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Valizadeh M, Rahmani F, Nikoohemmat M, Ramezani Ahmadi A, Hosseinpanah F, Niroomand M, Khameneh Bagheri A, Grossman A, Abiri B. Diagnostic Accuracy of the Desmopressin Stimulation Test in the Comprehensive Assessment of ACTH-Dependent Cushing's Syndrome: A Comparative Analysis with BIPSS and TSS. Endocr Res 2024:1-11. [PMID: 39030706 DOI: 10.1080/07435800.2024.2381720] [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: 02/29/2024] [Accepted: 07/14/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Cushing's syndrome (CS) poses diagnostic challenges, particularly in distinguishing pituitary-dependent Cushing's syndrome, Cushing's disease (CD), from the ectopic ACTH syndrome (EAS). This study evaluated the diagnostic value of the desmopressin stimulation test (DST) in patients with ACTH-dependent CS in helping this discrimination. METHODS Twenty-three ACTH-dependent CS patients underwent sequential DST, bilateral inferior petrosal sinus sampling (BIPSS), and transsphenoidal surgery (TSS). Two definitions of a positive DST results were applied. Diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios. To avoid bias from predetermined criteria, we generated univariate receiver-operating characteristic (ROC) curves, plotting sensitivity against 1-specificity at various percentage cortisol and ACTH response levels. RESULTS Against BIPSS, DST demonstrated robust sensitivity (Definition 1: 90.0%, Definition 2: 76.2%) and overall accuracy (Definition 1: 87.0%, Definition 2: 73.9%). PPV was high (Definition 1: 95.0%, Definition 2: 94.1%), but NPV indicated potential false negatives. Compared to TSS, DST showed good sensitivity (Definition 1: 90.9-77.3%) and PPV (100.0%) but limited NPV (16.7%). The likelihood ratios emphasized the diagnostic value of the test. Notably, against TSS, DST showed perfect discriminatory power (AUC 1.000 for percent ACTH, 0.983 for percent cortisol). CONCLUSION The desmopressin test shows promise in accurately identifying the underlying cause of ACTH-dependent CS, potentially reducing the reliance on invasive procedures and providing a practical solution for managing complex cases. Further research with larger cohorts is required to validate the utility of the DST in routine clinical practice.
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Affiliation(s)
- Majid Valizadeh
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Rahmani
- Clinical Research and Development Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Nikoohemmat
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Farhad Hosseinpanah
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahtab Niroomand
- Endocrinology Division, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Ashley Grossman
- Centre for Endocrinology, Barts and The London School of Medicine, London, UK
- ENETS Centre of Excellence, Royal Free Hospital, London, UK
- Green Templeton College, University of Oxford, Oxford, UK
| | - Behnaz Abiri
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Liu Z, Hou B, You H, Lu L, Duan L, Li M, Fan X, Deng K, Yao Y, Zhu H, Feng F. Three-Dimensional Fast Spin Echo Pituitary MRI in Treatment-Naïve Cushing's Disease: Reduced Impact of Reader Experience and Increased Diagnostic Accuracy. J Magn Reson Imaging 2024; 59:2115-2123. [PMID: 37656167 DOI: 10.1002/jmri.28975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND In patients with Cushing's disease, the preoperative identification of pituitary adenomas is crucial to treatment. However, increasing diagnostic accuracy remains an unresolved issue. PURPOSE To evaluate the diagnostic accuracy and the impact of readers' experience regarding high-resolution contrast-enhanced magnetic resonance imaging (hrMRI) for identifying pituitary adenomas in comparison with conventional contrast-enhanced MRI (cMRI) and dynamic contrast-enhanced MRI (dMRI). STUDY TYPE Retrospective. POPULATION Sixty-five patients (median age, 39 years; interquartile range [IQR], 28-53 years; 60% females) with treatment-naïve Cushing's disease. FIELD STRENGTH/SEQUENCE 3-T, seven fast spin echo sequences. ASSESSMENT The diagnostic accuracies of identifying pituitary adenomas on cMRI, dMRI, combined cMRI and dMRI (cdMRI), and hrMRI were independently evaluated by six readers with three experience levels (high: >20 years, modest: 10-20 years, low: <10 years; two readers for each experience level). Readers were asked to localize the lesion, and measure its diameter on the sequence where identified. The reference standard was postoperative histopathology. The impact of readers' experience and interobserver agreement were assessed. Image quality was assessed using a 5-point Likert scale, including overall image quality, sharpness, and structural conspicuity. STATISTICAL TESTS McNemar's test, Cochran's test, Wilcoxon signed-rank test, Mann-Whitney U test, and κ statistics for interobserver agreement. A P-value <0.05 was considered statistically significant. RESULTS For identifying pituitary adenomas (median diameter, 5 mm; IQR, 4-5 mm), hrMRI had significantly higher sensitivity (87.7%-93.8%) than cMRI, dMRI, and cdMRI (52.3%-75.4%) for readers with different experience levels. The interobserver agreement was moderate (κ = 0.461-0.523). The sensitivity for hrMRI was comparable between readers with different experience levels (P = 0.371). All image quality scores on hrMRI were significantly higher than cMRI and dMRI (5.0 vs. 4.0). DATA CONCLUSION For identifying pituitary adenomas in patients with treatment-naïve Cushing's disease, hrMRI may show high diagnostic accuracy and seems not to be affected by readers' experience. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Zeyu Liu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lian Duan
