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Manstein MC, Piel E, Stumvoll M, Kische S. [A diagnostic maze: Cushing's disease]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:730-733. [PMID: 38175281 DOI: 10.1007/s00108-023-01653-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/05/2024]
Abstract
The case of a 78-year-old female presenting to the authors' department with heart failure with dyspnea at minimal exertion (NYHA III) as well as hypertensive blood pressure and hypokalaemia is reported. Laboratory workup showed hypercortisolism. Further workup, including imaging studies and selective catheterisation of the inferior petrosal sinus, resulted in the diagnosis of Cushing's disease caused by a pituitary microadenoma.
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Affiliation(s)
- Moritz C Manstein
- Klinik für Innere Medizin - Abteilung für Kardiologie und konservative Intensivmedizin, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland.
| | - Esther Piel
- Klinik für Innere Medizin - Abteilung für Kardiologie und konservative Intensivmedizin, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland
| | - Michael Stumvoll
- Klinik und Poliklinik für Endokrinologie, Nephrologie, Rheumatologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Stephan Kische
- Klinik für Innere Medizin - Abteilung für Kardiologie und konservative Intensivmedizin, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland
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2
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Capatina C, Hanzu FA, Hinojosa-Amaya JM, Fleseriu M. Medical treatment of functional pituitary adenomas, trials and tribulations. J Neurooncol 2024; 168:197-213. [PMID: 38760632 DOI: 10.1007/s11060-024-04670-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/27/2024] [Indexed: 05/19/2024]
Abstract
CONTEXT Functioning pituitary adenomas (FPAs) include most frequently prolactinomas, somatotroph or corticotroph adenomas, while thyrotroph and gonadotroph adenomas are very rare. Despite their benign histological nature (aggressive tumors are rare and malignant ones exceptional), FPAs could cause significant morbidity and increased mortality due to complications associated with hormonal excess syndromes and/or mass effect leading to compression of adjacent structures. This mini review will focus on the increasing role of medical therapy in the multimodal treatment, which also includes transsphenoidal surgery (TSS) and radiotherapy. EVIDENCE SYNTHESIS Most patients with prolactinomas are treated only with medications, but surgery could be considered for some patients in a specialized pituitary center, if higher chances of cure. Dopamine agonists, especially cabergoline, are efficient in reducing tumor size and normalizing prolactin. TSS is the first-line treatment for all other FPAs, but most patients require complex adjuvant treatment, including a combination of therapeutic approaches. Medical therapy is the cornerstone of treatment in all patients after unsuccessful surgery or when surgery cannot be offered and includes somatostatin receptor ligands and dopamine agonists (almost all FPAs), growth hormone receptor antagonists (acromegaly), adrenal steroidogenesis inhibitors and glucocorticoid receptor blockers (Cushing's disease). Novel medical treatments, especially for acromegaly and Cushing's disease are under research. CONCLUSIONS An enlarged panel of effective drugs available with increased knowledge of predictive factors for response and/or adverse effects will enhance the possibility to offer a more individualized treatment. This would not only improve disease control and prognosis, but also quality of life.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, University of Medicine and Pharmacy "Carol Davila" Bucharest, and Department of Pituitary and Neuroendocrine Pathology, C.I. Parhon National Institute of Endocrinology, Bucharest, Romania
| | - Felicia Alexandra Hanzu
- Endocrinology Department, Hospital Clínic de Barcelona, Spain, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Miguel Hinojosa-Amaya
- Endocrinology Division and Department of Medicine, Pituitary Clinic, Hospital Universitario U.A.N.L, Monterrey, Mexico
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health and Science University, Portland, OR, USA.
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Seibold J, Hönemann M, Tönjes A, Sandner B. Safe long-term therapy of Cushing's syndrome over 37 years with mitotane. Front Endocrinol (Lausanne) 2024; 15:1294415. [PMID: 38440784 PMCID: PMC10911286 DOI: 10.3389/fendo.2024.1294415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
While suggested, surgery is not always possible as a first-line treatment of Cushing's Disease (CD). In such cases, patients require medical therapy in order to prevent complications resulting from hypercortisolism. Although there has been a wide expansion in pharmacological options in recent years, mitotane was the agent of choice for treating hypercortisolism decades ago. Due to the introduction of other therapies, long-term experience with mitotane remains limited. Here, we report the case of a woman with CD who was treated with mitotane for 37 years. During the treatment period, biochemical and clinical disease control was achieved and the patient had two uncomplicated pregnancies. Drug-related side effects remained moderate and could be controlled by several dose adjustments. Our case highlights the ability of mitotane to allow an effective control of hypercortisolism and to represent a safe treatment option in special situations where CD requires an alternative therapeutic approach. Furthermore, we provide a literature review of the long-term use of mitotane and reported cases of pregnancy in the context of mitotane therapy.
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Affiliation(s)
- Jonas Seibold
- Medical Department III - Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mario Hönemann
- Institute of Medical Microbiology and Virology, University of Leipzig Medical Center, Leipzig, Germany
| | - Anke Tönjes
- Medical Department III - Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
| | - Benjamin Sandner
- Medical Department III - Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
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Divaris E, Kostopoulos G, Efstathiadou ZA. Current and Emerging Pharmacological Therapies for Cushing's Disease. Curr Pharm Des 2024; 30:757-777. [PMID: 38424426 DOI: 10.2174/0113816128290025240216110928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/09/2024] [Accepted: 01/31/2024] [Indexed: 03/02/2024]
Abstract
Cushing's Disease (CD), hypercortisolism due to pituitary ACTH secreting neuroendocrine neoplasm, is associated with increased morbidity and, if untreated, mortality in about half of the affected individuals. Consequently, the timely initiation of effective treatment is mandatory. Neurosurgery is the first line and the only potentially curative treatment; however, 30% of patients will have persistent disease post-surgery. Furthermore, a small percentage of those initially controlled will develop hypercortisolism during long-term follow- up. Therefore, patients with persistent or recurrent disease, as well as those considered non-eligible for surgery, will need a second-line therapeutic approach, i.e., pharmacotherapy. Radiation therapy is reserved as a third-line therapeutic option due to its slower onset of action and its unfavorable profile regarding complications. During the past few years, the understanding of molecular mechanisms implicated in the physiology of the hypothalamus-pituitary-adrenal axis has evolved, and new therapeutic targets for CD have emerged. In the present review, currently available treatments, compounds currently tested in ongoing clinical trials, and interesting, potentially new targets emerging from unraveling molecular mechanisms involved in the pathophysiology of Cushing's disease are discussed.
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Affiliation(s)
- Efstathios Divaris
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Georgios Kostopoulos
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Zoe A Efstathiadou
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
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5
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Gadelha M, Gatto F, Wildemberg LE, Fleseriu M. Cushing's syndrome. Lancet 2023; 402:2237-2252. [PMID: 37984386 DOI: 10.1016/s0140-6736(23)01961-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
Endogenous Cushing's syndrome results from excess glucocorticoid secretion, which leads to a myriad of clinical manifestations, comorbidities, and increased mortality despite treatment. Molecular mechanisms and genetic alterations associated with different causes of Cushing's syndrome have been described in the last decade. Imaging modalities and biochemical testing have evolved; however, both the diagnosis and management of Cushing's syndrome remain challenging. Surgery is the preferred treatment for all causes, but medical therapy has markedly advanced, with new drug options becoming available. Nevertheless, several comorbidities remain even after patient remission, which can affect quality of life. Accurate and timely diagnosis and treatment are essential for mitigating chronic complications of excess glucocorticoids and improving patient quality of life. In this Seminar, we aim to update several important aspects of diagnosis, complications, and treatment of endogenous Cushing's syndrome of all causes.
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Affiliation(s)
- Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Molecular Genetics Laboratory, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
| | - Federico Gatto
- Endocrinology Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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Jimenez-Canizales CE, Rojas W, Alonso D, Romero I, Tabares S, Veronesi Zuluaga LA, Modica R, Colao A. Clinical presentation and recurrence of pituitary neuroendocrine tumors: results from a single referral center in Colombia. J Endocrinol Invest 2023; 46:2275-2286. [PMID: 37002436 DOI: 10.1007/s40618-023-02080-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Pituitary neuroendocrine tumors (PitNETs) represent 15-18.2% of all intracranial tumors. Their clinical presentation can range from chronic headache, visual defects, hypopituitarism to hormone excess syndromes. PitNETS are commonly classified as functioning neuroendocrine tumors (F-PitNETs) and non-functioning neuroendocrine tumors (NF-PitNETs). At the moment, new classification has emerged based on cell lineages. Almost 50% of all patients with PitNETs require surgical intervention, and about 25% of these have residual and persistent disease that may require additional management. SUBJECTS AND METHODS A retrospective cohort of medical records of patients with PitNETs, aiming to describe the incidence of recurrence of patients who received surgical treatment over a 12 month follow up period at San Jose Hospital (SJH) in Bogotá, Colombia, over an observation period of 10 years. Furthermore, clinical presentation, biochemical characteristics and immunohistochemistry, postoperative complications are detailed. RESULTS Eight hundred and eighty-seven patients with pituitary tumors were included in the cohort; 83% (737/887) had a diagnosis of PitNET. Of these, 18.9% (140) received surgical management. The majority 58% (98/140) had nonfunctional-PitNETs (NF-PitNETs), followed by growth-hormone-secreting pituitary adenoma (22.1%; 33/140), adrenocorticotropic- hormone-secreting pituitary adenoma (9.3%; 13/140), and prolactinomas (9.3%; 13/140). A recurrence was found in 45.71% (64/140), subclassified as biochemical in 15.71% (22/140), controlled with medications in 20% (28/140), and remission occurred in 18.57% (26/140). CONCLUSION Clinical presentation and incidence of recurrence in patients with PitNETs in a referral center in Colombia are similar to other surgical cohorts with low cure rates and high recurrence.
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Affiliation(s)
- C E Jimenez-Canizales
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia.
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia.
| | - W Rojas
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - D Alonso
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - I Romero
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - S Tabares
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - L A Veronesi Zuluaga
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - R Modica
- Endocrinology, Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - A Colao
- Endocrinology, Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
- UNESCO Chair, Education for Health and Sustainable Development, Federico II University, Naples, Italy
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7
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Fleseriu M, Varlamov EV, Hinojosa-Amaya JM, Langlois F, Melmed S. An individualized approach to the management of Cushing disease. Nat Rev Endocrinol 2023; 19:581-599. [PMID: 37537306 DOI: 10.1038/s41574-023-00868-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
Cushing disease caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary corticotroph adenoma leads to hypercortisolaemia with high mortality due to metabolic, cardiovascular, immunological, neurocognitive, haematological and infectious conditions. The disorder is challenging to diagnose because of its common and heterogenous presenting features and the biochemical pitfalls of testing levels of hormones in the hypothalamic-pituitary-adrenal axis. Several late-night salivary cortisol and 24-h urinary free cortisol tests are usually required as well as serum levels of cortisol after a dexamethasone suppression test. MRI might only identify an adenoma in 60-75% of patients and many adenomas are small. Therefore, inferior petrosal sinus sampling remains the gold standard for confirmation of ACTH secretion from a pituitary source. Initial treatment is usually transsphenoidal adenoma resection, but preoperative medical therapy is increasingly being used in some countries and regions. Other management approaches are required if Cushing disease persists or recurs following surgery, including medications to modulate ACTH or block cortisol secretion or actions, pituitary radiation, and/or bilateral adrenalectomy. All patients require lifelong surveillance for persistent comorbidities, clinical and biochemical recurrence, and treatment-related adverse effects (including development of treatment-associated hypopituitarism). In this Review, we discuss challenges in the management of Cushing disease in adults and provide information to guide clinicians when planning an integrated and individualized approach for each patient.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Elena V Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Jose M Hinojosa-Amaya
- Division of Endocrinology, Department of Medicine, Hospital Universitario "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Page-Wilson G, Oak B, Silber A, Okeyo J, Ortiz N, O'Hara M, Moloney S, Geer EB. Evaluating the burden of endogenous Cushing's syndrome using a web-based questionnaire and validated patient-reported outcome measures. Pituitary 2023; 26:364-374. [PMID: 37074630 PMCID: PMC10113723 DOI: 10.1007/s11102-023-01314-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Endogenous Cushing's syndrome (CS) is a rare endocrine condition caused by chronic oversecretion of cortisol, resulting in a diverse constellation of symptoms. This study examined the ongoing burden of illness (BOI), from the first appearance of symptoms through treatment, which is currently not well evaluated. METHODS A quantitative, cross-sectional, web-enabled survey including 5 validated patient reported outcomes (PRO) measures was conducted in patients with CS who had been diagnosed ≥ 6 months prior and who had received ≥ 1 treatment for their endogenous CS at the time of the survey. RESULTS Fifty-five patients participated in this study; 85% were women. The mean age was 43.4 ± 12.3 years (± standard deviation, SD). On average, respondents reported a 10-year gap between the first occurrence of symptoms and diagnosis; 80% underwent surgical treatment for CS. Respondents experienced symptoms on 16 days in a typical month, and their health-related quality of life was moderately impacted based on the CushingQoL score. Weight gain, muscle fatigue, and weakness were the most common symptoms and 69% percent of patients reported moderate or severe fatigue using the Brief Fatigue Inventory. Following treatment, the occurrence of most symptoms declined over time, although anxiety and pain did not significantly decrease. Overall, 38% of participants reported an annual average of 25 missed workdays due to CS symptoms. CONCLUSIONS These results demonstrate a BOI in CS despite ongoing treatment and illustrate the need for interventions to address persistent symptoms, particularly weight gain, pain, and anxiety.
