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Pecori Giraldi F, Ferraù F, Ragonese M, Cannavò S. Endocrine disruptors, aryl hydrocarbon receptor and cortisol secretion. J Endocrinol Invest 2024; 47:2407-2419. [PMID: 38637430 PMCID: PMC11393124 DOI: 10.1007/s40618-024-02371-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: 12/21/2023] [Accepted: 03/29/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE Endocrine disruptors exert a plethora of effects in endocrine tissues, from altered function to carcinogenesis. Given its lipophilic nature, the adrenal cortex represents an ideal target for endocrine disruptors and thus, possibly, xenobiotic-induced adrenocortical dysfunction. However, there is no clear understanding of the effect of endocrine disruptors on adrenal steroidogenesis, in particular as regards the aryl hydrocarbon receptor (AHR) pathway, one of the key mediators. METHODS The present review recapitulates available evidence on the effects of AHR ligands on adrenal steroidogenesis, with focus on cortisol secretion. RESULTS Short-term exposure to AHR ligands most often induced a stress-like corticosteroid response followed by decreased responsiveness to stressors with long-term exposure. This was observed in several experimental models across species as well as in animals and humans in real-life settings. Prenatal exposure led to different effects according to sex of the offspring, as observed in murine models and in children from mothers in several countries. In vitro findings proved highly dependent on the experimental setting, with reduced cortisol response and steroidogenic enzyme synthesis mostly observed in fish and increased cortisol synthesis and secretion observed in murine and human adrenal cell lines. Of note, no AHR-binding element was detected in steroidogenic enzyme promoters, suggesting the involvement of additional factors. CONCLUSION Our review provides evidence for the impact of AHR ligands on adrenocortical function and indicates further avenues of research to better clarify its effects.
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Affiliation(s)
- F Pecori Giraldi
- Department of Clinical Sciences and Community Health, University of Milan, Via Commenda 19, Milan, Italy.
| | - F Ferraù
- Department of Human Pathology of Adulthood and Childhood "Gaetano Barresi,", University of Messina, Messina, Italy
| | - M Ragonese
- Department of Human Pathology of Adulthood and Childhood "Gaetano Barresi,", University of Messina, Messina, Italy
| | - S Cannavò
- Department of Human Pathology of Adulthood and Childhood "Gaetano Barresi,", University of Messina, Messina, Italy
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A radiomic signature based on magnetic resonance imaging to determine adrenal Cushing's syndrome. Pol J Radiol 2023; 88:e41-e46. [PMID: 36819225 PMCID: PMC9907166 DOI: 10.5114/pjr.2023.124435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/23/2022] [Indexed: 01/25/2023] Open
Abstract
Purpose The aim of this study was to develop radiomics signature-based magnetic resonance imaging (MRI) to determine adrenal Cushing's syndrome (ACS) in adrenal incidentalomas (AI). Material and methods A total of 50 patients with AI were included in this study. The patients were grouped as nonfunctional adrenal incidentaloma (NFAI) and ACS. The lesions were segmented on unenhanced T1-weighted (T1W) in-phase (IP) and opposed-phase (OP) as well as on T2-weighted (T2-W) 3-Tesla MRIs. The LASSO regression model was used for the selection of potential predictors from 111 texture features for each sequence. The radiomics scores were compared between the groups. Results The median radiomics score in T1W-Op for the NFAI and ACS were -1.17 and -0.17, respectively (p < 0.001). Patients with ACS had significantly higher radiomics scores than NFAI patients in all phases (p < 0.001 for all). The AUCs for radiomics scores in T1W-Op, T1W-Ip, and T2W were 0.862 (95% CI: 0.742-0.983), 0.892 (95% CI: 0.774-0.999), and 0.994 (95% CI: 0.982-0.999), respectively. Conclusion The developed MRI-based radiomic scores can yield high AUCs for prediction of ACS.
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Antonić T, Petrović-Mucok A, Stefanović A. Current challenges in laboratory diagnostics of autonomous cortisol secretion in adrenal incidentalomas. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-36043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Adrenal incidentalomas are unexpectedly identified adrenal masses without prior suspicion of the existence of adrenal disease. The majority of adrenal incidentalomas are benign adrenal adenomas (80-90%), and they are non-functioning adrenocortical adenomas in more than 70% of cases. Mild hypercortisolemia is the most common finding in hormonally active adrenal incidentalomas. It is defined as autonomous cortisol secretion in up to 15% of patients. Despite a lot of research that anticipated higher cardiometabolic risk in patients with autonomous cortisol secretion, there is still no clear consensus on biochemical criteria for an autonomous cortisol secretion diagnosis in patients with adrenal incidentalomas. This review delineates the advantages and limitations of different laboratory tests recommended for the diagnosis of autonomous cortisol secretion in adrenal incidentalomas.