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingli Li
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyuan Fan
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Webb KL, Hinkle ML, Walsh MT, Bancos I, Shinya Y, Van Gompel JJ. Inferior Petrosal Sinus Sampling Tumor Lateralization and the Surgical Treatment of Cushing Disease: A Meta-Analysis and Systematic Review. World Neurosurg 2024; 182:e712-e720. [PMID: 38081579 DOI: 10.1016/j.wneu.2023.12.024] [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: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVE To determine whether accurate inferior petrosal sinus sampling (IPSS) tumor lateralization is associated with improved clinical outcomes following the surgical treatment of Cushing disease. METHODS The presented study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data regarding patient demographics, IPSS tumor lateralization, and postoperative endocrinologic outcomes were abstracted and pooled with random effects meta-analysis models. Additional meta-regression models were used to examine the association between the accuracy of IPSS tumor lateralization and postoperative outcomes (recurrence/persistence or remission/cure). Statistical analyses were performed using the Comprehensive Meta-Analysis software (significance of P < 0.05). RESULTS Seventeen eligible articles were identified, yielding data on 461 patients. Within average follow-up duration (∼59 months), the rate of correct IPSS tumor lateralization was 69% [95% confidence interval: 61%, 76%], and the rate of postoperative remission/cure was 78% [67%, 86%]. Preoperative IPSS tumor lateralization was concordant with magnetic resonance imaging lateralization for 53% of patients [40%, 66%]. There was no significant association between the rate of correct IPSS tumor lateralization and postoperative remission/cure among study-level data (P = 0.735). Additionally, there was no association among subgroup analyses for studies using stimulatory agents during IPSS (corticotropin-releasing hormone or desmopressin, P = 0.635), nor among subgroup analyses for adult (P = 0.363) and pediatric (P = 0.931) patients. CONCLUSIONS Limited data suggest that the rate of correct IPSS tumor lateralization may not be positively associated with postoperative remission or cure in patients with Cushing disease. These findings bring into question the utility of IPSS tumor lateralization in the context of preoperative planning and surgical approach rather than confirming a pituitary source.
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Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Liu Z, Hou B, You H, Lu L, Duan L, Li M, Deng K, Yao Y, Zhu H, Feng F. High-resolution contrast-enhanced MRI with three-dimensional fast spin echo improved the diagnostic performance for identifying pituitary microadenomas in Cushing's syndrome. Eur Radiol 2023; 33:5984-5992. [PMID: 37212846 PMCID: PMC10415427 DOI: 10.1007/s00330-023-09585-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 02/10/2023] [Accepted: 02/20/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVES To assess the diagnostic performance of high-resolution contrast-enhanced MRI (hrMRI) with three-dimensional (3D) fast spin echo (FSE) sequence by comparison with conventional contrast-enhanced MRI (cMRI) and dynamic contrast-enhanced MRI (dMRI) with 2D FSE sequence for identifying pituitary microadenomas. METHODS This single-institutional retrospective study included 69 consecutive patients with Cushing's syndrome who underwent preoperative pituitary MRI, including cMRI, dMRI, and hrMRI, between January 2016 to December 2020. Reference standards were established by using all available imaging, clinical, surgical, and pathological resources. The diagnostic performance of cMRI, dMRI, and hrMRI for identifying pituitary microadenomas was independently evaluated by two experienced neuroradiologists. The area under the receiver operating characteristics curves (AUCs) were compared between protocols for each reader by using the DeLong test to assess the diagnostic performance for identifying pituitary microadenomas. The inter-observer agreement was assessed by using the κ analysis. RESULTS The diagnostic performance of hrMRI (AUC, 0.95-0.97) was higher than cMRI (AUC, 0.74-0.75; p ≤ .002) and dMRI (AUC, 0.59-0.68; p ≤ .001) for identifying pituitary microadenomas. The sensitivity and specificity of hrMRI were 90-93% and 100%, respectively. There were 78% (18/23) to 82% (14/17) of the patients, who were misdiagnosed on cMRI and dMRI and correctly diagnosed on hrMRI. The inter-observer agreement for identifying pituitary microadenomas was moderate on cMRI (κ = 0.50), moderate on dMRI (κ = 0.57), and almost perfect on hrMRI (κ = 0.91), respectively. CONCLUSIONS The hrMRI showed higher diagnostic performance than cMRI and dMRI for identifying pituitary microadenomas in patients with Cushing's syndrome. KEY POINTS • The diagnostic performance of hrMRI was higher than cMRI and dMRI for identifying pituitary microadenomas in Cushing's syndrome. • About 80% of patients, who were misdiagnosed on cMRI and dMRI, were correctly diagnosed on hrMRI. • The inter-observer agreement for identifying pituitary microadenomas was almost perfect on hrMRI.