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Affiliation(s)
| | | | | | - Janetricks Okeyo
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc, Trevose, USA
| | - Nancy Ortiz
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc, Trevose, USA
| | | | - Stephen Moloney
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc, Trevose, USA
| | - Eliza B Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Viecceli C, Mattos ACV, Hirakata VN, Garcia SP, Rodrigues TDC, Czepielewski MA. Ketoconazole as second-line treatment for Cushing's disease after transsphenoidal surgery: systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1145775. [PMID: 37223017 PMCID: PMC10200879 DOI: 10.3389/fendo.2023.1145775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/07/2023] [Indexed: 05/25/2023] Open
Abstract
Introduction The first-line treatment for Cushing's disease is transsphenoidal surgery for pituitary tumor resection. Ketoconazole has been used as a second-line drug despite limited data on its safety and efficacy for this purpose. The objective of this meta-analysis was to analyze hypercortisolism control in patients who used ketoconazole as a second-line treatment after transsphenoidal surgery, in addition to other clinical and laboratory criteria that could be related to therapeutic response. Methods We searched for articles that evaluated ketoconazole use in Cushing's disease after transsphenoidal surgery. The search strategies were applied to MEDLINE, EMBASE, and SciELO. Independent reviewers assessed study eligibility and quality and extracted data on hypercortisolism control and related variables such as therapeutic dose, time, and urinary cortisol levels. Results After applying the exclusion criteria, 10 articles (one prospective and nine retrospective studies, totaling 270 patients) were included for complete data analysis. We found no publication bias regarding reported biochemical control or no biochemical control (p = 0.06 and p = 0.42 respectively). Of 270 patients, biochemical control of hypercortisolism occurred in 151 (63%, 95% CI 50-74%) and no biochemical control occurred in 61 (20%, 95% CI 10-35%). According to the meta-regression, neither the final dose, treatment duration, nor initial serum cortisol levels were associated with biochemical control of hypercortisolism. Conclusion Ketoconazole can be considered a safe and efficacious option for Cushing's disease treatment after pituitary surgery. Systematic review registration https://www.crd.york.ac.uk/prospero/#searchadvanced, (CRD42022308041).
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Affiliation(s)
- Camila Viecceli
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Ana Carolina Viana Mattos
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Vânia Naomi Hirakata
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Sheila Piccoli Garcia
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Ticiana da Costa Rodrigues
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Mauro Antônio Czepielewski
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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10
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Abstract
Importance Pituitary adenomas are neoplasms of the pituitary adenohypophyseal cell lineage and include functioning tumors, characterized by the secretion of pituitary hormones, and nonfunctioning tumors. Clinically evident pituitary adenomas occur in approximately 1 in 1100 persons. Observations Pituitary adenomas are classified as either macroadenomas (≥10 mm) (48% of tumors) or microadenomas (<10 mm). Macroadenomas may cause mass effect, such as visual field defects, headache, and/or hypopituitarism, which occur in about 18% to 78%, 17% to 75%, and 34% to 89% of patients, respectively. Thirty percent of pituitary adenomas are nonfunctioning adenomas, which do not produce hormones. Functioning tumors are those that produce an excess of normally produced hormones and include prolactinomas, somatotropinomas, corticotropinomas, and thyrotropinomas, which produce prolactin, growth hormone, corticotropin, and thyrotropin, respectively. Approximately 53% of pituitary adenomas are prolactinomas, which can cause hypogonadism, infertility, and/or galactorrhea. Twelve percent are somatotropinomas, which cause acromegaly in adults and gigantism in children, and 4% are corticotropinomas, which secrete corticotropin autonomously, resulting in hypercortisolemia and Cushing disease. All patients with pituitary tumors require endocrine evaluation for hormone hypersecretion. Patients with macroadenomas additionally require evaluation for hypopituitarism, and patients with tumors compressing the optic chiasm should be referred to an ophthalmologist for formal visual field testing. For those requiring treatment, first-line therapy is usually transsphenoidal pituitary surgery, except for prolactinomas, for which medical therapy, either bromocriptine or cabergoline, is usually first line. Conclusions and Relevance Clinically manifest pituitary adenomas affect approximately 1 in 1100 people and can be complicated by syndromes of hormone excess as well as visual field defects and hypopituitarism from mass effect in larger tumors. First-line therapy for prolactinomas consists of bromocriptine or cabergoline, and transsphenoidal pituitary surgery is first-line therapy for other pituitary adenomas requiring treatment.
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Affiliation(s)
- Nicholas A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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11
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Araujo-Castro M, Reincke M. Primary bilateral macronodular adrenal hyperplasia: A series of 32 cases and literature review. ENDOCRINOL DIAB NUTR 2023; 70:229-239. [PMID: 37116968 DOI: 10.1016/j.endien.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/17/2022] [Indexed: 04/30/2023]
Abstract
Primary bilateral macronodular adrenal hyperplasia (PBMAH) accounts for <2% of cases of Cushing's syndrome. The majority of patients present with no obvious steroid excess it means with autonomous cortisol secretion (ACS). The classic treatment for patients with overt Cushing's syndrome is bilateral adrenalectomy, but unilateral resection of the larger adrenal gland can result in clinical and/or biochemical remission in >90% of cases, especially in cases of ACS. In this article, a series of 32 cases with PBMAH is described. Most of the cases of PBMAH had ACS, except for one case with overt Cushing's syndrome. A study of aberrant receptors was performed in six patients, being negative in three cases, positive in the metoclopramide test in two cases and positive in the metoclopramide test and in the mixed meal test in another patient. The patient with overt Cushing's syndrome was treated with adrenostatic therapy achieving biochemical control, while two patients with ACS underwent unilateral adrenalectomy with resection of the largest adrenal gland, demonstrating hypercortisolism remission and improvement of cardiovascular risk factors after surgery. This article describes a series of 32 cases of PBMAH and offers a comprehensive review of PBMAH.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal [Ramon y Cajal University Hospital], Instituto de Investigación Ramón y Cajal (IRYCIS) [Ramon y Cajal Research Institute], Spain; Universidad de Alcalá [University of Alcalá], Madrid, Spain.
| | - Martín Reincke
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
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Sabahi M, Ghasemi-Nesari P, Maroufi SF, Shahbazi T, Yousefi O, Shahtaheri SA, Bin-Alamer O, Dabecco R, Velasquez N, Arce KM, Adada B, Benjamin CG, Borghei-Razavi H. Recurrent Cushing Disease: An Extensive Review on Pros and Cons of Different Therapeutic Approaches. World Neurosurg 2023; 172:49-65. [PMID: 36739900 DOI: 10.1016/j.wneu.2023.01.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission. METHODS We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020. RESULTS We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60-0.70), 0.57 (95% CI 0.51-0.63), and 0.75 (95% CI 0.60-0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60-0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28). CONCLUSIONS Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range.
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Affiliation(s)
- Mohammadmahdi Sabahi
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paniz Ghasemi-Nesari
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Taha Shahbazi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Yousefi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Alireza Shahtaheri
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Othman Bin-Alamer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nathalia Velasquez
- Department of Otolaryngology/Head and Neck Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Karla M Arce
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA.
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13
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Martino M, Aboud N, Lucchetti B, Salvio G, Arnaldi G. An evaluation of pharmacological options for Cushing's disease: what are the state-of-the-art options? Expert Opin Pharmacother 2023; 24:557-576. [PMID: 36927238 DOI: 10.1080/14656566.2023.2192349] [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: 03/18/2023]
Abstract
INTRODUCTION Untreated Cushing's syndrome (CS) is associated with significant morbidity and mortality. Cortisol normalization is a key goal to treatment. Pituitary surgery remains the first-line approach for Cushing's disease, but sometimes it is impracticable, unsuccessful, or complicated by recurrence. Medical therapy has been historically considered a palliative. However, in the latest years, interest on this topic has grown due to both the availability of new drugs and the reevaluation of the old, commonly used drugs in clinical practice. AREAS COVERED In this article, we will discuss the current options and future directions of medical therapy for CS, aiming at fitting best patients' features. An extensive literature search regarding already approved and investigational principles was conducted (PubMed, ClinicalTrials.gov. Available drugs include inhibitors of ACTH secretion, steroidogenesis inhibitors, and glucocorticoid receptor antagonists; drugs acting at different levels can be also combined in uncontrolled patients. EXPERT OPINION Since there is still no standardized pharmacological approach and the superiority of one drug over another has not been established yet in the absence of comparative studies, each time clinicians' choices should be patient-tailored. Age, gender, tumor features, severity of hypercortisolism, comorbidities/complications, rapidity of action, side effects, drug-drug interactions, contraindications, availability, patients' preferences, and costs should be all considered.
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Affiliation(s)
- Marianna Martino
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Nairus Aboud
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Beatrice Lucchetti
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Gianmaria Salvio
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Giorgio Arnaldi
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
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14
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Gao Y, Wang M, Wu Y, Deng H, Xu Y, Ren Y, Wang C, Wang W. Gamma Knife Radiosurgery for Cushing's Disease: Evaluation of Biological Effective Dose from a Single-Center Experience. J Clin Med 2023; 12:jcm12041288. [PMID: 36835822 PMCID: PMC9966465 DOI: 10.3390/jcm12041288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/31/2022] [Accepted: 01/06/2023] [Indexed: 02/09/2023] Open
Abstract
Objective: Gamma knife radiosurgery (GKRS) has served as an adjunctive treatment in Cushing's disease (CD) for decades and has become a vital part of therapy in the management of CD. Biological effective dose (BED) is a radiobiological parameter with time correction, considering the cellular deoxyribonucleic acid repairment. We aimed to investigate the safety and efficacy of GKRS for CD and evaluate the association of BED and treatment outcome. Methods: A cohort study of 31 patients with CD received GKRS in West China Hospital between June 2010 and December 2021. Endocrine remission was defined as normalization of 24 h urinary free cortisol (UFC) or serum cortisol ≤ 50 nmol/L after a 1 mg dexamethasone suppression test. Result: The mean age was 38.6 years old, and females accounted for 77.4%. GKRS was the initial treatment for 21 patients (67.7%), and 32.3% of patients underwent GKRS after surgery due to residual disease and recurrence. The mean endocrine follow-up duration was 22 months. The median marginal dose was 28.0 Gy, and the median BED was 221.5 Gy2.47. Fourteen patients (45.1%) experienced control of hypercortisolism in the absence of pharmacological treatment, and the median duration to remission was 20.0 months. The cumulative rates of endocrine remission at 1, 2, and 3 years after GKRS were 18.9%, 55.3%, and 72.21%, respectively. The total complication rate was 25.8%, and the mean duration from GKRS to hypopituitary was 17.5 months. The new hypopituitary rate at 1, 2, and 3 years were 7.1%, 30.3%, and 48.4%, respectively. A high BED level (BED > 205 Gy2.47) was associated with better endocrine remission than a low BED level (BED ≤ 205 Gy2.47), while no significant differences were found between the BED level and hypopituitarism. Conclusions: GKRS was a second-line therapeutic option for CD with satisfactory safety and efficacy. BED should be considered during GKRS treatment planning, and optimization of BED is a potentially impactful avenue toward improving the efficacy of GKRS.