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Pecori Giraldi F, Sesta A, Tapella L, Cassarino MF, Castelli L. Dual effects of 9-cis retinoic acid on ACTH-dependent hyperplastic adrenal tissues. Sci Rep 2021; 11:14315. [PMID: 34253781 PMCID: PMC8275666 DOI: 10.1038/s41598-021-93672-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/04/2021] [Indexed: 12/29/2022] Open
Abstract
Retinoids play a pivotal role in adrenal development and differentiation. Recent clinical trials revealed therapeutic potential of both all-trans and 9-cis retinoic acid in patients with cortisol excess due to a pituitary ACTH-secreting adenoma and indicated that retinoids might act also on the adrenal. Aim of the present study was to evaluate the effect of 9-cis retinoic acid on adrenals from patients with ACTH-dependent Cushing’s syndrome. Adrenal specimens from six patients with Cushing’s disease were incubated with 10 nM–1 µM 9-cis retinoic acid with and without 10 nM ACTH. Cortisol secretion was measured by immunoassay and expression of genes involved in steroidogenesis as well as retinoic acid action were evaluated by real-time RT-PCR. Incubation with 10–100 nM 9-cis retinoic acid increased spontaneous cortisol secretion and expression of STAR and CYP17A. On the other hand, in wells treated with ACTH, 9-cis retinoic acid markedly diminished ACTH receptor upregulation and no stimulatory effect on cortisol secretion or steroidogenic enzyme synthesis was observed. ACTH itself increased ligand-induced retinoic acid receptor expression, possibly enhancing sensitivity to retinoic acid. Our findings indicate that the effect of 9-cis retinoic acid in presence of ACTH is distinct from unchallenged wells and support the hypothesis of a direct adrenal action in patients with Cushing’s disease.
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Affiliation(s)
- Francesca Pecori Giraldi
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy. .,Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano IRCCS, Via Zucchi 18, 20095, Cusano Milanino, MI, Italy.
| | - Antonella Sesta
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano IRCCS, Via Zucchi 18, 20095, Cusano Milanino, MI, Italy
| | - Laura Tapella
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano IRCCS, Via Zucchi 18, 20095, Cusano Milanino, MI, Italy
| | - Maria Francesca Cassarino
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano IRCCS, Via Zucchi 18, 20095, Cusano Milanino, MI, Italy
| | - Luigi Castelli
- Ospedale San Carlo, Reparto di Chirurgia, 20037, Paderno Dugnano, MI, Italy
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Casals G, Hanzu FA. Cortisol Measurements in Cushing's Syndrome: Immunoassay or Mass Spectrometry? Ann Lab Med 2020; 40:285-296. [PMID: 32067427 PMCID: PMC7054699 DOI: 10.3343/alm.2020.40.4.285] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/20/2019] [Accepted: 02/07/2020] [Indexed: 11/19/2022] Open
Abstract
Determination of cortisol levels in the urine (24 hours urine free cortisol), saliva (late-night), or serum (total cortisol after dexamethasone suppression) is recommended to screen for Cushing's syndrome (CS). This review focuses on the differences between the frequently used cortisol-antibody immunoassay-based methods and the highly specific mass-spectrometry-based methods that are progressively being employed in clinical laboratories for CS screening. The particular characteristics of cortisol metabolism and the lack of specificity of the immunoassays cause marked differences between both methods that are in turn highly dependent on the biological matrix, in which the cortisol is measured. Understanding the origin of these differences is essential for the interpretation of these results. Although cross-reactivity with endogenous steroids leads to grossly inaccurate results of immunoassay measurements of cortisol in the saliva and urine, preliminary evidence suggests that the clinical sensitivity of CS screening using immunoassays may be similar to CS screening using mass spectrometry. However, mass spectrometry offers more accurate results and considerably reduced variation across laboratories, while avoiding false-positive results. Moreover, mass spectrometry can overcome some common diagnostic challenges, such as identification of exogenous corticosteroids or simultaneous assessment of appropriate dexamethasone levels in suppression tests. Further, comprehensive mass spectrometry-based profiling of several steroid metabolites may be useful for discriminating among different subtypes of CS. Finally, this review discusses the main preanalytical factors that could cause variations in cortisol measurements and their influence on the reliability of the results.