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Affiliation(s)
- Zeyu Liu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China.
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Lian Duan
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Mingli Li
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China.
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China.
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de Almeida TS, Rodrigues TDC, Costenaro F, Scaffaro LA, Farenzena M, Gastaldo F, Czepielewski MA. Enhancing Cushing's disease diagnosis: exploring the impact of desmopressin on ACTH gradient during BIPSS. Front Endocrinol (Lausanne) 2023; 14:1224001. [PMID: 37600715 PMCID: PMC10436086 DOI: 10.3389/fendo.2023.1224001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction The differential diagnosis between Cushing's disease (CD) and ectopic ACTH syndrome (EAS) is complex, and bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold-standard test. However, BIPSS with corticotropin-releasing hormone (CRH) stimulation is rarely available. Objective This retrospective cohort study aimed to assess the accuracy of the inferior petrosal sinus to peripheral ACTH gradient (IPS:P) before and after desmopressin stimulation for the differential diagnosis of ACTH-dependent Cushing's syndrome (CS), applying different cutoff values. Methods A total of 50 patients (48 with CD and 2 with EAS) who underwent BIPSS were included in this study. The sensitivity and specificity of IPS:P in BIPSS before and after desmopressin stimulation were evaluated. Various cutoff values for IPS:P were examined to determine their diagnostic accuracy. Results Using the traditional IPS:P cutoff, the sensitivity was 85.1% before stimulation, 89.6% after stimulation, and a combined sensitivity of 91.7%. Applying cutoff values of IPS:P >1.4 before and >2.8 after stimulation, the sensitivity was 87.2% and 89.6%, respectively, with a combined sensitivity of 91.7%. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values of 1.2 before stimulation and 1.57 after stimulation, resulting in a sensitivity of 93.6% and 93.8%, respectively, with a combined sensitivity of 97.9%. Specificity remained at 100% throughout all analyses. Among the 43 patients who responded positively to stimulation, 42 (97.7%) did so within the first three minutes, and all 43 (100%) did so within the first five minutes. None of the assessed clinical variables predicted the ACTH response to stimulation in BIPSS with statistical significance. Discussion ACTH stimulation with desmopressin during BIPSS improves the accuracy of IPS:P, making it a valuable tool for investigating ACTH-dependent Cushing's syndrome. Considering the low risk of complications, we recommend the use of desmopressin stimulation during BIPSS for the differential diagnosis of ACTH-dependent CS.
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Affiliation(s)
- Tobias Skrebsky de Almeida
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Ticiana da Costa Rodrigues
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fabíola Costenaro
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Leandro Armani Scaffaro
- Radiology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Maurício Farenzena
- Radiology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fernando Gastaldo
- Department of Radiology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mauro Antônio Czepielewski
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Taheri MS, Ghomi Z, Mirshahi R, Moradpour M, Niroomand M, Yarmohamadi P, Zeidabadi H. Usefulness of subtraction images for accurate diagnosis of pituitary microadenomas in dynamic contrast-enhanced magnetic resonance imaging. Acta Radiol 2023; 64:1148-1154. [PMID: 35731731 DOI: 10.1177/02841851221107344] [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: 11/15/2022]
Abstract
BACKGROUND Dynamic contrast-enhanced magnetic resonance imaging (MRI) is the modality of choice for the diagnosis of pituitary microadenomas; however, it may be associated with a relatively high false-negative rate, especially in small lesions. PURPOSE To evaluate the usefulness of subtraction images for enhancing the visual detection of pituitary microadenomas. MATERIAL AND METHODS In total, 50 patients with clinically established diagnosis hyperprolactinemia, acromegaly, and Cushing's disease were enrolled. Ten patients referred for brain MRI for reasons other than pituitary abnormality were selected as control group. Routine dynamic MRI of the pituitary gland and obtained subtraction MRI scans were scrutinized separately on different sessions by an experienced radiologist blinded to the study design and patient's data. The investigator's opinion on the presence or absence of a lesion and lesion size were collected. RESULTS In patients with pituitary microadenoma, dynamic MRI images were reported positive in 42 (84%) patients and negative in 8 (16%). Subtraction images were described as positive in all patients (100%)-including all patients with negative dynamic MRI-and the difference was statistically significant (P=0.016). Undetected lesions on dynamic MRI had a mean size of 2.84 ± 1.79 mm (median= 2.20 mm, interquartile range=1.62-4.62 mm) and a significant inverse correlation was noted between lesion size and negative report of dynamic MRI (P=0.018). Brain MRI scans in the control group were reported negative for pituitary microadenoma in both dynamic contrast-enhanced and subtraction images. CONCLUSION Subtraction images can successfully identify all lesions detectable with conventional dynamic MRI as well as improving visualization of lesions undetected on dynamic MRI, especially in small lesions.