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Affiliation(s)
- Yuan Gao
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610000, China
| | - Mengqi Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610000, China
| | - Yang Wu
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610000, China
| | - Hao Deng
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610000, China
| | - Yangyang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610000, China
| | - Yan Ren
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610000, China
| | - Chun Wang
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610000, China
- Correspondence: (C.W.); (W.W.)
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610000, China
- Correspondence: (C.W.); (W.W.)
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15
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Gumaste N, Shah L, Cheesman KC, Geer EB. Evaluating Patient-Reported Outcomes in Cushing's Syndrome. Endocrinol Metab Clin North Am 2022; 51:691-707. [PMID: 36244687 DOI: 10.1016/j.ecl.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The importance of the patient's perspective on disease has increasingly gained traction among clinical investigators and clinicians. Patient-reported outcomes (PROs) are those which pertain to a patient's health, quality of life, or functional status (associated with health care or treatment) that are reported directly by the patient, without interpretation by a clinician. In this article, we will review PROs as they relate to the signs, symptoms, health-related quality of life, and comorbidities of active Cushing's syndrome (CS), and CS after treatment with surgery, radiotherapy, and medical therapy. We will explore long-term outcomes in the setting of remission, persistence, and recurrence in this population.
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Affiliation(s)
- Namrata Gumaste
- Department of Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, 505 East 70th Street, Suite 450, New York, NY 10021, USA
| | - Leena Shah
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1055, New York, NY 10029, USA
| | - Khadeen Christi Cheesman
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1055, New York, NY 10029, USA
| | - Eliza B Geer
- Department of Medicine, Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, David H. Koch Center for Cancer Care, 530 East 74th Street, Box 19, New York, NY 10021, USA; Department of Neurosurgery, Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, David H. Koch Center for Cancer Care, 530 East 74th Street, Box 19, New York, NY 10021, USA.
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16
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von Selzam V, Theodoropoulou M. Innovative tumour targeting therapeutics in Cushing's disease. Best Pract Res Clin Endocrinol Metab 2022; 36:101701. [PMID: 36511278 DOI: 10.1016/j.beem.2022.101701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cushing's disease (CD) is the most frequent form of endogenous hypercortisolism. Management of this devastating condition relies on pituitary surgery, while effective pharmacological treatment mainly focus on periphery targeting pharmaceuticals. Approved tumour-targeting drugs are limited to dopamine agonists and somatostatin analogues with frequently low efficacy and substantial side effects. Discoveries on the genetics and pathophysiology of corticotroph tumorigenesis brought forward new potential pharmacological targets. Compounds such as retinoic acid although promising in preclinical studies, are not as efficient in the clinic. Others, such as, silibinin, gefitinib and roscovitine are effective in preclinical models, but their efficacy and safety still needs to be determined in patients with CD.
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Affiliation(s)
- Vivian von Selzam
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany.
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17
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Ekladios C, Khoury J, Mehr S, Feghali K. Osilodrostat-induced adrenal insufficiency in a patient with Cushing's disease. Clin Case Rep 2022; 10:e6607. [PMID: 36415717 PMCID: PMC9675382 DOI: 10.1002/ccr3.6607] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/03/2022] [Accepted: 10/15/2022] [Indexed: 05/30/2024] Open
Abstract
Cushing's disease is a rare condition caused by a benign pituitary tumor underlying adrenocorticotropic hormone excess. Medical treatment is implemented when surgical resection is not curative. We present a case of Cushing's disease with recurrence of macroadenoma who developed iatrogenic adrenal insufficiency in the setting of Osilodrostat treatment.
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Affiliation(s)
| | | | - Shahzad Mehr
- Roger Williams Medical CenterProvidenceRhode IslandUSA
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18
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Hamblin R, Coulden A, Fountas A, Karavitaki N. The diagnosis and management of Cushing's syndrome in pregnancy. J Neuroendocrinol 2022; 34:e13118. [PMID: 35491087 PMCID: PMC9541401 DOI: 10.1111/jne.13118] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 11/28/2022]
Abstract
Endogenous Cushing's syndrome (CS) is rarely encountered during pregnancy. Clinical and biochemical changes in healthy pregnancy overlap with those seen in pregnancy complicated by CS; the diagnosis is therefore challenging and can be delayed. During normal gestation, adrenocorticotrophic hormone, corticotrophin-releasing hormone, cortisol, and urinary free cortisol levels rise. Dexamethasone administration fails to fully suppress cortisol in pregnant women without CS. Localisation may be hindered by non-suppressed adrenocorticotrophic hormone levels in a large proportion of those with adrenal CS; smaller corticotroph adenomas may go undetected as a result of a lack of contrast administration or the presence of pituitary hyperplasia; and inferior petrosal sinus sampling is not recommended given the risk of radiation and thrombosis. Yet, diagnosis is essential; active disease is associated with multiple insults to both maternal and foetal health, and those cured may normalise the risk of maternal-foetal complications. The published literature consists mostly of case reports or small case series affected by publication bias, heterogeneous definitions of maternal or foetal outcomes or lack of detail on severity of hypercortisolism. Consequently, conclusive recommendations, or a standardised management approach for all, cannot be made. Management is highly individualised: the decision for surgery, medical control of hypercortisolism or adoption of a conservative approach is dependent on the timing of diagnosis (respective to stage of gestation), the ability to localise the tumour, severity of CS, pre-existing maternal comorbidity, and, ultimately, patient choice. Close communication is a necessity with the patient placed at the centre of all decisions, with risks, benefits, and uncertainties around any investigation and management carefully discussed. Care should be delivered by an experienced, multidisciplinary team, with the resources and expertise available to manage such a rare and challenging condition during pregnancy.
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Affiliation(s)
- Ross Hamblin
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Amy Coulden
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
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19
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Albani A, Perez-Rivas LG, Tang S, Simon J, Lucia KE, Colón-Bolea P, Schopohl J, Roeber S, Buchfelder M, Rotermund R, Flitsch J, Thorsteinsdottir J, Herms J, Stalla G, Reincke M, Theodoropoulou M. Improved pasireotide response in USP8 mutant corticotroph tumours in vitro. Endocr Relat Cancer 2022; 29:503-511. [PMID: 35686696 DOI: 10.1530/erc-22-0088] [Citation(s) in RCA: 1] [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] [Received: 05/16/2022] [Accepted: 06/10/2022] [Indexed: 12/13/2022]
Abstract
Cushing's disease is a rare but devastating and difficult to manage condition. The somatostatin analogue pasireotide is the only pituitary-targeting pharmaceutical approved for the treatment of Cushing's disease but is accompanied by varying efficacy and potentially severe side effects. Finding means to predict which patients are more likely to benefit from this treatment may improve their management. More than half of corticotroph tumours harbour mutations in the USP8 gene, and there is evidence of higher somatostatin receptor 5 (SSTR5) expression in the USP8-mutant tumours. Pasireotide has a high affinity for SSTR5, indicating that these tumours may be more sensitive to treatment. To test this hypothesis, we examined the inhibitory action of pasireotide on adrenocorticotrophic hormone synthesis in primary cultures of human corticotroph tumour with assessed USP8 mutational status and in immortalized murine corticotroph tumour cells overexpressing human USP8 mutants frequent in Cushing's disease. Our in vitro results demonstrate that pasireotide exerts a higher antisecretory response in USP8-mutant corticotroph tumours. Overexpressing USP8 mutants in a murine corticotroph tumour cell model increased endogenous somatostatin receptor 5 (Sstr5) transcription. The murine Sstr5 promoter has two binding sites for the activating protein 1 (AP-1) and USP8 mutants possibly to mediate their action by stimulating AP-1 transcriptional activity. Our data corroborate the USP8 mutational status as a potential marker of pasireotide response and describe a potential mechanism through which USP8 mutants may regulate SSTR5 gene expression.
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Affiliation(s)
- Adriana Albani
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Sicheng Tang
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Julia Simon
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kristin Elisabeth Lucia
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Paula Colón-Bolea
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Sigrun Roeber
- Center for Neuropathology and Prion Research, LMU Munich, Munich, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Roman Rotermund
- Department of Neurosurgery, Universitätskrankenhaus Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, Universitätskrankenhaus Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jochen Herms
- Center for Neuropathology and Prion Research, LMU Munich, Munich, Germany
| | - Günter Stalla
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
- Medicover Neuroendocrinology, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
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20
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Gadelha M, Bex M, Feelders RA, Heaney AP, Auchus RJ, Gilis-Januszewska A, Witek P, Belaya Z, Yu Y, Liao Z, Ku CHC, Carvalho D, Roughton M, Wojna J, Pedroncelli AM, Snyder PJ. Randomized Trial of Osilodrostat for the Treatment of Cushing Disease. J Clin Endocrinol Metab 2022; 107:e2882-e2895. [PMID: 35325149 PMCID: PMC9202723 DOI: 10.1210/clinem/dgac178] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT Cushing disease, a chronic hypercortisolism disorder, is associated with considerable morbidity and mortality. Normalizing cortisol production is the primary treatment goal. OBJECTIVE We aimed to evaluate the safety and efficacy of osilodrostat, a potent, orally available 11βhydroxylase inhibitor, compared with placebo in patients with Cushing disease. METHODS LINC 4 was a phase III, multicenter trial comprising an initial 12-week, randomized, double-blind, placebo-controlled (osilodrostat:placebo, 2:1) period followed by a 36-week, open-label treatment period (NCT02697734). Adult patients (aged 18-75 years) with confirmed Cushing disease and mean urinary free cortisol (mUFC) excretion ≥ 1.3 times the upper limit of normal (ULN) were eligible. The primary endpoint was the proportion of randomized patients with mUFC ≤ ULN at week 12. The key secondary endpoint was the proportion achieving mUFC ≤ ULN at week 36 (after 24 weeks' open-label osilodrostat). RESULTS Seventy-three patients (median age, 39 years [range, 19-67]; mean/median mUFC, 3.1 × ULN/2.5 × ULN) received randomized treatment with osilodrostat (n = 48) or placebo (n = 25). At week 12, significantly more osilodrostat (77%) than placebo (8%) patients achieved mUFC ≤ ULN (odds ratio 43.4; 95% CI 7.1, 343.2; P < 0.0001). Response was maintained at week 36, when 81% (95% CI 69.9, 89.1) of all patients achieved mUFC ≤ ULN. The most common adverse events during the placebo-controlled period (osilodrostat vs placebo) were decreased appetite (37.5% vs 16.0%), arthralgia (35.4% vs 8.0%), and nausea (31.3% vs 12.0%). CONCLUSION Osilodrostat rapidly normalized mUFC excretion in most patients with Cushing disease and maintained this effect throughout the study. The safety profile was favorable.