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Affiliation(s)
- Gregori Casals
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centrode Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), ISCIII, Madrid, Spain.
| | - Felicia Alexandra Hanzu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain.,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Chen AX, Haas AV, Williams GH, Vaidya A. Dietary sodium intake and cortisol measurements. Clin Endocrinol (Oxf) 2020; 93:539-545. [PMID: 32511774 PMCID: PMC7859973 DOI: 10.1111/cen.14262] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/09/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the influence of a dietary sodium intake intervention on cortisol measurements within the general population. DESIGN Cross-over intervention. PATIENTS Six hundred thirty adults without known Cushing syndrome, cardiovascular or renal disease completed a restricted dietary sodium diet (10 mmol/d, 230 mg/d) followed by cross-over to a liberalized dietary sodium diet (200 mmol/d, 4600 mg/d). Twenty-four-hour urine collection and biochemical investigations were performed at the end of each dietary intervention. RESULTS Mean 24-hour urinary free cortisol increased with liberalized sodium intake when compared with restricted sodium intake (178.0 ± 89.7 vs 121.3 ± 65.6 nmol/d, P < .001). Nearly all participants (84%) had an increase in the urinary free cortisol following liberalized sodium intake. This translated to a substantial difference in the proportion of participants exceeding categorical thresholds of urinary cortisol on liberalized vs restricted sodium intake: 62% vs 27% for 138 nmol/d (50 mcg/d), 46% vs 17% for 166 nmol/d (60 mcg/d), 32% vs 10% for 193 nmol/d (70 mcg/d), 23% vs 6% for 221 nmol/d (80 mcg/d), 17% vs 4% for 248 nmol/d (90 mcg/d). In parallel, there was a small decrease in morning total serum cortisol with liberalized sodium intake (303.0 ± 117.3 vs 326.4 ± 162.5 nmol/L, P < .001). CONCLUSIONS Increased dietary sodium intake increases urinary free cortisol excretion and may increase the risk for false-positive results. Variations in dietary sodium intake may influence the interpretations of cortisol measurements performed to evaluate for hypercortisolism.
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Affiliation(s)
- Angela X Chen
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department Endocrinology, Flinders Medical Centre, Bedford Park, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, Australia
| | - Andrea V. Haas
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gordon H. Williams
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anand Vaidya
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Pecori Giraldi F, Cassarino MF, Sesta A, Terreni M, Lasio G, Losa M. Sexual Dimorphism in Cellular and Molecular Features in Human ACTH-Secreting Pituitary Adenomas. Cancers (Basel) 2020; 12:E669. [PMID: 32183012 PMCID: PMC7139870 DOI: 10.3390/cancers12030669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022] Open
Abstract
(1) Background. Cushing's disease presents gender disparities in prevalence and clinical course. Little is known, however, about sexual dimorphism at the level of the corticotrope adenoma itself. The aim of the present study was to evaluate molecular features of ACTH-secreting pituitary adenomas collected from female and male patients with Cushing's disease. (2) Methods. We analyzed 153 ACTH-secreting adenomas collected from 31 men and 122 women. Adenomas were established in culture and ACTH synthesis and secretion assessed in basal conditions as well as during incubation with CRH or dexamethasone. Concurrently, microarray analysis was performed on formalin-fixed specimens and differences in the expression profiles between specimens from male and female patients identified. (3) Results. ACTH medium concentrations in adenomas obtained from male patients were significantly lower than those observed in adenomas from female patients. This could be observed for baseline as well as modulated secretion. Analysis of corticotrope transcriptomes revealed considerable similarities with few, selected differences in functional annotations. Differentially expressed genes comprised genes with known sexual dimorphism, genes involved in tumour development and genes relevant to pituitary pathophysiology. (4) Conclusions. Our study shows for the first time that human corticotrope adenomas present sexual dimorphism and underlines the need for a gender-dependent analysis of these tumours. Differentially expressed genes may represent the basis for gender-tailored target therapy.