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Affiliation(s)
- Morteza Sanei Taheri
- Department of Radiology, Shohade-E-Tajrish hospital, 556492Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Ghomi
- Department of Radiology, School of Medicine, 556492Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Mirshahi
- Eye Research Center, The Five Senses Health Institute, 48492Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Moein Moradpour
- Department of Radiology, Shohade-E-Tajrish hospital, 556492Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahtab Niroomand
- Internal Medicine Department, Endocrinology Division, 556492Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parsa Yarmohamadi
- Young Researchers and Elite Club, Tehran Medical Sciences, 68106Islamic Azad University, Tehran, Iran
| | - Hamideh Zeidabadi
- Gynecology and Obstetrics Department,Tehran University of Medical Science, 213474Imam Khomeini Hospital Complex Imam Hospital, Tehran, Iran
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Castle-Kirszbaum M, Amukotuwa S, Fuller P, Goldschlager T, Gonzalvo A, Kam J, Kow CY, Shi MD, Stuckey S. MRI for Cushing Disease: A Systematic Review. AJNR Am J Neuroradiol 2023; 44:311-316. [PMID: 36759141 PMCID: PMC10187804 DOI: 10.3174/ajnr.a7789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 10/11/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND MR imaging is key in the diagnostic work-up of Cushing disease. The sensitivity of MR imaging in Cushing disease is not known nor is the prognostic significance of "MR imaging-negative" disease. PURPOSE Our aim was to determine the overall sensitivity and prognostic significance of MR imaging localization of Cushing disease. DATA SOURCES We performed a systematic review of the MEDLINE and PubMed databases for cohort studies reporting the sensitivity of MR imaging for the detection of adenomas in Cushing disease. STUDY SELECTION This study included 57 studies, comprising 5651 patients. DATA ANALYSIS Risk of bias was assessed using the methodological index for non-randomized studies criteria. Meta-analysis of proportions and pooled subgroup analysis were performed. DATA SYNTHESIS Overall sensitivity was 73.4% (95% CI, 68.8%-77.7%), and the sensitivity for microadenomas was 70.6% (66.2%-74.6%). There was a trend toward greater sensitivity in more recent studies and with the use of higher-field-strength scanners. Thinner-section acquisitions and gadolinium-enhanced imaging, particularly dynamic sequences, also increased the sensitivity. The use of FLAIR and newer 3D spoiled gradient-echo and FSE sequences, such as spoiled gradient-echo sequences and sampling perfection with application-optimized contrasts by using different flip angle evolutions, may further increase the sensitivity but appear complementary to standard 2D spin-echo sequences. MR imaging detection conferred a 2.63-fold (95% CI, 2.06-3.35-fold) increase in remission for microadenomas compared with MR imaging-negative Cushing disease. LIMITATIONS Pooled analysis is limited by heterogeneity among studies. We could not account for variation in image interpretation and tumor characteristics. CONCLUSIONS Detection on MR imaging improves the chances of curative resection of adenomas in Cushing disease. The evolution of MR imaging technology has improved the sensitivity for adenoma detection. Given the prognostic importance of MR imaging localization, further effort should be made to improve MR imaging protocols for Cushing disease.
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Affiliation(s)
- M Castle-Kirszbaum
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | | | - P Fuller
- Endocrinology (P.F.)
- Hudson Institute (P.F.), Melbourne, Australia
| | - T Goldschlager
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | - A Gonzalvo
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - J Kam
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - C Y Kow
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
| | - M D Shi
- Barwon Health (M.D.S.), Geelong, Australia
| | - S Stuckey
- Department of Radiology (S.S.), Peter MacCallum Cancer Centre, Melbourne, Australia
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Prevalence of perioperative asymptomatic venous thromboses of the lower extremity in 30 consecutive patients undergoing transsphenoidal surgery for Cushing's disease. Sci Rep 2023; 13:3217. [PMID: 36828936 PMCID: PMC9957978 DOI: 10.1038/s41598-023-30070-8] [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: 05/15/2022] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
Cushing´s disease is a rare endocrinological disorder which is caused by an adrenocorticotropic hormone secreting pituitary adenoma. The condition is associated with an increased risk for venous thromboembolism. While there exist reports on symptomatic venous thromboses complicating Cushing's disease, the prevalence of incidental leg vein thromboses accompanying pituitary surgery for Cushing's disease is yet unknown. 30 consecutive patients (9 male; age 25-77 years) with histologically confirmed Cushing's disease underwent transsphenoidal adenomectomy between October 2018 and September 2019. All patients received perioperative pharmacological thromboprophylaxis. Whole leg compression ultrasound was performed within one week after surgery (median 2 days) to exclude leg vein thromboses (primary endpoint). Preoperative laboratory values including plasma cortisol and various coagulation parameters were evaluated as secondary outcome measures. A comparison was made between patients with and without thrombotic events (p value ≤ 0.05). A total of 2 out of 30 patients (6.7%; CI 0.8-24.1%) presented with asymptomatic perioperative deep vein thromboses of the lower legs. Thrombosis patients differed not significantly from their counterparts with respect to age, sex, and comorbidities, but preoperative morning plasma cortisol was significantly higher in patients with venous thromboses (421.0 ± 49.5 μg/l vs. 188.1 ± 78.2 μg/l; p = 0.01). Moreover, von Willebrand factor activity was markedly increased in one case (409.0%) compared to the mean value obtained from 28 patients without phlebothromboses (146.9 ± 60.7%; p < 0.01). Perioperative asymptomatic leg vein thrombosis can be found with the aid of compression ultrasound in a considerable proportion of patients undergoing transsphenoidal adenomectomy for Cushing's disease despite the administration of pharmacological thromboprophylaxis.