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Affiliation(s)
- Mônica Gadelha
- Correspondence: Mônica Gadelha, Endocrine Unit, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Professor Rodolpho Paulo Rocco, 255, 9° floor - 9F - Sala de Pesquisa em Neuroendocrinologia, Rio de Janeiro – RJ – Brazil, CEP: 21941-913
| | - Marie Bex
- University Hospitals Leuven, Leuven, Belgium
| | - Richard A Feelders
- Department of Internal Medicine, Endocrine Section, Erasmus Medical Center, Rotterdam CA, The Netherlands
| | - Anthony P Heaney
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI, USA
| | | | - Przemyslaw Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Zhanna Belaya
- Department of Neuroendocrinology and Bone Disease, Endocrinology Research Centre, Moscow, Russia
| | - Yerong Yu
- West China Hospital of Sichuan University, Chengdu, China
| | - Zhihong Liao
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | | | - Davide Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Universidade do Porto, Porto, Portugal
| | | | - Judi Wojna
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Peter J Snyder
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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Delivanis DA, Vassiliadi DA, Tsagarakis S. Current approach of primary bilateral adrenal hyperplasia. Curr Opin Endocrinol Diabetes Obes 2022; 29:243-252. [PMID: 35621176 DOI: 10.1097/med.0000000000000725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To discuss the most recent findings on the pathophysiology, the genetic and molecular causes of primary bilateral adrenal hyperplasia (PBAH). The diagnostic approach of patients with PBAH will also be presented in detail with an emphasis on the emerging diagnostic tools and finally, the treatment of PBAH will be discussed with an emphasis on the newest surgical and medical treatment approaches. RECENT FINDINGS PBAH is a highly heterogeneous condition mostly detected incidentally on abdominal imaging. Based on the size of the nodules, PBAH is subdivided into primary bilateral macronodular adrenal hyperplasia (PBMAH) and micronodular adrenal hyperplasia. A substantial proportion of patients with PBMAH harbor a germline mutation of the armadillo repeat containing 5 tumor suppression gene and therefore genetic testing is strongly recommended. Measurements of plasma or urinary multisteroid profiles show promising results in that PBMAH has a distinctive plasma steroid fingerprint that can help in diagnosis and subtyping of PBMAH. Finally, although surgery is the mainstay of treatment of patients with PBAH, medical therapy is increasingly emerging as an alternative option. SUMMARY PBAH is a poorly studied and therefore a challenging disease to diagnose and treat. Hopefully with these newest diagnostic and therapeutic tools, a more comprehensive approach will be adopted.
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Affiliation(s)
- Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Cai Z, Qian B, Pang J, Tan ZB, Zhao K, Lei T. Celastrol Induces Apoptosis and Autophagy via the AKT/mTOR Signaling Pathway in the Pituitary ACTH-secreting Adenoma Cells. Curr Med Sci 2022; 42:387-396. [PMID: 35419676 DOI: 10.1007/s11596-022-2568-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/14/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pituitary adrenocorticotropic hormone (ACTH)-secreting adenoma is a relatively intractable endocrine adenoma that can cause a range of severe metabolic disorders and pathological changes involving multiple systems. Previous studies have shown that celastrol has antitumor effects on a variety of tumor cells via the AKT/mTOR signaling. However, whether celastrol has pronounced antitumor effects on pituitary ACTH-secreting adenoma is unclear. This study aimed to identify a new effective therapeutic drug for pituitary ACTH-secreting adenoma. METHODS Mouse pituitary ACTH-secreting adenoma cells (AtT20 cells) were used as an experimental model in vitro and to establish a xenograft tumor model in mice. Cells and animals were administered doses of celastrol at various levels. The effects of celastrol on cell viability, migration, apoptosis and autophagy were then examined. Finally, the potential involvement of AKT/mTOR signaling in celastrol's mechanism was assessed. RESULTS Celastrol inhibited the proliferation and migration of pituitary adenoma cells in a time- and concentration-dependent manner. It blocked AtT20 cells in the G0/G1 phase, and induced apoptosis and autophagy by downregulating the AKT/mTOR signaling pathway. Similar results were obtained in mice. CONCLUSION Celastrol exerts potent antitumor effects on ACTH-secreting adenoma by downregulating the AKT/mTOR signaling in vitro and in vivo.
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Affiliation(s)
- Zhi Cai
- Sino-German Neuro-Oncology Molecular Laboratory, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Bin Qian
- Key Laboratory of Human Functional Genomics of Jiangsu Province, Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, 211100, China
| | - Jing Pang
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai, 200240, China
| | - Zhou-Bin Tan
- Sino-German Neuro-Oncology Molecular Laboratory, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Kai Zhao
- Sino-German Neuro-Oncology Molecular Laboratory, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ting Lei
- Sino-German Neuro-Oncology Molecular Laboratory, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Non-surgical Interventions for Pituitary Lesions. Otolaryngol Clin North Am 2022; 55:287-304. [DOI: 10.1016/j.otc.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gilis-Januszewska A, Bogusławska A, Rzepka E, Ziaja W, Hubalewska-Dydejczyk A. Individualized medical treatment options in Cushing disease. Front Endocrinol (Lausanne) 2022; 13:1060884. [PMID: 36531477 PMCID: PMC9755355 DOI: 10.3389/fendo.2022.1060884] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022] Open
Abstract
Cushing disease (CD) is caused by a pituitary tumor which oversecretes adrenocorticotropic hormone (ACTH). It is a serious endocrine disease associated with increased mortality and impaired quality of life. The management of CD remains challenging. Although transsphenoidal surgery is the treatment of choice in most cases, in approximately half of CD patients, second or third-line treatment options are needed. Currently, new medical therapies are available which target adrenal steroidogenesis, pituitary somatostatin and dopamine receptors, and glucocorticoid receptors. Selection of which medication to use should be individualized and is determined by many factors including severity of the disease, possible side effects, patients preferences and local availability. The aim of this article is to describe currently available medical therapy to help clinicians individualize the treatment options in the context of recently updated Pituitary Society recommendations.
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Vega-Beyhart A, Laguna-Moreno J, Díaz-Catalán D, Boswell L, Mora M, Halperin I, Casals G, Hanzu FA. Ketoconazole- and Metyrapone-Induced Reductions on Urinary Steroid Metabolites Alter the Urinary Free Cortisol Immunoassay Reliability in Cushing Syndrome. Front Endocrinol (Lausanne) 2022; 13:833644. [PMID: 35282465 PMCID: PMC8905543 DOI: 10.3389/fendo.2022.833644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Twenty-four-hour urinary free cortisol (24h-UFC) is the most used test for follow-up decision-making in patients with Cushing syndrome (CS) under medical treatment. However, 24h-UFC determinations by immunoassays (IA) are commonly overestimated because of steroid metabolites' cross-reaction. It is still uncertain how ketoconazole (KTZ)- and metyrapone (MTP)-induced changes on the urinary steroid metabolites can alter the 24h-UFC*IA determinations' reliability. METHODS 24h-UFC was analyzed by IA and gas chromatography-mass spectrometry (GC-MS) in 193 samples (81 before treatment, 73 during KTZ, and 39 during MTP) from 34 CS patients. In addition, urinary steroidome was analyzed by GC-MS on each patient before and during treatment. RESULTS Before treatment, 24h-UFC*IA determinations were overestimated by a factor of 1.75 (95% CI 1.60-1.94) compared to those by GC-MS. However, during KTZ treatment, 24h-UFC*IA results were similar (0.98:1) to those by GC-MS (95% CI, 0.83-1.20). In patients taking MTP, IA bias only decreased 0.55, resulting in persistence of an overestimation factor of 1.33:1 (95% CI, 1.09-1.76). High method agreement between GC-MS and IA before treatment (R2 = 0.954) declined in patients under KTZ (R2 = 0.632) but not in MTP (R2 = 0.917). Upper limit normal (ULN) reductions in patients taking KTZ were 27% larger when using 24h-UFC*IA compared to 24h-UFC*GC-MS, which resulted in higher false efficacy and misleading biochemical classification of 15% of patients. Urinary excretion changes of 22 urinary steroid metabolites explained 86% of the 24h-UFC*IA interference. Larger urinary excretion reductions of 6β-hydroxy-cortisol, 20α-dihydrocortisol, and 18-hydroxy-cortisol in patients with KTZ elucidated the higher 24h-UFC*IA bias decrement compared to MTP-treated patients. CONCLUSION KTZ and MTP alter the urinary excretion of IA cross-reactive steroid metabolites, thus decreasing the cross-reactive interference of 24h-UFC*IA determinations present before treatment. Consequently, this interference reduction in 24h-UFC*IA leads to loss of method agreement with GC-MS and high risk of overestimating the biochemical impact of KTZ and MTP in controlling CS because of poor reliability of reference ranges and ULN.
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Affiliation(s)
- Arturo Vega-Beyhart
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | | | - Daniela Díaz-Catalán
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Laura Boswell
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Mireia Mora
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Irene Halperin
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Gregori Casals
- Biomedical Diagnostics Center, Hospital Clinic, Barcelona, Spain
| | - Felicia A. Hanzu
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- *Correspondence: Felicia A. Hanzu,
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Update in Cushing disease: What the neurosurgeon has to KNOW, on behalf of the EANS skull base section. BRAIN AND SPINE 2022; 2:100917. [PMID: 36248125 PMCID: PMC9560580 DOI: 10.1016/j.bas.2022.100917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/27/2022] [Accepted: 07/19/2022] [Indexed: 12/02/2022]
Abstract
Introduction Cushing's disease is a state of chronic and excessive cortisol levels caused by a pituitary adenoma Research question CD is a complex entity and often entails difficulties in its diagnosis and management. For that reason, there are still controversial points to that respect. The aim of this consensus paper of the skull base section of the EANS is to review the main aspects of the disease a neurosurgeon has to know and also to offer updated recommendations on the controversial aspects of its management. Material and methods PUBMED database was used to search the most pertinent articles published on the last 5 years related with the management of CD. A summary of literature evidence was proposed for discussion within the EANS skull base section and other international experts. Results This article represents the consensual opinion of the task force regarding optimal management and surgical strategy in CD Discussion and conclusion After discussion in the group several recommendations and suggestions were elaborated. Patients should be treated by an experienced multidisciplinary team. Accurate clinical, biochemical and radiological diagnosis is mandatory. The goal of treatment is the complete adenoma resection to achieve permanent remission. If this is not possible, the treatment aims to achieving eucortisolism. Radiation therapy is recommended to patients with CD when surgical options have been exhausted. All patients in remission should be tested all life-long. Modalities of management of Cushing disease and recommendations based on the literature and expert's opinion.
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Vogel F, Braun L, Reincke M. [Morbidity and mortality in Cushing's syndrome]. Internist (Berl) 2021; 63:34-42. [PMID: 34928397 DOI: 10.1007/s00108-021-01222-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/30/2022]
Abstract
Endogenous Cushing's syndrome is a rare endocrine disorder that is fatal if left untreated. It can be distinguished into adrenocorticotropic hormone (ACTH)-dependent (central and ectopic Cushing's syndrome) and ACTH-independent subtypes (unilateral or bilateral adrenal adenomas). The clinical presentation of patients includes typical stigmata of cortisol excess with physical symptoms of catabolic metabolism (myopathy, striae, parchment skin, osteoporosis) and components of metabolic syndrome (diabetes mellitus, obesity, arterial hypertension, hypercholesterolemia). Biochemical diagnosis is performed in three steps: 1. Confirmation of the diagnosis by 1‑mg dexamethasone suppression test, 24‑h urine free cortisol, and measurement of late-night salivary cortisol. 2. Differentiation of ACTH-dependent Cushing's syndrome from ACTH-independent adrenal Cushing's syndrome by measurement of plasma ACTH. 3. Further subtyping by corticotropin-releasing hormone (CRH) test, inferior petrosal sinus sampling, and imaging modalities. Therapeutic decisions are made on an interdisciplinary basis. First-line therapy for all subtypes is surgery when possible; additional options for all forms include drug therapy and bilateral adrenalectomy. Despite adequate treatment, Cushing's syndrome is associated with increased long-term morbidity and mortality. Interdisciplinary and multimodal therapy management is necessary in the long term to positively influence mortality and reduced quality of life.
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Affiliation(s)
- Frederick Vogel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstraße 5, 80336, München, Deutschland
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstraße 5, 80336, München, Deutschland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstraße 5, 80336, München, Deutschland.
