beta-LPH in the same tumor cells could be shown in one pancreatic tumor. A combination of production of orthotopic and ectopic hormones was found in one, and secretion of two ectopic hormones was detected in another pancreatic endocrine tumor.

Mixed pancreatic apudoma with symptoms of excess vasoactive intestinal polypeptide and insulin: improvement of diarrhoea with metoclopramide

A female patient is described with a single pancreatic tumour producing vasoactive intestinal polypeptide (VIP), insulin, and pancreatic polypeptide. The initial presentation was with diarrhoea and hypokalaemia and a raised plasma VIP was demonstrated. Her symptoms improved with metoclopramide administration and absolute concentrations of 28 aminoacid (peak IV) VIP were found to have fallen. She then developed hypoglycaemia with hyperinsulinism. All symptoms resolved after surgical excision. This case emphasises the potential of these tumours to contain more than one endocrine cell type synthesising different biologically active peptides.

Cushing's syndrome due to an ACTH-secreting adrenal medullary tumour

A 35-year-old man with Cushing's syndrome due to ectopic ACTH production is described. The six-week history and severe proximal myopathy were highly suggestive of a malignant tumour, but a solitary phaeochromocytoma of the left adrenal gland was the source of ACTH production. The surgical outcome was successful and three months post-operatively the hypothalamic-pituitary-adrenal axis was normal. At 12 months follow-up he remains well with complete regression of the features of Cushing's syndrome.

Diagnostic and therapeutic implications of ectopic hormone production in small cell carcinoma of the lung

In 75 unselected and untreated patients with small cell carcinoma of the lung, plasma ACTH, serum calcitonin, and antidiuretic hormone (ADH) in plasma and urine were related to corresponding clinical symptoms and biochemical findings at the time of diagnosis. The significance of elevated concentrations of these substances in relation to treatment was also investigated. Plasma ACTH concentrations were increased in 22 patients (29%), and 25 patients (33%) were considered to have inappropriate ADH secretion. Only one patient had definite hypokalaemic alkalosis, and one patient pronounced hyponatraemia, with associated clinical syndromes of ectopic ACTH and ADH secretion. Serum calcitonin concentrations were increased in 48 patients (65%). No related clinical symptoms were disclosed, and all these patients had normal serum calcium concentrations. Thirty-three of 66 patients (50%) had raised levels of free cortisol in a 24-hour urine and these levels were significantly related to plasma ACTH concentrations. The median survival was slightly shorter in patients with increased values of the three substances, but this was not related to increased plasma ACTH concentrations and was not statistically significant. Survival rates and results of treatment were independent of the pretreatment levels of the three substances.

Argyrophil cell carcinoma of the uterine cervix with ectopic production of ACTH, beta-MSH, serotonin, histamine, and amylase

The case of a 38-year-old female with primary argyrophil cell carcinoma of the uterine cervix is reported. Two years after operation the patient developed widespread metastases with typical Cushing's syndrome. Microscopically, the tumor consisted of solid anaplastic cells, adenocarcinoma, and squamous cells. The plasma levels of ACTH and cortisol were elevated. Many cells of both the primary and metastatic tumors showed argyrophilia. Almost all the cells of the metastases contained numerous round secretory granules measuring about 117 micrometers in diameter. Small rod-shaped or larger round secretory granules, measuring 250 and 430 micrometers respectively, were also found in a few of these cells. The tumors in the right lung, pancreas, and kidney contained high levels of ACTH, beta-MSH, serotonin, histamine, and amylase. This is the first report of ectopic production of these five substances from argyrophil cell carcinoma of the uterine cervix.

The glucagonoma syndrome

The glucagonoma syndrome is another of those systemic disorders in which skin manifestations provide a clue to the diagnosis. The patient will most often be a middle-aged woman who has the characteristic, indolent skin lesions in the face of diabetes mellitus and additional features to suggest an occult carcinoma. Marked elevation of the levels of plasma glucagon should confirm the suspicion cure of the skin lesions follows cure of the tumor. Two lines of speculation seem promising. Either the initial event is an overproduction of glucagon and all other observations follow. Or the syndrome is another of the polyendocrine disorders. Cases are still too few to resolve either the pathophysiology, prognosis, or even to guess at the true frequency of the syndrome.