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Affiliation(s)
- Francesca Pecori Giraldi
- Department of Clinical Sciences & Community Health, University of Milan; 20122 Milan, Italy
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricerca e Cura a Carattere Scientifico, 20095 Milan, Italy
| | - Maria Francesca Cassarino
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricerca e Cura a Carattere Scientifico, 20095 Milan, Italy
| | - Antonella Sesta
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricerca e Cura a Carattere Scientifico, 20095 Milan, Italy
| | | | - Giovanni Lasio
- Deparment of Neurosurgery, Istituto Clinico Humanitas, 20089 Rozzano (Milan), Italy;
| | - Marco Losa
- Department of Neurosurgery, Ospedale San Raffaele, 20136 Milan, Italy;
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Sesta A, Cassarino MF, Terreni M, Ambrogio AG, Libera L, Bardelli D, Lasio G, Losa M, Pecori Giraldi F. Ubiquitin-Specific Protease 8 Mutant Corticotrope Adenomas Present Unique Secretory and Molecular Features and Shed Light on the Role of Ubiquitylation on ACTH Processing. Neuroendocrinology 2019; 110:119-129. [PMID: 31280266 PMCID: PMC6979434 DOI: 10.1159/000500688] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Somatic mutations in the ubiquitin-specific protease 8 (USP8) gene have recently been shown to occur in ACTH-secreting pituitary adenomas, thus calling attention to the ubiquitin system in corticotrope adenomas. OBJECTIVES Assess the consequences of USP8 mutations and establish the role of ubiquitin on ACTH turnover in human ACTH-secreting pituitary adenomas. METHODS USP8 mutation status was established in 126 ACTH-secreting adenomas. Differences in ACTH secretion and POMC expression from adenoma primary cultures and in microarray gene expression profiles from archival specimens were sought according to USP8 sequence. Ubiquitin/ACTH coimmunoprecipitation and incubation with MG132, a proteasome inhibitor, were performed in order to establish whether ubiquitin plays a role in POMC/ACTH degradation in corticotrope adenomas. RESULTS USP8 mutations were identified in 29 adenomas (23%). Adenomas presenting USP8 mutations secreted greater amounts of ACTH and expressed POMC at higher levels compared to USP wild-type specimens. USP8 mutant adenomas were also more sensitive to modulation by CRH and dexamethasone in vitro. At microarray analysis, genes associated with endosomal protein degradation and membrane components were downregulated in USP8 mutant adenomas as were AVPR1B, IL11RA, and PITX2. Inhibition of the ubiquitin-proteasome pathway increased ACTH secretion and POMC itself proved a target of ubiquitylation, independently of USP8 sequence status. CONCLUSIONS Our study has shown that USP8 mutant ACTH-secreting adenomas present a more "typical" corticotrope phenotype and reduced expression of several genes associated with protein degradation. Further, ubiquitylation is directly involved in intracellular ACTH turnover, suggesting that the ubiquitin-proteasome system may represent a target for treatment of human ACTH-secreting adenomas.
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Affiliation(s)
- Antonella Sesta
- Istituto Auxologico Italiano IRCCS, Neuroendocrinology Research Laboratory, Cusano Milanino, Milan, Italy
| | - Maria Francesca Cassarino
- Istituto Auxologico Italiano IRCCS, Neuroendocrinology Research Laboratory, Cusano Milanino, Milan, Italy
| | | | - Alberto G Ambrogio
- Istituto Auxologico Italiano IRCCS, Neuroendocrinology Research Laboratory, Cusano Milanino, Milan, Italy
| | - Laura Libera
- Istituto Auxologico Italiano IRCCS, Neuroendocrinology Research Laboratory, Cusano Milanino, Milan, Italy
| | - Donatella Bardelli
- Istituto Auxologico Italiano IRCCS, Neuroendocrinology Research Laboratory, Cusano Milanino, Milan, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Marco Losa
- Department of Neurosurgery, Ospedale San Raffaele, Milan, Italy
| | - Francesca Pecori Giraldi
- Istituto Auxologico Italiano IRCCS, Neuroendocrinology Research Laboratory, Cusano Milanino, Milan, Italy,
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy,
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Verbeeten KC, Ahmet AH. The role of corticosteroid-binding globulin in the evaluation of adrenal insufficiency. J Pediatr Endocrinol Metab 2018; 31:107-115. [PMID: 29194043 DOI: 10.1515/jpem-2017-0270] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/01/2017] [Indexed: 12/29/2022]
Abstract
Cortisol is a hydrophobic molecule that is largely bound to corticosteroid-binding globulin (CBG) in the circulation. In the assessment of adrenal insufficiency, many clinicians measure a total serum cortisol level, which assumes that CBG is present in normal concentrations and with a normal binding affinity for cortisol. CBG concentration and affinity are affected by a number of common factors including oral contraceptive pills (OCPs), fever and infection, as well as rare mutations in the serine protease inhibitor A6 (SERPINA6) gene, and as such, total cortisol levels might not be the ideal way to assess adrenal function in all clinical circumstances. This paper reviews the limitations of immunoassay and liquid chromatography-tandem mass spectrometry (LC-MS/MS) in the measurement of total cortisol, the challenges of measuring free serum cortisol directly as well as the difficulties in calculating an estimated free cortisol from total cortisol, CBG and albumin concentrations. Newer approaches to the evaluation of adrenal insufficiency, including the measurement of cortisol and cortisone in the saliva, are discussed and a possible future role for these tests is proposed.