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Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, Casanueva FF, Castinetti F, Chanson P, Findling J, Gadelha M, Geer EB, Giustina A, Grossman A, Gurnell M, Ho K, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Kelly DF, Lacroix A, McCormack A, Melmed S, Molitch M, Mortini P, Newell-Price J, Nieman L, Pereira AM, Petersenn S, Pivonello R, Raff H, Reincke M, Salvatori R, Scaroni C, Shimon I, Stratakis CA, Swearingen B, Tabarin A, Takahashi Y, Theodoropoulou M, Tsagarakis S, Valassi E, Varlamov EV, Vila G, Wass J, Webb SM, Zatelli MC, Biller BMK. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol 2021; 9:847-875. [PMID: 34687601 PMCID: PMC8743006 DOI: 10.1016/s2213-8587(21)00235-7] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
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Affiliation(s)
| | | | | | | | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, Hôpital Cochin, Paris, France
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | | | | | | | - John D Carmichael
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Felipe F Casanueva
- Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM, Marseille, France; Assistance Publique Hopitaux de Marseille, Marseille, France; Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza B Geer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Ashley Grossman
- University of London, London, UK; University of Oxford, Oxford, UK
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK; NIHR Cambridge Biomedical Research Center, Cambridge, UK; Addenbrooke's Hospital, Cambridge, UK
| | - Ken Ho
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Ursula B Kaiser
- Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - André Lacroix
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ann McCormack
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Alberto M Pereira
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | | | - Hershel Raff
- Medical College of Wisconsin, Milwaukee, WI, USA; Advocate Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Martin Reincke
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | | | - Ilan Shimon
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | | | | | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | | | - Marily Theodoropoulou
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital General de Catalunya, Barcelona, Spain; Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- Churchill Hospital, Oxford, United Kingdom
| | - Susan M Webb
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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Andereggen L, Mariani L, Beck J, Andres RH, Gralla J, Luedi MM, Weis J, Christ E. Lateral one-third gland resection in Cushing patients with failed adenoma identification leads to low remission rates: long-term observations from a small, single-center cohort. Acta Neurochir (Wien) 2021; 163:3161-3169. [PMID: 33811521 PMCID: PMC8520517 DOI: 10.1007/s00701-021-04830-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Currently, there are no guidelines for neurosurgeons treating patients with Cushing's disease (CD) when intraoperative adenoma identification is negative. Under these circumstances, a total hypophysectomy or hemi-hypophysectomy on the side indicated by inferior petrosal sinus sampling (IPSS) is the approach being used, although there is a subsequent risk of hypopituitarism. Data on whether one-third lateral pituitary gland resection results in cure of hypercortisolism and low rates of hypopituitarism remain inconclusive. METHODS Retrospective single-center study of CD patients with failed intraoperative adenoma identification and subsequent resection of the lateral one-third of the pituitary gland as predicted by IPSS. We assessed (i) histopathological findings, (ii) early and long-term remission rates, and (iii) rates of additional pituitary hormone insufficiency. RESULTS Ten women and three men met the inclusion criteria. At 3 months, remission was noted in six (46%) patients: three (23%) had histologically confirmed adenomas, two (15%) had ACTH hyperplasia, and one patient (8%) was positive for Crooke's hyaline degeneration. New pituitary hormone deficits were noted in two patients (15%). After a median (±SD) follow-up of 14±4 years, recurrence was noted in two (15%) patients. Long-term control of hypercortisolism was attained by 10 patients (77%), with additional therapies required in nine (69%) of them. CONCLUSIONS In CD patients with failed intraoperative adenoma visualization, lateral one-third gland resection resulted in low morbidity and long-term remission in 31% of patients without the need for additional therapies. Bearing in mind the sample size of this audit, the indication for lateral one-third-gland resection has to be critically appraised and discussed with the patients before surgery.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Robert H Andres
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joachim Weis
- Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany
| | - Emanuel Christ
- Department of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
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Abstract
Cushing's disease (CD) is the most prevalent cause of endogenous hypercortisolism. CD is responsible for multiple co-morbidities and increased mortality. Accurate and prompt diagnosis and optimal treatment are essential to improve the prognosis of CD. However, the diagnosis of CD is probably one of the most difficult in endocrinology and, therefore, diagnostic workup should be performed in an experienced center. Transsphenoidal surgery performed by an expert surgeon is the only therapeutic option that can offer definitive cure and remains the first-line treatment in most patients. Second-line treatments include pharmacotherapy, pituitary radiotherapy and bilateral adrenalectomy. The second-line therapeutic strategy is complex, must be individualized and performed in a multidisciplinary expert center. Symptomatic treatments of persisting co-morbidities after remission, which are responsible for increased mortality and impaired quality of life is an important part of medical management.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France; INSERM U1215, NeuroCentre Magendie, University of Bordeaux, France.
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Favero V, Cremaschi A, Falchetti A, Gaudio A, Gennari L, Scillitani A, Vescini F, Morelli V, Aresta C, Chiodini I. Management and Medical Therapy of Mild Hypercortisolism. Int J Mol Sci 2021; 22:ijms222111521. [PMID: 34768949 PMCID: PMC8584167 DOI: 10.3390/ijms222111521] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/30/2022] Open
Abstract
Mild hypercortisolism (mHC) is defined as an excessive cortisol secretion, without the classical manifestations of clinically overt Cushing's syndrome. This condition increases the risk of bone fragility, neuropsychological alterations, hypertension, diabetes, cardiovascular events and mortality. At variance with Cushing's syndrome, mHC is not rare, with it estimated to be present in up to 2% of individuals older than 60 years, with higher prevalence (up to 10%) in individuals with uncontrolled hypertension and/or diabetes or with unexplainable bone fragility. Measuring cortisol after a 1 mg overnight dexamethasone suppression test is the first-line test for searching for mHC, and the degree of cortisol suppression is associated with the presence of cortisol-related consequences and mortality. Among the additional tests used for diagnosing mHC in doubtful cases, the basal morning plasma adrenocorticotroph hormone, 24-h urinary free cortisol and/or late-night salivary cortisol could be measured, particularly in patients with possible cortisol-related complications, such as hypertension and diabetes. Surgery is considered as a possible therapeutic option in patients with munilateral adrenal incidentalomas and mHC since it improves diabetes and hypertension and reduces the fracture risk. In patients with mHC and bilateral adrenal adenomas, in whom surgery would lead to persistent hypocortisolism, and in patients refusing surgery or in whom surgery is not feasible, medical therapy is needed. Currently, promising though scarce data have been provided on the possible use of pituitary-directed agents, such as the multi-ligand somatostatin analog pasireotide or the dopamine agonist cabergoline for the-nowadays-rare patients with pituitary mHC. In the more frequently adrenal mHC, encouraging data are available for metyrapone, a steroidogenesis inhibitor acting mainly against the adrenal 11-βhydroxylase, while data on osilodrostat and levoketoconazole, other new steroidogenesis inhibitors, are still needed in patients with mHC. Finally, on the basis of promising data with mifepristone, a non-selective glucocorticoid receptor antagonist, in patients with mild cortisol hypersecretion, a randomized placebo-controlled study is ongoing for assessing the efficacy and safety of relacorilant, a selective glucocorticoid receptor antagonist, for patients with mild adrenal hypercortisolism and diabetes mellitus/impaired glucose tolerance and/or uncontrolled systolic hypertension.
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Affiliation(s)
- Vittoria Favero
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
| | - Arianna Cremaschi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
| | - Alberto Falchetti
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy;
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy;
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology “Casa Sollievo della Sofferenza” Hospital, IRCCS, 71013 San Giovanni Rotondo (FG), Italy;
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. M. Misericordia of Udine, 33100 Udine, Italy;
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
- Correspondence: ; Tel.: +39-02-61911-2738
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
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Simões Corrêa Galendi J, Correa Neto ANS, Demetres M, Boguszewski CL, Nogueira VDSN. Effectiveness of Medical Treatment of Cushing's Disease: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:732240. [PMID: 34603209 PMCID: PMC8485729 DOI: 10.3389/fendo.2021.732240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/20/2021] [Indexed: 12/22/2022] Open
Abstract
Objective The objective of this systematic review was to evaluate the effectiveness and safety of pasireotide, cabergoline, ketoconazole, levoketoconazole, metyrapone, osilodrostat, and temozolomide for the treatment of Cushing's disease (CD). Methods The primary outcomes were the proportion of CD control, adverse events (AE), and reduction of urinary free cortisol. Search strategies were applied to Embase, Medline, and CENTRAL. Independent reviewers assessed the study eligibility, extracted data, and evaluated risk of bias. Standardized mean difference was calculated with 95% confidence interval (CI) for continuous data (i.e., pre- and post-intervention). Random meta-analyses for the proportion of CD control and AE were conducted. Results Twenty-nine controlled and non-controlled studies were included. No study with temozolomide and levoketoconazole and one study with osilodrostat fulfilled the inclusion criteria. The meta-analyses of proportion of CD control was 35% for cabergoline (95% CI: 27-43%, six studies, 141 participants), 44% for pasireotide (95% CI: 25-35%, eight studies, 522 participants), 41% for ketoconazole (95% CI: 36-46%, six studies, 450 participants), 66% for metyrapone (95% CI: 46-87%, four studies, 66 participants), and of 66.4% for osilodrostat (95% CI: 57.9, 74.3, 97 participants, one study). One study compared two different treatments (cabergoline vs. ketoconazole), and no statistical difference was observed in CD control (RR: 0.53, 95% CI: 0.15 to 1.87, 14 participants, very low certainty of evidence). The most frequent AE associated with pasireotide was hyperglycemia, dizziness and nausea with cabergoline and metyrapone, and elevated transaminases with ketoconazole. Conclusion The superiority of one drug over another could not be determined due to lack of controlled studies, but the proportion of disease control identified in our meta-analysis may support clinical decision. New therapeutic options should be investigated due to the limited efficacy and tolerability of the currently available medical treatment for patients with Cushing's disease. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020205567, identifier CRD42020205567.
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Affiliation(s)
- Julia Simões Corrêa Galendi
- University of Cologne, Faculty of Medicine and University Hospital of Cologne, Institute of Health Economics and Clinical Epidemiology, Cologne, Germany
| | | | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, United States
| | - Cesar Luiz Boguszewski
- Department of Internal Medicine, Endocrine Division (SEMPR), Federal University of Parana, Curitiba, Brazil
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Lisco G, De Tullio A, Stragapede A, Solimando AG, Albanese F, Capobianco M, Giagulli VA, Guastamacchia E, De Pergola G, Vacca A, Racanelli V, Triggiani V. COVID-19 and the Endocrine System: A Comprehensive Review on the Theme. J Clin Med 2021; 10:jcm10132920. [PMID: 34209964 PMCID: PMC8269331 DOI: 10.3390/jcm10132920] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/31/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background and aim. The review aimed to summarize advances in the topic of endocrine diseases and coronavirus disease 2019 (COVID-19). Methods. Scientific and institutional websites and databases were searched and data were collected and organized, when plausible, to angle the discussion toward the following clinical issues. (1) Are patients with COVID-19 at higher risk of developing acute or late-onset endocrine diseases or dysfunction? (2) May the underlying endocrine diseases or dysfunctions be considered risk factors for poor prognosis once the infection has occurred? (3) Are there defined strategies to manage endocrine diseases despite pandemic-related constraints? Herein, the authors considered only relevant and more frequently observed endocrine diseases and disorders related to the hypothalamic-pituitary region, thyroid and parathyroid glands, calcium-phosphorus homeostasis and osteoporosis, adrenal glands, and gonads. Main. Data highlight the basis of some pathophysiological mechanisms and anatomical alterations of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)-induced endocrine dysfunctions. Some conditions, such as adrenal insufficiency and cortisol excess, may be risk factors of worse clinical progression once the infection has occurred. These at-risk populations may require adequate education to avoid the SARS-CoV-2 infection and adequately manage medical therapy during the pandemic, even in emergencies. Endocrine disease management underwent a palpable restraint, especially procedures requiring obligate access to healthcare facilities for diagnostic and therapeutic purposes. Strategies of clinical triage to prioritize medical consultations, laboratory, instrumental evaluations, and digital telehealth solutions should be implemented to better deal with this probably long-term situation.