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Ceccato F, Barbot M, Mondin A, Boscaro M, Fleseriu M, Scaroni C. Dynamic testing for differential diagnosis of ACTH-dependent Cushing Syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab 2022; 108:e178-e188. [PMID: 36453141 DOI: 10.1210/clinem/dgac686] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Diagnostic accuracy of testing currently used for the differential diagnosis of Cushing's disease (CD) vs ectopic -ACTH secretion (EAS) is difficult to interpret. The present study aimed to identify and evaluate the diagnostic accuracy of corticotropin-releasing hormone (CRH) test, desmopressin test, and high-dose dexamethasone suppression test (HDDST) when used to establish a CD or EAS diagnosis. DESIGN This study is a systematic review of the literature and meta-analysis. METHODS MEDLINE, OVID, and Web of Science databases were searched for articles published between the years 1990-2021. Articles included described at least one test(s) (CRH, desmopressin, or HDDST) and the diagnostic reference standard(s) (histopathology, petrosal sinus sampling, surgical remission, imaging, and long-term follow-up) used to establish a CD or EAS diagnosis. RESULTS Sixty-two studies were included: 43 reported the use of HDDST, 32 CRH test, and 21 desmopressin test. CRH test was found to have the highest sensitivity in detecting CD (ACTH 86.9%, 95% confidence interval [CI] 82.1-90.6, cortisol 86.2%, 95%CI 78.3-91.5) and the highest specificity in detecting EAS (ACTH 93.9%, 95%CI 87-98.3, cortisol 89.4%, 95%CI 82.8-93.7). This resulted in a high diagnostic odds ratio (58, 95%CI 43.25-77.47), large area under the curve, and a receiver-operating characteristic (ROC) of 0.934. The diagnostic accuracy of HDDST and desmopressin test(s) was lower than that of the CRH test. CONCLUSION The meta-analysis indicates that a patient with a positive ACTH response after a CRH test is highly likely to have CD. Further studies analysing role of dynamic testing in addition to imaging are needed.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Alessandro Mondin
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Maria Fleseriu
- Oregon Health & Science University, Pituitary Center, Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition and Department of Neurological Surgery, Portland, USA
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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10
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Nasi-Kordhishti I, Grimm F, Giese S, Lörincz KN, Bender B, Honegger J. The importance of MRI quality and reader's experience for detecting an adenoma in Cushing's disease. Eur J Endocrinol 2022; 187:349-359. [PMID: 35895719 DOI: 10.1530/eje-22-0180] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/28/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In Cushing's disease (CD), detection of an adenoma by MRI is challenging. The aim of this study is to compare real-life MRI in the initial diagnostic workup of CD with high-quality MRI performed in a tertiary center for pituitary diseases. DESIGN AND METHODS We retrospectively analyzed 139 patients with CD who underwent primary transsphenoidal surgery (TSS) in our department and had both an MRI conducted at a different institution (external MRI; extMRI) and an MRI conducted at our institution (internal MRI; intMRI). Preoperative interpretation of MRI was performed independently by an external radiologist (extRAD), an internal neuroradiologist (intRAD) and a pituitary surgeon (SURG). Intraoperative detection of an adenoma and endocrinological remission provided proof of the true adenoma localization in 105 patients. RESULTS Interpretation of extMRI by extRAD and SURG was concordant in only 64% (89/139) of cases, while 74.1% (103/139) concordance was observed for interpretation of intMRI by intRAD and SURG. Based on extMRI, the true localization of the adenoma was correctly predicted in only 46.7% of the patients by extRAD and in 65.7% by SURG. In contrast, the sensitivity to correctly identify the adenoma on intMRI was 80.0% for intRAD and 94.3% for SURG. CONCLUSION Both the quality of MRI and the reader's experience are paramount for detection of microadenomas in CD. Every effort should be made to perform high-quality initial MRI according to current standards and to ensure rating by an expert in pituitary imaging.