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10
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Moraitis AG. Nonfunctional Adrenal Adenomas: Truth or Myth? Presentation and Treatment of 2 Patients. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171897.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ambrogio AG, Andrioli M, De Martin M, Cavagnini F, Pecori Giraldi F. Usefulness of desmopressin testing to predict relapse during long-term follow-up in patients in remission from Cushing's disease. Endocr Connect 2017; 6:791-799. [PMID: 29018154 PMCID: PMC5682421 DOI: 10.1530/ec-17-0292] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/08/2022]
Abstract
Recurrence of Cushing's disease after successful transsphenoidal surgery occurs in some 30% of the patients and the response to desmopressin shortly after surgery has been proposed as a marker for disease recurrence. The aim of the present study was to evaluate the response to desmopressin over time after surgery. We tested 56 patients with Cushing's disease in remission after transsphenoidal surgery with desmopressin for up to 20 years after surgery. The ACTH and cortisol response to desmopressin over time was evaluated in patients on long-term remission or undergoing relapse; an increase by at least 27 pg/mL in ACTH levels identified responders. The vast majority of patients who underwent successful adenomectomy failed to respond to desmopressin after surgery and this response pattern was maintained over time in patients on long-term remission. Conversely, a response to desmopressin reappeared in patients who subsequently developed a recurrence of Cushing's disease, even years prior to frank hypercortisolism. It appears therefore that a change in the response pattern to desmopressin proves predictive of recurrence of Cushing's disease and may indicate which patients require close monitoring.
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Affiliation(s)
| | - Massimiliano Andrioli
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Martina De Martin
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesco Cavagnini
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesca Pecori Giraldi
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
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Asuzu D, Chatain GP, Hayes C, Benzo S, McGlotten R, Keil M, Beri A, Sharma ST, Nieman L, Lodish M, Stratakis C, Lonser RR, Oldfield EH, Chittiboina P. Normalized Early Postoperative Cortisol and ACTH Values Predict Nonremission After Surgery for Cushing Disease. J Clin Endocrinol Metab 2017; 102:2179-2187. [PMID: 28323961 PMCID: PMC6283430 DOI: 10.1210/jc.2016-3908] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/06/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Perioperative increases in adrenocorticotropic hormone (ACTH) and cortisol mimic results of corticotropin-releasing hormone (CRH) stimulation testing. This phenomenon may help identify patients with residual adenoma after transsphenoidal surgery (TSS) for Cushing disease (CD). OBJECTIVE To predict nonremission after TSS for CD. DESIGN Retrospective case-control study of patients treated at a single center from December 2003 until July 2016. Early and medium-term remission were assessed at 10 days and 11 months. PATIENTS AND SETTING Two hundred and ninety-one consecutive TSS cases from 257 patients with biochemical evidence of CD seen at a clinical center. INTERVENTIONS Normalized early postoperative values (NEPVs) for cortisol and ACTH were calculated as immediate postoperative cortisol or ACTH levels minus preoperative post-CRH-stimulation test levels. MAIN OUTCOME MEASURES Prediction of early nonremission was evaluated using logistic regression. Prediction of medium-term remission was assessed using Cox regression. Predictive ability was quantified by area under the receiver operating characteristic curve (AUROC). RESULTS NEPVs for cortisol and ACTH predicted early nonremission [adjusted odds ratio (OR): 1.1; 95% confidence interval (CI): 1.0, 1.1; P = 0.016 and adjusted OR: 1.0; 95% CI: 1.0, 1.0; P = 0.048, respectively]. AUROC for NEPV of cortisol was 0.78 (95% CI: 0.61, 0.95); for NEPV of ACTH, it was 0.80 (95% CI: 0.61, 0.98). NEPVs for cortisol and ACTH predicted medium-term nonremission [hazard ratio (HR): 1.1; 95% CI: 1.0, 1.1; P = 0.023 and HR: 1.0; 95% CI: 1.0, 1.0; P = 0.025, respectively]. CONCLUSIONS NEPVs for cortisol and ACTH predicted nonremission after TSS for CD.