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Affiliation(s)
- Giuseppe Lisco
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (V.T.)
| | - Anna De Tullio
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (V.T.)
| | - Assunta Stragapede
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine “G. Baccelli”, University of Bari School of Medicine, 70124 Bari, Italy; (A.S.); (A.G.S.); (F.A.); (M.C.); (A.V.)
| | - Antonio Giovanni Solimando
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine “G. Baccelli”, University of Bari School of Medicine, 70124 Bari, Italy; (A.S.); (A.G.S.); (F.A.); (M.C.); (A.V.)
| | - Federica Albanese
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine “G. Baccelli”, University of Bari School of Medicine, 70124 Bari, Italy; (A.S.); (A.G.S.); (F.A.); (M.C.); (A.V.)
| | - Martina Capobianco
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine “G. Baccelli”, University of Bari School of Medicine, 70124 Bari, Italy; (A.S.); (A.G.S.); (F.A.); (M.C.); (A.V.)
| | - Vito Angelo Giagulli
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (V.T.)
| | - Edoardo Guastamacchia
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (V.T.)
| | - Giovanni De Pergola
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, 70124 Bari, Italy;
- National Institute of Gastroenterology “Saverio de Bellis”, Research Hospital, 70013 Castellana Grotte, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine “G. Baccelli”, University of Bari School of Medicine, 70124 Bari, Italy; (A.S.); (A.G.S.); (F.A.); (M.C.); (A.V.)
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine “G. Baccelli”, University of Bari School of Medicine, 70124 Bari, Italy; (A.S.); (A.G.S.); (F.A.); (M.C.); (A.V.)
- Correspondence: ; Tel.: +39-(0)-80-547-82-54
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (V.T.)
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Okada Y, Matsushita S, Yamaguchi K. Investigation of Cushing's and subclinical Cushing's syndromes using adrenocortical scintigraphy. Nucl Med Commun 2021; 42:619-624. [PMID: 33596032 DOI: 10.1097/mnm.0000000000001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study assessed the factors related to the intake rate of adrenocortical scintigraphy in Cushing's and subclinical Cushing's syndromes, in addition to the methods for differentiating between the two. METHODS Clinical findings, blood sampling, and adrenocortical scintigraphy collected at St. Marianna University School of Medicine from 1 January 2010 to 31 December 2019 were used to diagnose initial-onset Cushing's syndrome and subclinical Cushing's syndrome, and patients who underwent 131I-NP-59 adrenocortical scintigraphy were used as study subjects. RESULTS A total of 24 (8 male and 16 female) patients were selected. Of them, 7 had Cushing's syndrome and 17 had subclinical Cushing's syndrome. A correlation coefficient of -0.474 (P = 0.026) was determined between the intake rate after 7 days and adrenocorticotropic hormone levels. Intake rates after 5 days were 0.51% and 0.31% for Cushing's and subclinical Cushing's syndromes, respectively, and were statistically significant (P = 0.03). Intake rates after 7 days were 0.47% and 0.30% for Cushing's and subclinical Cushing's syndromes, respectively, and were statistically significant (P = 0.04). Receiver operating characteristic analysis results of Cushing's and subclinical Cushing's syndromes for intake rates after 7 days were as follows: cutoff value, 0.248; area under curve, 0.769; and 95% confidence interval, 0.561-0.977. CONCLUSION There were differences in the intake rates of adrenocortical scintigraphy between the Cushing's syndrome group and subclinical Cushing's syndrome group, making it possible to differentiate between the two using the intake rate.
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Affiliation(s)
| | | | - Keiichiro Yamaguchi
- Department of Proton Therapy and Tumor Imaging, St. Marianna University School of Medicine, Kawasaki, Japan
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Qiang W, Song S, Chen T, Wang Z, Feng J, Zhang J, Guo H. A rare case of ectopic ACTH syndrome with rhabdomyolysis. BMC Endocr Disord 2021; 21:98. [PMID: 33971870 PMCID: PMC8111963 DOI: 10.1186/s12902-021-00755-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 04/19/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Manifestations of hypokalaemia in ectopic adrenocorticotropic hormonesyndrome(EAS) vary from mild muscle weakness to life-threatening arrhythmia. Herein, we present a rare case of EAS with concomitant rhabdomyolysis(RM) as a result of intractable hypokalaemia. CASE PRESENTATION A 64-year-old man was admitted for limb weakness and facial hyperpigmentation for 2 weeks. Lab tests revealed intractable hypokalaemia (lowest at 1.8 mmol/L) and metabolic alkalosis. The diagnosis of RM was based on a creatine kinase(CK)level of 5 times the upper limit. The elevated CK and myohemoglobin (Mb) levels returned to within the normal range after the alleviation of hypokalaemia. The patient was diagnosed with ACTH-dependent Cushing's syndrome (CS) based on unsuppressed serum cortisol after a low-dose dexamethasone suppression test(LDDST) and remarkably elevated ACTH levels. The diagnosis of EAS was made based on the results of a high-dose dexamethasone suppression test(HDDST) and bilateral inferior petrosal sinus sampling(BIPSS). Multiple lymph nodes in the left supraclavicular fossa, right root of neck, mediastinum and bilateral hili of the lung were found with abnormal uptake of 68Ga-DOTA-NOC. Mediastinoscopic lymph node biopsy was performed. The pathological diagnosis was small-cell and large-cell neuroendocrine carcinoma with positive ACTH staining. The patient was prescribed mifepristone and received one cycle of chemotherapy. The patient could not tolerate subsequent chemotherapy and died of dyscrasia. CONCLUSIONS RM is a rare complication of EAS with insidious onset and atypical clinical manifestations. Serum potassium levels should be vigilantly monitored to avoid RM in EAS.
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Affiliation(s)
- Wei Qiang
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
| | - Sucai Song
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
- Department of Endocrinology, The First Affiliated Hospital of Zhengzhou University, 450052 Zhengzhou, People’s Republic of China
| | - Tianjun Chen
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Zhe Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jun Feng
- Department of Vascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jiaojiao Zhang
- Department of Pathology, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Hui Guo
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
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Ivović M, Marina LV, Šojat AS, Tančić-Gajić M, Arizanović Z, Kendereški A, Vujović S. Approach to the Patient with Subclinical Cushing's Syndrome. Curr Pharm Des 2021; 26:5584-5590. [PMID: 32787757 DOI: 10.2174/1381612826666200813134328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/08/2020] [Indexed: 01/07/2023]
Abstract
A growing number of patients with adrenal incidentalomas and subclinical Cushing's syndrome (SCS) led to an increasing number of different guidelines, and diagnostic and treatment recommendations. Excess cortisol secretion in patients with SCS is associated with several comorbidities, such as hypertension, dyslipidemia, type 2 diabetes mellitus, and obesity, which in the long-term increase mortality of these patients. Subtle cortisol secretion affects bone health, quality of life and causes depression, but due to the unapparent clinical features, patients with SCS are often at risk between over and under treatment. This narrative review aimed to summarize the latest recommendations on the approach to the patient with subclinical Cushing's syndrome.
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Affiliation(s)
- Miomira Ivović
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Ljiljana V Marina
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Antoan S Šojat
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Milina Tančić-Gajić
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Zorana Arizanović
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Aleksandra Kendereški
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Svetlana Vujović
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
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Treppiedi D, Di Muro G, Mangili F, Catalano R, Giardino E, Barbieri AM, Locatelli M, Arosio M, Spada A, Peverelli E, Mantovani G. Filamin A is required for somatostatin receptor type 5 expression and pasireotide-mediated signaling in pituitary corticotroph tumor cells. Mol Cell Endocrinol 2021; 524:111159. [PMID: 33428965 DOI: 10.1016/j.mce.2021.111159] [Citation(s) in RCA: 4] [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: 07/28/2020] [Revised: 12/16/2020] [Accepted: 01/03/2021] [Indexed: 01/08/2023]
Abstract
Somatostatin receptor type 5 (SST5) represents the main pharmacological target in the treatment of adrenocorticotroph hormone (ACTH)-secreting tumors. However, molecular predictors of responsiveness to pasireotide require further investigation. The cytoskeleton protein filamin A (FLNA) modulates the responsiveness to somatostatin analogs (SSA) treatment in other types of pituitary tumors by regulating somatostatin receptor type 2 (SST2)/dopamine receptor type 2 (DRD2) expression and activity. Here, we aimed to test the involvement of FLNA in the modulation of SST5 response to SSA in human and murine tumor corticotrophs. Western blot analysis of human corticotropinomas showed that FLNA and SST5 correlate. Both in human primary cultures and AtT-20 cells, FLNA genetic silencing caused a decrease of receptor expression level. Moreover, pasireotide-mediated SST5 downregulation observed in AtT-20 control cells was no further detected in FLNA silenced cells. In AtT-20 cells, in situ PLA experiments revealed an increased number of SST5-FLNA complexes following pasireotide incubation. Finally, FLNA knock down abolished pasireotide-induced SST5 actions on hormone secretion, cell proliferation and apoptosis. In conclusion, FLNA is implicated in SST5 expression modulation and signaling.
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Affiliation(s)
- Donatella Treppiedi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Genesio Di Muro
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federica Mangili
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rosa Catalano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; PhD Program in Endocrinological Sciences, Sapienza University of Rome, Rome, Italy
| | - Elena Giardino
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Maria Barbieri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Locatelli
- Department of Pathophysiology and Transplantation, University of Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Unit, Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
| | - Anna Spada
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Erika Peverelli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
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Cardinal T, Zada G, Carmichael JD. The role of reoperation after recurrence of Cushing's disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101489. [PMID: 33814302 DOI: 10.1016/j.beem.2021.101489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Surgical failure or recurrence of Cushing's disease can be treated with medical therapy, radiotherapy, adrenalectomy, and/or repeat transsphenoidal surgery, all of which have their respective benefits and drawbacks. Redo transsphenoidal surgery has been shown to achieve at least short-term remission in about 40-80% of patients and is associated with low rates of morbidity and near-zero mortality, albeit higher rates of postoperative hypopituitarism, diabetes insipidus, and cerebrospinal fluid leak than initial resection. Despite this, recurrence may ensue in 50% of patients. When selecting patient candidates for reoperation, many predictors of postoperative outcomes have been proposed including imaging characteristics, histopathological staining, intraoperative tumor visualization, and tumor size, however no single predictor consistently predicts outcomes. Redo transsphenoidal surgery should be performed by an experienced pituitary surgeon and patients should be followed at a tertiary care center by a multidisciplinary team consisting of an experienced endocrinologist and neurosurgeon to monitor closely for remission and recurrence.
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Affiliation(s)
- Tyler Cardinal
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, 1300 N. State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | - Gabriel Zada
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, 1300 N. State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | - John D Carmichael
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, 1300 N. State Street, Suite 3300, Los Angeles, CA, 90033, USA; Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, 1333 San Pablo Street, BMT-B11, Los Angeles, CA, 90033, USA.
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Geer EB, Salvatori R, Elenkova A, Fleseriu M, Pivonello R, Witek P, Feelders RA, Bex M, Borresen SW, Puglisi S, Biller BMK, Cohen F, Pecori Giraldi F. Levoketoconazole improves clinical signs and symptoms and patient-reported outcomes in patients with Cushing's syndrome. Pituitary 2021; 24:104-115. [PMID: 33216275 PMCID: PMC7864823 DOI: 10.1007/s11102-020-01103-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The efficacy of levoketoconazole in treating hypercortisolism was demonstrated in an open-label phase 3 study (SONICS) of adults with endogenous Cushing's syndrome (CS) and baseline mean urinary free cortisol (mUFC) ≥ 1.5× ULN. Clinical signs and symptoms and patient-reported outcomes from the SONICS trial were evaluated in the current manuscript. METHODS Patients titrated to an individualized therapeutic dose entered a 6-month maintenance phase. Secondary endpoints included investigator-graded clinical signs and symptoms of CS during the maintenance phase, and patient-reported quality of life (CushingQoL questionnaire) and depression symptoms (Beck Depression Inventory II [BDI-II]). RESULTS Of 94 enrolled patients, 77 entered the maintenance phase following individualized dose titration. Significant mean improvements from baseline were noted at end of maintenance (Month 6) for acne, hirsutism (females only), and peripheral edema. These improvements were observed as early as Day 1 of maintenance for hirsutism (mean baseline score, 7.8; ∆ - 1.9; P < 0.0001), end of Month 1 for acne (mean baseline score, 2.8; ∆ - 1.2; P = 0.0481), and Month 4 for peripheral edema (mean baseline score, 1.0; ∆ - 0.5; P = 0.0052). Significant mean improvements from baseline were observed by Month 3 of maintenance for CushingQoL (mean baseline score, 44.3; ∆ + 6.9; P = 0.0018) and at Month 6 for BDI-II (mean baseline score, 17.1; ∆ - 4.3; P = 0.0043) scores. No significant mean improvement was identified in a composite score of 7 other clinical signs and symptoms. CONCLUSIONS Treatment with levoketoconazole was associated with sustained, meaningful improvements in QoL, depression, and certain clinical signs and symptoms characteristic of CS. ClinialTrials.gov identifier: NCT01838551.