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Affiliation(s)
| | - Florian Grimm
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
| | - Sabrina Giese
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
| | | | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls-University, Tübingen, Germany
| | - Jürgen Honegger
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
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11
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Sabahi M, Shahbazi T, Maroufi SF, Vidal K, Recinos PF, Kshettry VR, Roser F, Adada B, Borghei-Razavi H. MRI-Negative Cushing's Disease: A Review on Therapeutic Management. World Neurosurg 2022; 162:126-137.e1. [PMID: 35338018 DOI: 10.1016/j.wneu.2022.03.076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In this systematic review and meta-analysis, we review the literature regarding patients with Cushing's disease (CD) with negative or inconclusive magnetic resonance imaging (MRI). METHODS A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), EMBASE, and Cochrane electronic bibliographic databases. RESULTS 28 articles described surgical management of inconclusive MRI or MRI-negative CD. A total of 858 patients underwent surgery for their Cushing adenoma. Different types of surgery, including endoscopic endonasal transsphenoidal surgery (EETS) (190 cases) and microscopic endonasal transsphenoidal surgery (METS) (488 cases), were performed on patients with MRI-negative CD. 7 studies, which included 164 patients, did not describe any surgery. EETS and METS are conducted to achieve selective adenomectomy (231 cases), partial adenomectomy (80 cases), total adenomectomy (13 cases), hemihypophysectomy (15 cases), or enlarged adenomectomy (48 cases). Based on available data on these studies, the remission rate, persistence rate, and recurrence rate after different types of surgeries on patients with MRI-negative CD were 72.97%, 27.03%, and 12.05%, respectively. There was no statistically significant difference between EETS and METS in the subanalysis regarding recurrence rate, remission rate, and persistence rate. However, the recurrence rate in the METS group is almost 3 times higher than in the EETS group. CONCLUSIONS Surgery has a good prognosis in patients with MRI-negative CD in terms of remission, and EETS has a lower rate of disease recurrence than METS; therefore, EETS seems to be the potential recommended treatment technique, while to confirm the therapeutic method of choice, further investigations should be done.
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Affiliation(s)
- Mohammadmahdi Sabahi
- 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
| | - 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
| | - 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
| | - Kevin Vidal
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Pablo F Recinos
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Florian Roser
- Department of Neurosurgery, Cleveland Clinic, Abu Dhabi, UAE
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA.
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12
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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13
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Wu Y, Cai Y, Rui W, Tang Y, Yang Z, He M, Ye H, Wang Y, Zhao Y, Ma Z, Yao Z. Contrast-enhanced 3D-T2-weighted SPACE sequence for MRI detection and localization of adrenocorticotropin (ACTH)-secreting pituitary microadenomas. Clin Endocrinol (Oxf) 2022; 96:578-588. [PMID: 34323314 DOI: 10.1111/cen.14574] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Cushing disease is a potentially fatal endocrine disorder caused by adrenocorticotropin (ACTH)-secreting microadenomas in the pituitary gland. Accurate detection and localization of the adenomas is the key to clinical treatment. This study analysed the value of contrast-enhanced Sampling Perfection with Application-optimized Contrasts using different flip angle Evolutions (SPACE) sequence in magnetic resonance imaging (MRI) assessment of ACTH-secreting pituitary microadenomas. DESIGN AND PATIENTS We carried out a retrospective study in which 45 patients with ACTH-secreting pituitary microadenomas were enrolled. Dynamic contrast-enhanced (DCE) coronal T1-SE sequence was performed. A contrast-enhanced coronal SPACE sequence was added immediately after DCE MRI finished. Two independent observers assessed the tumour existence and location, then the results were compared with surgical findings. RESULTS Twenty-four lesions (53.3%) were detected by the DCE T1-SE sequence alone, while 35 lesions (80.0%) were detected with the addition of contrast-enhanced SPACE sequence. The sensitivity (58.5% vs. 85.3%; p < .05) and best diagnostic accuracy (62.0% vs. 84.4%; p < .05) were significantly better for addition with SPACE sequence than DCE-SE images alone in detection of ACTH-secreting pituitary microadenomas. For lesions <5 mm, the detected numbers were 4 (16.6%) versus 10 (27.8%) by DCE T1-SE sequence and combined DCE T1-SE with SPACE sequence. CONCLUSIONS A combination of contrast-enhanced SPACE with DCE T1-SE sequence could improve the detection of ACTH-secreting pituitary microadenomas. Contrast-enhanced SPACE sequence could be a supplementary sequence for imaging of ACTH-secreting pituitary adenomas when T1-SE sequence provides negative or equivocal findings.