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Affiliation(s)
- David Asuzu
- Yale School of Medicine, New Haven, Connecticut 06510
- Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, Bethesda, Maryland 20824
| | - Grégoire P Chatain
- Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, Bethesda, Maryland 20824
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, Bethesda, Maryland 20824
| | - Christina Hayes
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, Bethesda, Maryland 20824
| | - Sarah Benzo
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, Bethesda, Maryland 20824
| | - Raven McGlotten
- Section on Clinical Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20847
| | - Meg Keil
- Section on Endocrinology and Genetics, Developmental Endocrinology Branch, and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20847
| | - Andrea Beri
- NIH Biomedical Translational Research Information System, National Institutes of Health Clinical Center, Bethesda, Maryland 20814
| | - Susmeeta T Sharma
- Pituitary Endocrinology Section, MedStar Washington Hospital Center, Washington, DC 20010
| | - Lynnette Nieman
- Section on Clinical Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20847
| | - Maya Lodish
- Section on Endocrinology and Genetics, Developmental Endocrinology Branch, and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20847
| | - Constantine Stratakis
- Section on Endocrinology and Genetics, Developmental Endocrinology Branch, and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20847
| | - Russell R Lonser
- Department of Neurologic Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio 43202
| | - Edward H Oldfield
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia 22908
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, Bethesda, Maryland 20824
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, Bethesda, Maryland 20824
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Ueland GÅ, Methlie P, Kellmann R, Bjørgaas M, Åsvold BO, Thorstensen K, Kelp O, Thordarson HB, Mellgren G, Løvås K, Husebye ES. Simultaneous assay of cortisol and dexamethasone improved diagnostic accuracy of the dexamethasone suppression test. Eur J Endocrinol 2017; 176:705-713. [PMID: 28298353 DOI: 10.1530/eje-17-0078] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/10/2017] [Accepted: 03/15/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The overnight dexamethasone (DXM) suppression test (DST) has high sensitivity, but moderate specificity, for diagnosing hypercortisolism. We have evaluated if simultaneous measurement of S-DXM may correct for variable DXM bioavailability and increase the diagnostic performance of DST, and if saliva (sa) is a feasible adjunct or alternative to serum. DESIGN AND METHODS Prospective study of DST was carried out in patients with suspected Cushing's syndrome (CS) (n = 49), incidentaloma (n = 152) and healthy controls (n = 101). Cortisol, cortisone and DXM were assayed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS Three hundred and two subjects underwent DST; S-cortisol was ≥50 nmol/L in 83 patients, of whom 11 had CS and 27 had autonomous cortisol secretion. The lower 2.5 percentile of S-DXM in subjects with negative DST (n = 208) was 3.3 nmol/L, which was selected as the DXM cut-off level. Nine patients had the combination of low S-DXM and positive DST. Of these, three had been misdiagnosed as having autonomous cortisol secretion. DST results were highly reproducible and confirmed in a replication cohort (n = 58). Patients with overt CS had significantly elevated post-DST sa-cortisol and sa-cortisone levels compared with controls; 23 of 25 with autonomous cortisol secretion had elevated sa-cortisone and 14 had elevated sa-cortisol. CONCLUSIONS Simultaneous measurement of serum DXM and cortisol reduced false-positive DSTs by 20% and improved the specificity. S-DXM >3.3 nmol/L is sufficient for the suppression of cortisol <50 nmol/L. Measurement of glucocorticoids in saliva is a non-invasive and easy procedure and post-DST sa-cortisone was found particularly useful in the diagnosis of CS.
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Affiliation(s)
- Grethe Å Ueland
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of Medicine
- Department of the Hormone LaboratoryHaukeland University Hospital, Bergen, Norway
| | - Paal Methlie
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of Medicine
| | - Ralf Kellmann
- Department of the Hormone LaboratoryHaukeland University Hospital, Bergen, Norway
| | - Marit Bjørgaas
- Department of EndocrinologySt. Olav's Hospital, Trondheim, Norway
| | - Bjørn O Åsvold
- Department of EndocrinologySt. Olav's Hospital, Trondheim, Norway
- Department of Public Health and General PracticeNorwegian University of Science and Technology, Trondheim, Norway
| | | | - Oskar Kelp
- Department of EndocrinologyAkershus University Hospital, Lørenskog, Norway
| | | | - Gunnar Mellgren
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of the Hormone LaboratoryHaukeland University Hospital, Bergen, Norway
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of Medicine
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of Medicine
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14
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Abstract
PURPOSE OF REVIEW This review focuses on the pathophysiological and clinical aspects of diabetes mellitus occurring in patients with Cushing disease (CD). RECENT FINDINGS Insulin resistance and impairment in insulin secretion are both involved in the pathogenesis of glucocorticoid-induced diabetes. Correction of glucocorticoid excess does not always resolve abnormalities of glucose homeostasis, and correction of hyperglycaemia is specifically required. In fact, insulin resistance may persist even after correction of glucocorticoid excess and diabetes needs to be treated for long term. On the other hand, emerging drugs used in the treatment of CD, such as the novel somatostatin analog pasireotide, may have direct effects on glucose homeostasis regardless of control of cortisol excess. Diabetes mellitus is a frequent and early complication of CD with important diagnostic, prognostic and therapeutic implications. Specifically, diagnosis of CD in patients with diabetes may be difficult due to potential misinterpretation of markers of cortisol hypersecretion. Moreover, diabetes mellitus is often difficult to be controlled in CD requiring a careful and dedicated therapeutic approach. Finally, the coexistence of diabetes may influence the therapeutic decision making in CD, since drugs used in this setting may variably influence glucose homeostasis regardless of control of hypercortisolism.