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Affiliation(s)
- Eliza B Geer
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | | | | | | | | | - Przemyslaw Witek
- Department of Internal Diseases, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | | | - Marie Bex
- University Hospitals Leuven, Leuven, Belgium
| | - Stina W Borresen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Soraya Puglisi
- Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | | | | | - Francesca Pecori Giraldi
- Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano IRCCS, Milan, Italy
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Newman C, Costello M, Casey M, Davern R, Dinneen K, Lowery A, McHale T, O’Shea PM, Quinn AM, Bell M. A case of adrenal Cushing's syndrome and primary hyperparathyroidism due to an atypical parathyroid adenoma. Ther Adv Endocrinol Metab 2021; 12:20420188211030160. [PMID: 34377432 PMCID: PMC8326812 DOI: 10.1177/20420188211030160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/16/2021] [Indexed: 11/17/2022] Open
Abstract
Cushing's syndrome is a rare disorder of cortisol excess and is associated with significant morbidity and mortality. Hypercalcaemia due to hyperparathyroidism is a common condition; however, in 10% of young patients, it is associated with other endocrinopathies and occurs due to a genetic variant [e.g. multiple endocrine neoplasia (MEN) type 1 (MEN1), MEN2 or MEN4]. We report the case of a 31-year-old woman who was referred to the endocrinology out-patient service with an 8-month history of hirsutism, amenorrhoea and weight gain. Her biochemical work up was significant for adrenocorticotropic hormone (ACTH)-independent Cushing's syndrome. Radiological investigations revealed an adrenal adenoma. During investigation she was also found to have primary hyperparathyroidism due to a parathyroid adenoma. Pre-operatively, the patient was commenced on metyrapone and both her adrenal and parathyroid lesions were resected successfully. There were several concerning findings on initial examination of the parathyroid tumour, including possible extension of the tumour through the capsule and vascular invasion; however, following extensive review, it was ultimately defined as an adenoma. Given the unusual presence of two endocrinopathies in a young patient, she subsequently underwent genetic testing. Analysis of multiple genes did not reveal any pathogenic variants. The patient is currently clinically well, with a normal adjusted calcium and no clinical features of cortisol excess. She will require long-term follow up for recurrence of both hypercalcaemia and hypercortisolaemia.
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Affiliation(s)
| | - Maria Costello
- College of Nursing, Midwifery, Medicine and Health Science, National University of Ireland, Galway, Galway, Ireland
- Department of Endocrinology, Galway University Hospital, Ireland
| | - Mary Casey
- Department of Pathology, Galway University Hospital, Galway, Ireland
| | - Recie Davern
- Department of Endocrinology, Galway University Hospital, Galway, Ireland
| | - Kate Dinneen
- Department of Pathology, Galway University Hospital, Galway, Ireland
| | - Aoife Lowery
- Department of Endocrine Surgery, Galway University Hospital, Galway, Ireland
| | - Teresa McHale
- Department of Pathology, Galway University Hospital, Galway, Ireland
| | - Paula M O’Shea
- Department of Clinical Biochemistry, Galway University Hospital, Galway, Ireland
| | - Anne M Quinn
- Department of Pathology, Galway University Hospital, Galway, Ireland
| | - Marcia Bell
- Department of Endocrinology, Galway University Hospital, Galway, Ireland
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Yamamoto M, Nakao T, Ogawa W, Fukuoka H. Aggressive Cushing's Disease: Molecular Pathology and Its Therapeutic Approach. Front Endocrinol (Lausanne) 2021; 12:650791. [PMID: 34220707 PMCID: PMC8242934 DOI: 10.3389/fendo.2021.650791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022] Open
Abstract
Cushing's disease is a syndromic pathological condition caused by adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas (ACTHomas) mediated by hypercortisolemia. It may have a severe clinical course, including infection, psychiatric disorders, hypercoagulability, and metabolic abnormalities, despite the generally small, nonaggressive nature of the tumors. Up to 20% of ACTHomas show aggressive behavior, which is related to poor surgical outcomes, postsurgical recurrence, serious clinical course, and high mortality. Although several gene variants have been identified in both germline and somatic changes in Cushing's disease, the pathophysiology of aggressive ACTHomas is poorly understood. In this review, we focused on the aggressiveness of ACTHomas, its pathology, the current status of medical therapy, and future prospects. Crooke's cell adenoma (CCA), Nelson syndrome, and corticotroph pituitary carcinoma are representative refractory pituitary tumors that secrete superphysiological ACTH. Although clinically asymptomatic, silent corticotroph adenoma is an aggressive ACTH-producing pituitary adenoma. In this review, we summarize the current understanding of the pathophysiology of aggressive ACTHomas, including these tumors, from a molecular point of view based on genetic, pathological, and experimental evidence. The treatment of aggressive ACTHomas is clinically challenging and usually resistant to standard treatment, including surgery, radiotherapy, and established medical therapy (e.g., pasireotide and cabergoline). Temozolomide is the most prescribed pharmaceutical treatment for these tumors. Reports have shown that several treatments for patients with refractory ACTHomas include chemotherapy, such as cyclohexyl-chloroethyl-nitrosourea combined with 5-fluorouracil, or targeted therapies against several molecules including vascular endothelial growth factor receptor, cytotoxic T lymphocyte antigen 4, programmed cell death protein 1 (PD-1), and ligand for PD-1. Genetic and experimental evidence indicates that some possible therapeutic candidates are expected, such as epidermal growth factor receptor tyrosine kinase inhibitor, cyclin-dependent kinase inhibitor, and BRAF inhibitor. The development of novel treatment options for aggressive ACTHomas is an emerging task.
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Affiliation(s)
- Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | | | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
- *Correspondence: Hidenori Fukuoka,
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Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
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Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
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Pivonello R, Fleseriu M, Newell-Price J, Bertagna X, Findling J, Shimatsu A, Gu F, Auchus R, Leelawattana R, Lee EJ, Kim JH, Lacroix A, Laplanche A, O'Connell P, Tauchmanova L, Pedroncelli AM, Biller BMK. Efficacy and safety of osilodrostat in patients with Cushing's disease (LINC 3): a multicentre phase III study with a double-blind, randomised withdrawal phase. Lancet Diabetes Endocrinol 2020; 8:748-761. [PMID: 32730798 DOI: 10.1016/s2213-8587(20)30240-0] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cushing's disease is a rare endocrine disorder characterised by cortisol overproduction with severe complications. Therapies for cortisol reduction are often necessary. Here we report the outcomes from the pivotal phase III study of osilodrostat (a potent oral inhibitor of cytochrome P450 11B1, mitochondrial [11β-hydroxylase]; Novartis Pharma AG, Basel, Switzerland) in patients with Cushing's disease. METHODS LINC 3 was a prospective, multicentre, open-label, phase III study with a double-blind randomised withdrawal period, that comprised four periods. Patients aged 18-75 years, with confirmed persistent or recurrent Cushing's disease (defined as mean 24-h urinary free cortisol [UFC] concentration >1·5 times the upper limit of normal [ULN] and morning plasma adrenocorticotropic hormone above the lower limit of normal) who had previously had pituitary surgery or irradiation, or were newly diagnosed and who refused surgery or were not surgical candidates, were recruited from 66 hospital sites and private clinical practices in 19 countries. In period 1, open-label osilodrostat was initiated in all participants and adjusted every 2 weeks (1-30 mg twice daily; film-coated tablets for oral administration) on the basis of mean 24-h UFC concentration and safety until week 12. In period 2, weeks 13-24, osilodrostat was continued at the therapeutic dose determined during period 1. In period 3, beginning at week 26, participants who had a mean 24-h UFC concentration of less than or equal to the ULN at week 24, without up-titration after week 12, were randomly assigned (1:1), via an interactive-response technology, stratified by osilodrostat dose at week 24 and history of pituitary irradiation, to continue osilodrostat or switch to placebo for 8 weeks. Participants and investigators were masked to treatment assignment. Ineligible participants continued open-label osilodrostat. In period 4, weeks 35-48, all participants were given open-label osilodrostat until core-study end. The primary objective was to compare the efficacy of osilodrostat versus placebo at the end of period 3. The primary endpoint was the proportion of participants who had been randomly assigned to treatment or placebo with a complete response (ie, mean 24-h UFC concentration of ≤ULN) at the end of the randomised withdrawal period (week 34), without up-titration during this period. The key secondary endpoint was the proportion of participants with a complete response at the end of the single-arm, open-label period (ie, period 2, week 24) without up-titration during weeks 13-24. Analysis was by intention-to-treat for all patients who received at least one dose of osilodrostat (full analysis set; key secondary endpoint) or randomised treatment (randomised analysis set; primary endpoint) and safety was assessed in all enrolled patients who received at least one dose of osilodrostat and had at least one post-baseline safety assessment. LINC 3 is registered with ClinicalTrials.gov, NCT02180217, and is now complete. FINDINGS Between Nov 12, 2014, and March 22, 2017, 202 patients were screened and 137 were enrolled. The median age was 40·0 years (31·0-49·0) and 106 (77%) participants were female. 72 (53%) participants were eligible for randomisation during the withdrawal phase, of whom 36 were assigned to continue osilodrostat and 35 were assigned to placebo; one patient was not randomly assigned due to investigator decision and continued open-label osilodrostat. More patients maintained a complete response with osilodrostat versus with placebo at week 34 (31 [86%] vs ten [29%]; odds ratio 13·7 [95% CI 3·7-53·4]; p<0·0001). At week 24, 72 (53%; 95% CI 43·9-61·1) of 137 patients maintained a complete response without up-titration after week 12. Most common adverse events (ie, occurred in >25% of participants) were nausea (57 [42%]), headache (46 [34%]), fatigue (39 [28%]), and adrenal insufficiency (38 [28%]). Hypocortisolism occurred in 70 (51%) patients and adverse events related to adrenal hormone precursors occurred in 58 (42%) patients. One patient died, unrelated to study drug, after the core study phase. INTERPRETATION Twice-daily osilodrostat rapidly reduced mean 24-h UFC and sustained this reduction alongside improvements in clinical signs of hypercortisolism; it was also generally well tolerated. Osilodrostat is an effective new treatment option that is approved in Europe for the treatment of endogenous Cushing's syndrome and in the USA for Cushing's disease. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.
| | - Maria Fleseriu
- Northwest Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - Xavier Bertagna
- Department of Endocrinology, Centre de Référence des Maladies Rares de la Surrénale, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris 5, Paris, France
| | - James Findling
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan; Advanced Medical Care Center, Kusatsu General Hospital, Kusatsu, Japan
| | - Feng Gu
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
| | - Richard Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | | | - Eun Jig Lee
- Pituitary Tumor Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - André Lacroix
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | | | | | | | - Beverly M K Biller
- Neuroendocrine and Pituitary Tumor Clinical Center, Massachusetts General Hospital, Boston, MA, USA
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Tanaka T, Satoh F, Ujihara M, Midorikawa S, Kaneko T, Takeda T, Suzuki A, Sato M, Shimatsu A. A multicenter, phase 2 study to evaluate the efficacy and safety of osilodrostat, a new 11β-hydroxylase inhibitor, in Japanese patients with endogenous Cushing's syndrome other than Cushing's disease. Endocr J 2020; 67:841-852. [PMID: 32378529 DOI: 10.1507/endocrj.ej19-0617] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This phase 2, single-arm, open-label, dose-titration, multicenter study evaluated osilodrostat (11β-hydroxylase inhibitor) in Japanese patients with endogenous Cushing's syndrome (CS) caused by adrenal tumor/hyperplasia or ectopic adrenocorticotropic hormone syndrome. The primary endpoint was percent change from baseline to week 12 in mean urinary free cortisol (mUFC) at the individual patient level. Of the nine patients enrolled in the study, seven completed the 12-week core treatment period and two discontinued at or prior to week 12 due to adverse events (AEs). Of the seven patients who completed 12 weeks of study treatment, two completed 48 weeks of study treatment. Median osilodrostat exposure was 12 weeks. Median (range) average dose including dose interruption (0 mg/day) was 2.143 (1.16-7.54) mg/day. Median (range, population) percentage change in mUFC was -94.47% (-99.0% to -52.6%, n = 7) at week 12. At week 12, 6/9 patients were complete responders (mUFC ≤ upper limit of normal [ULN]) and 1/9 was a partial responder (mUFC > ULN but decreased by ≥50% from baseline). Most frequent AEs were adrenal insufficiency (n = 7), gamma-glutamyl transferase increase, malaise, and nasopharyngitis (n = 3 each). Serious AEs were seen in four patients. No deaths occurred in this study. In conclusion, osilodrostat treatment led to a reduction in mUFC in all nine patients with endogenous CS other than Cushing's disease (CD), regardless of disease type, with >80% reduction seen in 6/7 patients at week 12. The safety profile was consistent with previous reports in CD patients, and the reported AEs were manageable.