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Affiliation(s)
- Yue Wu
- Department of Radiology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yixin Cai
- Department of Neurosurgery, National Center for Neurological Disorders (NCND), Shanghai Pituitary Tumor Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wenting Rui
- Department of Radiology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ying Tang
- Department of Radiology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhong Yang
- Department of Radiology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Min He
- Department of Endocrinology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hongying Ye
- Department of Endocrinology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yongfei Wang
- Department of Neurosurgery, National Center for Neurological Disorders (NCND), Shanghai Pituitary Tumor Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yao Zhao
- Department of Neurosurgery, National Center for Neurological Disorders (NCND), Shanghai Pituitary Tumor Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zengyi Ma
- Department of Neurosurgery, National Center for Neurological Disorders (NCND), Shanghai Pituitary Tumor Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhenwei Yao
- Department of Radiology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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14
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Difference in miRNA Expression in Functioning and Silent Corticotroph Pituitary Adenomas Indicates the Role of miRNA in the Regulation of Corticosteroid Receptors. Int J Mol Sci 2022; 23:ijms23052867. [PMID: 35270010 PMCID: PMC8911444 DOI: 10.3390/ijms23052867] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 02/01/2023] Open
Abstract
Corticotroph pituitary adenomas commonly cause Cushing’s disease (CD), but some of them are clinically silent. The reason why they do not cause endocrinological symptoms remains unclear. We used data from small RNA sequencing in adenomas causing CD (n = 28) and silent ones (n = 20) to explore the role of miRNA in hormone secretion and clinical status of the tumors. By comparing miRNA profiles, we identified 19 miRNAs differentially expressed in clinically functioning and silent corticotroph adenomas. The analysis of their putative target genes indicates a role of miRNAs in regulation of the corticosteroid receptors expression. Adenomas causing CD have higher expression of hsa-miR-124-3p and hsa-miR-135-5p and lower expression of their target genes NR3C1 and NR3C2. The role of hsa-miR-124-3p in the regulation of NR3C1 was further validated in vitro using AtT-20/D16v-F2 cells. The cells transfected with miR-124-3p mimics showed lower levels of glucocorticoid receptor expression than control cells while the interaction between miR-124-3p and NR3C1 3′ UTR was confirmed using luciferase reporter assay. The results indicate a relatively small difference in miRNA expression between clinically functioning and silent corticotroph pituitary adenomas. High expression of hsa-miR-124-3p in adenomas causing CD plays a role in the regulation of glucocorticoid receptor level and probably in reducing the effect of negative feedback mediated by corticosteroids.
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15
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Ferrante E, Barbot M, Serban AL, Ceccato F, Carosi G, Lizzul L, Sala E, Daniele A, Indirli R, Cuman M, Locatelli M, Manara R, Arosio M, Boscaro M, Mantovani G, Scaroni C. Indication to dynamic and invasive testing in Cushing's disease according to different neuroradiological findings. J Endocrinol Invest 2022; 45:629-637. [PMID: 34699044 PMCID: PMC8850245 DOI: 10.1007/s40618-021-01695-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/18/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE Dynamic testing represents the mainstay in the differential diagnosis of ACTH-dependent Cushing's syndrome. However, in case of undetectable or detectable lesion < 6 mm on MRI, bilateral inferior petrosal sinus sampling (BIPSS) is suggested by current guidelines. Aim of this study was to analyze the performance of CRH, desmopressin and high-dose dexamethasone suppression test (HDDST) in the differential diagnosis of ACTH-dependent Cushing's syndrome as well as the impact of invasive and noninvasive tests on surgical outcome in patients affected by Cushing's disease (CD). METHODS Retrospective analysis on 148 patients with CD and 26 patients with ectopic ACTH syndrome. RESULTS Among CD patients, negative MRI/lesion < 6 mm was detected in 97 patients (Group A); 29 had a 6-10 mm lesion (Group B) and 22 a macroadenoma (Group C). A positive response to CRH test, HDSST and desmopressin test was recorded in 89.4%, 91·4% and 70.1% of cases, respectively. Concordant positive response to both CRH/HDDST and CRH/desmopressin tests showed a positive predictive value of 100% for the diagnosis of CD. Among Group A patients with concordant CRH test and HDDST, no difference in surgical outcome was found between patients who performed BIPSS and those who did not (66.6% vs 70.4%, p = 0.78). CONCLUSIONS CRH, desmopressin test and HDDST have high accuracy in the differential diagnosis of ACTH-dependent CS. In patients with microadenoma < 6 mm or non-visible lesion, a concordant positive response to noninvasive tests seems sufficient to diagnose CD, irrespective of MRI finding. In these patients, BIPSS should be reserved to discordant tests.
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Affiliation(s)
- E Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - A L Serban
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - G Carosi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - L Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - E Sala
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - A Daniele
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - R Indirli
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Cuman
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - M Locatelli
- Neurosurgery Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - R Manara
- Department of Neurosciences, University of Padua, Padua, Italy
| | - M Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - G Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
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16
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Cozzi R, Ambrosio MR, Attanasio R, Battista C, Bozzao A, Caputo M, Ciccarelli E, De Marinis L, De Menis E, Faustini Fustini M, Grimaldi F, Lania A, Lasio G, Logoluso F, Losa M, Maffei P, Milani D, Poggi M, Zini M, Katznelson L, Luger A, Poiana C. Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors. Eur J Endocrinol 2022; 186:P1-P33. [PMID: 35000899 PMCID: PMC8859924 DOI: 10.1530/eje-21-0977] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022]
Abstract
Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.