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Affiliation(s)
- G Mazziotti
- Endocrinology Unit, ASST Carlo Poma, Mantova, Italy
| | - A M Formenti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - S Frara
- Vita-Salute University San Raffaele Milan, Milan, Italy
| | - F Maffezzoni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - M Doga
- Vita-Salute University San Raffaele Milan, Milan, Italy
| | - A Giustina
- Vita-Salute University San Raffaele Milan, Milan, Italy.
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15
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Findling JW, Raff H. DIAGNOSIS OF ENDOCRINE DISEASE: Differentiation of pathologic/neoplastic hypercortisolism (Cushing's syndrome) from physiologic/non-neoplastic hypercortisolism (formerly known as pseudo-Cushing's syndrome). Eur J Endocrinol 2017; 176:R205-R216. [PMID: 28179447 DOI: 10.1530/eje-16-0946] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/20/2017] [Accepted: 02/06/2017] [Indexed: 12/30/2022]
Abstract
Endogenous hypercortisolism (Cushing's syndrome) usually implies the presence of a pathologic condition caused by either an ACTH-secreting neoplasm or autonomous cortisol secretion from a benign or malignant adrenal neoplasm. However, sustained or intermittent hypercortisolism may also accompany many medical disorders that stimulate physiologic/non-neoplastic activation of the HPA axis (formerly known as pseudo-Cushing's syndrome); these two entities may share indistinguishable clinical and biochemical features. A thorough history and physical examination is often the best (and sometimes only) way to exclude pathologic/neoplastic hypercortisolism. The presence of alcoholism, renal failure, poorly controlled diabetes and severe neuropsychiatric disorders should always raise suspicion that the presence of hypercortisolism may be related to physiologic/non-neoplastic Cushing's syndrome. As late-night salivary cortisol and low-dose dexamethasone suppression have good sensitivity and negative predictive value, normal studies exclude Cushing's syndrome of any form. However, these tests have imperfect specificity and additional testing over time with clinical follow-up is often needed. When there is persistent diagnostic uncertainty, secondary tests such as the DDAVP stimulation test and the dexamethasone-CRH test may provide evidence for the presence or absence of an ACTH-secreting tumor. This review will define and characterize the numerous causes of physiologic/non-neoplastic hypercortisolism and provide a rational clinical and biochemical approach to distinguish it from pathologic/neoplastic hypercortisolism (true Cushing's syndrome).
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Affiliation(s)
- James W Findling
- Endocrinology Center and ClinicsMedical College of Wisconsin, Menomonee Falls, Wisconsin, USA
| | - Hershel Raff
- Departments of MedicineSurgery, and Physiology, Medical College of Wisconsin and Endocrine Research Laboratory, Aurora St Luke's Medical Center, Aurora Research Institute, Milwaukee, Wisconsin, USA
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16
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Valassi E, Franz H, Brue T, Feelders RA, Netea-Maier R, Tsagarakis S, Webb SM, Yaneva M, Reincke M, Droste M, Komerdus I, Maiter D, Kastelan D, Chanson P, Pfeifer M, Strasburger CJ, Tóth M, Chabre O, Tabarin A, Krsek M, Fajardo C, Bolanowski M, Santos A, Wass JAH, Trainer PJ. Diagnostic tests for Cushing's syndrome differ from published guidelines: data from ERCUSYN. Eur J Endocrinol 2017; 176:613-624. [PMID: 28377460 DOI: 10.1530/eje-16-0967] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/13/2017] [Accepted: 02/21/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate which tests are performed to diagnose hypercortisolism in patients included in the European Registry on Cushing's syndrome (ERCUSYN), and to examine if their use differs from the current guidelines. PATIENTS AND METHODS We analyzed data on the diagnostic tests performed in 1341 patients with Cushing's syndrome (CS) who have been entered into the ERCUSYN database between January 1, 2000 and January 31, 2016 from 57 centers in 26 European countries. Sixty-seven percent had pituitary-dependent CS (PIT-CS), 24% had adrenal-dependent CS (ADR-CS), 6% had CS from an ectopic source (ECT-CS) and 3% were classified as having CS from other causes (OTH-CS). RESULTS Of the first-line tests, urinary free cortisol (UFC) test was performed in 78% of patients, overnight 1 mg dexamethasone suppression test (DST) in 60% and late-night salivary cortisol (LSaC) in 25%. Use of LSaC increased in the last five years as compared with previous years (P < 0.01). Use of HDDST was slightly more frequent in the last 5 years as compared with previous years (P < 0.05). Of the additional tests, late-night serum cortisol (LSeC) was measured in 62% and 48-h 2 mg/day low-dose dexamethasone suppression test (LDDST) in 33% of cases. ACTH was performed in 78% of patients. LSeC and overnight 1 mg DST supported the diagnosis of both PIT-CS and ADR-CS more frequently than UFC (P < 0.05). CONCLUSIONS Use of diagnostic tests for CS varies across Europe and partly differs from the currently available guidelines. It would seem pertinent that a European consensus be established to determine the best diagnostic approach to CS, taking into account specific inter-country differences with regard to the availability of diagnostic tools.