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Affiliation(s)
- Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University Hospital/Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai 980-8574, Japan
| | - Makoto Ujihara
- Department of Internal Medicine, National Hospital Organization Yokohama Medical Center, Yokohama 245-8575, Japan
| | - Sanae Midorikawa
- Department of Radiation Health Management, Fukushima Medical University School of Medicine, Fukushima 960-1295, Japan
| | - Tomomi Kaneko
- Global Drug Development Division, Novartis Pharma K.K., Tokyo 105-6333, Japan
| | - Tamami Takeda
- Global Drug Development Division, Novartis Pharma K.K., Tokyo 105-6333, Japan
| | - Akina Suzuki
- Global Drug Development Division, Novartis Pharma K.K., Tokyo 105-6333, Japan
| | - Masahiko Sato
- Global Drug Development Division, Novartis Pharma K.K., Tokyo 105-6333, Japan
| | - Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555/Advanced Medical Care Center, Kusatsu General Hospital, Kusatsu 525-8585, Japan
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Bojoga A, Koot A, Bonenkamp J, de Wilt J, IntHout J, Stalmeier P, Hermens R, Smit J, Ottevanger P, Netea-Maier R. The Impact of the Extent of Surgery on the Long-Term Outcomes of Patients with Low-Risk Differentiated Non-Medullary Thyroid Cancer: A Systematic Meta-Analysis. J Clin Med 2020; 9:jcm9072316. [PMID: 32708218 PMCID: PMC7408649 DOI: 10.3390/jcm9072316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/10/2020] [Indexed: 12/15/2022] Open
Abstract
Recently, the management of patients with low-risk differentiated non-medullary thyroid cancer (DTC), including papillary and follicular thyroid carcinoma subtypes, has been critically appraised, questioning whether these patients might be overtreated without a clear clinical benefit. The American Thyroid Association (ATA) guideline suggests that thyroid lobectomy (TL) could be a safe alternative for total thyroidectomy (TT) in patients with DTC up to 4 cm limited to the thyroid, without metastases. We conducted a meta-analysis to assess the clinical outcomes in patients with low-risk DTC based on the extent of surgery. The risk ratio (RR) of recurrence rate, overall survival (OS), disease-free survival (DFS) and disease specific survival (DSS) were estimated. In total 16 studies with 175,430 patients met the inclusion criteria. Overall, low recurrence rates were observed for both TL and TT groups (7 vs. 7%, RR 1.10, 95% CI 0.61-1.96, I2 = 72%), and no statistically significant differences for OS (TL 94.1 vs. TT 94.4%, RR 0.99, CI 0.99-1.00, I2 = 53%), DFS (TL 87 vs. TT 91%, RR 0.96, CI 0.89-1.03, I2 = 85%), and DSS (TL 97.2 vs. TT 95.4%, RR 1.01, CI 1.00-1.01, I2 = 74%). The high degree of heterogeneity of the studies is a notable limitation. Conservative management and appropriate follow-up instead of bilateral surgery would be justifiable in selected patients. These findings highlight the importance of shared-decision making in the management of patients with small, low-risk DTC.
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Affiliation(s)
- Andreea Bojoga
- National Institute of Endocrinology “C.I. Parhon”, 011863 Bucharest, Romania;
| | - Anna Koot
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.I.); (P.S.)
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.S.); (R.N.-M.)
- Correspondence: ; Tel.: +31-651-637-081
| | - Johannes Bonenkamp
- Department of Surgical Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.B.); (J.d.W.)
| | - Johannes de Wilt
- Department of Surgical Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.B.); (J.d.W.)
| | - Joanna IntHout
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.I.); (P.S.)
| | - Peep Stalmeier
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.I.); (P.S.)
| | - Rosella Hermens
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands;
| | - Johannes Smit
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.S.); (R.N.-M.)
| | - Petronella Ottevanger
- Department of Internal Medicine, Division of Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Romana Netea-Maier
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.S.); (R.N.-M.)
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Abstract
Pituitary tumors are not rare if prevalence rates from autopsy or radiological series are considered; approximately 0.5% of all pituitary adenomas will come to medical attention. Less than 0.1% of these pituitary adenomas will become malignant, and probably around 0.5% of all detected adenomas will display an aggressive course. However, the exact incidence of both aggressive pituitary adenomas and pituitary carcinomas is unknown, as most data come from series with selected patients, such as surgically treated patients, which is likely not a reflection of all patients with a pituitary adenoma. An aggressive pituitary adenoma is not well-defined; even though an overarching definition, capturing both immunohistochemical and clinical characteristics is probably not waterproof, adoption of a widely accepted definition will be very helpful to harmonize research and establish more reliable epidemiological data.
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Affiliation(s)
- Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands.
- Department of Endocrinology, Leiden University Medical Center, Leiden, Netherlands.
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alberto M Pereira
- Department of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Center for Endocrine Tumors, Leiden University Medical Center, Leiden, Netherlands
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Ragnarsson O. Cushing's syndrome - Disease monitoring: Recurrence, surveillance with biomarkers or imaging studies. Best Pract Res Clin Endocrinol Metab 2020; 34:101382. [PMID: 32139169 DOI: 10.1016/j.beem.2020.101382] [Citation(s) in RCA: 8] [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] [Indexed: 12/18/2022]
Abstract
Pituitary surgery is the first-line treatment for patients with Cushing's disease. For patients who are not considered candidates for pituitary surgery, pituitary radiation and bilateral adrenalectomy are further treatment alternatives. Not all patients are cured with pituitary surgery, and a substantial number of patients develop recurrence, sometimes many years after an apparently successful treatment. The same applies to patients treated with radiotherapy. Far from all patients are cured, and in many cases the disease recurs. Bilateral adrenalectomy, although always curative, causes chronic adrenal insufficiency and the remaining pituitary tumour can continue to grow and cause symptoms due to pressure on adjacent tissues, a phenomenon called Nelson's syndrome. In this paper the rate of recurrence of hypercortisolism, as well as the rate of development of Nelson's syndrome, following treatment of patients with Cushing's syndrome, will be reviewed. The aim of the paper is also to summarize clinical and biochemical factors that are associated with recurrence of hypercortisolism and how the patients should be monitored following treatment.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, SE-41302, Sweden.
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Pivonello R, Ferrigno R, De Martino MC, Simeoli C, Di Paola N, Pivonello C, Barba L, Negri M, De Angelis C, Colao A. Medical Treatment of Cushing's Disease: An Overview of the Current and Recent Clinical Trials. Front Endocrinol (Lausanne) 2020; 11:648. [PMID: 33363514 PMCID: PMC7753248 DOI: 10.3389/fendo.2020.00648] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022] Open
Abstract
Cushing's disease (CD) is a serious endocrine disorder characterized by chronic hypercortisolism, or Cushing's syndrome (CS), caused by a corticotroph pituitary tumor, which induces an excessive adrenocorticotropic hormone (ACTH) and consequently cortisol secretion. CD presents a severe clinical burden, with impairment of the quality of life and increase in mortality. Pituitary surgery represents the first-line therapy, but it is non-curative in one third of patients, requiring additional treatments. Among second-line treatments, medical therapy is gradually gaining importance, although the current medical treatments are unable to reach optimal efficacy and safety profile. Therefore, new drugs and new formulations of presently available drugs are currently under clinical investigation in international clinical trials, in order to assess their efficacy and safety in CD, or in the general population of CS. Among pituitary-directed agents, pasireotide, in the twice-daily subcutaneous formulation, has been demonstrated to be an effective treatment both in clinical trials and in real-world studies, and extension studies of the phase II and III clinical trials reported evidence of long-term efficacy with general good safety profile, although associated with frequent hyperglycemia, which requires monitoring of glucose metabolism. Moreover, the most recent once-monthly intramuscular formulation, pasireotide long-acting release (LAR), showed similar efficacy and safety, but associated with potential better compliance profile in CD. Roscovitine is an experimental drug currently under investigation. Among adrenal-directed agents, metyrapone is the only historical agent currently under investigation in a prospective, multicenter, international clinical trial, that would likely clarify its efficacy and safety in a large population of patients with CS. Osilodrostat, a novel agent with a mechanism of action similar to metyrapone, seems to offer a rapid, sustained, and effective disease control of CD, according to recently completed clinical trials, whereas levoketoconazole, a different chemical formulation of the historical agent ketoconazole, is still under investigation in clinical trials, with preliminary evidences showing an effective and safe control of CS. ATR-101 is an experimental drug currently under investigation. Among glucocorticoid receptor-directed drugs, mifepristone has been demonstrated to improve clinical syndrome and comorbidities, especially hypertension and impairment of glucose metabolism, but the occurrence of hypokalemia and in women uterine disorders, due to the concomitant action on progestin receptor, requires caution, whereas the preliminary evidence on relacorilant, characterized by high selectivity for glucocorticoid receptor, suggested good efficacy in the control of hypertension and impairment of glucose metabolism, as well as a good safety profile, in CS. Finally, a limited experience has demonstrated that combination therapy might be an interesting approach in the management of CD. The current review provides a summary of the available evidences from current and recent clinical trials on CD, with a specific focus on preliminary data.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Nicola Di Paola
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Livia Barba
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Mariarosaria Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Cristina De Angelis
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
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Abstract
Cushing's disease (CD) is caused by a pituitary tumour that secretes adrenocorticotropin (ACTH) autonomously, leading to excess cortisol secretion from the adrenal glands. The condition is associated with increased morbidity and mortality that can be mitigated by treatments that result in sustained endocrine remission. Transsphenoidal pituitary surgery (TSS) remains the mainstay of treatment for CD but requires considerable neurosurgical expertise and experience in order to optimize patient outcomes. Up to 90% of patients with microadenomas (tumour below 1 cm in largest diameter) and 65% of patients with macroadenomas (tumour at or above 1 cm in greatest diameter) achieve endocrine remission after TSS by an experienced surgeon. Patients who are not in remission postoperatively or those who relapse may benefit from undergoing a second pituitary operation. Alternatively, radiation therapy to the sella with interim medical therapy, or bilateral adrenalectomy, can be effective as definitive treatments of CD. Medical therapy is currently adjunctive in most patients with CD and is generally prescribed to patients who are about to receive radiation therapy and will be awaiting its salutary effects to occur. Available treatment options include steroidogenesis inhibitors, centrally acting agents and glucocorticoid receptor antagonists. Several novel agents are in clinical trials and may eventually constitute additional treatment options for this serious condition.
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Affiliation(s)
- N A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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50
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From the Champion to the Team: New Treatment Paradigms in Contemporary Neurosurgery. World Neurosurg 2019; 131:141-148. [DOI: 10.1016/j.wneu.2019.07.196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 12/26/2022]
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