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Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Holger Franz
- Lohmann & Birkner Health Care Consulting GmbHBerlin, Germany
| | - Thierry Brue
- Aix-Marseille UniversitéCNRS, CRN2M UMR 7286, and APHM, Hôpital Conception, Marseille, France
| | | | | | | | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IVCampus Innestadt, Klinikum der Universität München, München, Germany
| | | | - Irina Komerdus
- Moscow Regional Research Clinical InstituteMoscow, Russia
| | | | - Darko Kastelan
- Department of EndocrinologyUniversity Hospital Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Philippe Chanson
- Univ Paris-SudUniversité Paris-Saclay UMR-S1185, Le Kremlin Bicêtre, Paris, France
- Assistance Publique-Hôpitaux de ParisHôpital de Bicêtre, Service de Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, Paris, France
- Institut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, Paris, France
| | - Marija Pfeifer
- Department of EndocrinologyUniversity Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Christian J Strasburger
- Division of Clinical EndocrinologyDepartment of Medicine CCM, Charité-Universitätsmedizin, Berlin, Germany
| | - Miklós Tóth
- 2nd Department of MedicineSemmelweis University, Budapest, Hungary
| | - Olivier Chabre
- Service d'Endocrinologie-Diabétologie-NutritionGrenoble Cedex, France
| | - Antoine Tabarin
- Centre Hospitalier Universitaire de BordeauxBordeaux, France
| | - Michal Krsek
- 2nd Department of Internal Medicine3rd Faculty of Medicine and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Carmen Fajardo
- Department of EndocrinologyHospital Universitario de la Ribera, Alzira, Spain
| | - Marek Bolanowski
- Department of EndocrinologyDiabetology and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | - Peter J Trainer
- Department of EndocrinologyChristie Hospital, Manchester, UK
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17
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Effect of retinoic acid on human adrenal corticosteroid synthesis. Life Sci 2016; 151:277-280. [PMID: 26979774 DOI: 10.1016/j.lfs.2016.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/08/2016] [Accepted: 03/11/2016] [Indexed: 11/23/2022]
Abstract
AIMS Retinoic acid has recently yielded promising results in the treatment of Cushing's disease, i.e., excess cortisol secretion due to a pituitary corticotropin (ACTH)-secreting adenoma. In addition to its effect on the tumoral corticotrope cell, clinical results suggest an additional adrenal site of action. Aim of this study was to evaluate whether retinoic acid modulates cortisol synthesis and secretion by human adrenals in vitro. MAIN METHODS Primary cultures from 10 human adrenals specimens were incubated with 10nM, 100nM and 1μM retinoic acid with and without 10nM ACTH for 24h. Cortisol levels were measured by radioimmunoassay and CYP11A1, STAR and MC2R gene expression analyzed by real-time PCR. KEY FINDINGS Retinoic acid increased cortisol secretion (149.5±33.01%, 151.3±49.45% and 129.3±8.32% control secretion for 10nM, 100nM and 1μM respectively, p<0.05) and potentiated STAR expression (1.51±0.22, 1.56±0.15 and 1.59±0.14 fold change over baseline, for 10nM, 100nM and 1μM respectively, p<0.05). Concurrently, retinoic acid markedly blunted constitutional and ACTH-induced MC2R expression (0.66±0.11, 0.62±0.08 and 0.53±0.07 fold change over baseline, for 10nM, 100nM and 1μM respectively, p<0.05; 0.71±0.10, 0.51±0.07 and 0.51±0.08 fold change over ACTH alone, for 10nM, 100nM and 1μM respectively, p<0.05). No effect on CYP11A1 was observed. SIGNIFICANCE Retinoic acid stimulates cortisol synthesis and secretion in human adrenals and at the same time markedly blunts ACTH receptor transcription. These results reveal a novel, adrenal effect of retinoic acid which may contribute to its efficacy in patients with Cushing's disease.
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