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Affiliation(s)
- Renato Cozzi
- Division of Endocrinology, Niguarda Hospital, Milan, Italy
- Correspondence should be addressed to R Cozzi;
| | - Maria Rosaria Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Claudia Battista
- Endocrinology Unit, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo (FG), Italy
| | - Alessandro Bozzao
- Neuroradiology, S. Andrea Hospital, NESMOS Department (Neuroscience, Mental Health, Sensorial Organs), Sapienza University of Rome, Rome, Italy
| | - Marco Caputo
- Laboratorio Analisi Cliniche e Microbiologia, Synlab SRL, Calenzano, Florence, Italy
| | | | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | | | | | - Franco Grimaldi
- AME President, Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Udine, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Endocrinology Unit, Rozzano, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | | | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Maffei
- Department of Medicine (DIMED), 3rd Medical Clinic, Padua University Hospital, Padua, Italy
| | - Davide Milani
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Maurizio Poggi
- Endocrinology, Department of Clinical and Molecular Medicine, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Michele Zini
- Endocrinology Unit, Azienda Ospedaliera S. Maria Nuova IRCCS, Reggio Emilia, Italy
| | | | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Catalina Poiana
- ‘Carol Davila’ University of Medicine and Pharmacy – Endocrinology, “C.I. Parhon” National Institute of Endocrinology – Pituitary and Neuroendocrine Disorders, Bucharest, Romania
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17
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Shi X, Du T, Zhu D, Ma D, Dong K, Peng X, Huang J, Lei T, Yu X, Chen J, Yang Y. High-dose dexamethasone suppression test is inferior to pituitary dynamic enhanced MRI in the differential diagnosis of ACTH-dependent Cushing's syndrome. Endocrine 2022; 75:516-524. [PMID: 34608552 DOI: 10.1007/s12020-021-02891-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The differential diagnosis of adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome remains a challenge in clinical practice. The present study was aimed at assessing the diagnostic performance of pituitary dynamic contrast-enhanced magnetic resonance imaging (dMRI), high-dose dexamethasone suppression test (HDDST), and a combination of both tests for patients with ACTH-dependent Cushing's syndrome. METHODS A total of 119 consecutive patients with ACTH-dependent Cushing's syndrome confirmed surgically were enrolled: 101 with proven Cushing's disease and 18 with proven ectopic ACTH syndrome. All patients underwent pituitary dMRI and HDDST. The sensitivity and specificity of pituitary dMRI, HDDST, and a combination of both tests were determined. RESULTS The sensitivity and specificity of pituitary dMRI for diagnosing Cushing's disease were 80.2 and 83.3%, respectively, with a positive predictive value of 96.4%. The sensitivity and specificity of HDDST were 70.3 and 77.8%, respectively, with positive predictive value of 94.7%. A combination of both tests showed that the combined criteria of more than 50% suppression of serum cortisol on HDDST and a positive pituitary dMRI finding yielded a high specificity of 94.4 and sensitivity of 59.4%. The combined criteria of more than 68% suppression on HDDST and/or a positive pituitary dMRI finding yielded a sensitivity of 86.1% and specificity of 83.3%. CONCLUSIONS Pituitary dMRI was superior to HDDST in the differential diagnosis of ACTH-dependent Cushing's syndrome. HDDST is recommended in combination with pituitary dMRI to establish a diagnosis process because of the significantly increased specificity with the combination.
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Affiliation(s)
- Xiaoli Shi
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Tingting Du
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Dan Zhu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Delin Ma
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Kun Dong
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Xuemin Peng
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Jiaojiao Huang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
| | - Xuefeng Yu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China
| | - Juan Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China.
| | - Yan Yang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China.
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, Hubei, P.R. China.
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18
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Detomas M, Ritzel K, Nasi-Kordhishti I, Wolfsberger S, Quinkler M, Losa M, Tröger V, Kroiss M, Fassnacht M, Vila G, Honegger JB, Reincke M, Deutschbein T. Outcome of CRH stimulation test and overnight 8 mg dexamethasone suppression test in 469 patients with ACTH-dependent Cushing's syndrome. Front Endocrinol (Lausanne) 2022; 13:955945. [PMID: 36277711 PMCID: PMC9583401 DOI: 10.3389/fendo.2022.955945] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate diagnostic accuracy of the corticotropin-releasing hormone (CRH) stimulation test and the overnight 8 mg dexamethasone suppression test (DST) for the differentiation of Cushing's disease (CD) and ectopic Cushing's syndrome (ECS). METHODS Retrospective study in 6 European centers. Inclusion criteria: patients with a) overt adrenocorticotropin (ACTH)-dependent Cushing's syndrome at the time of dynamic testing, b) histopathological confirmed tumors and/or c) postoperative biochemical remission and/or adrenal insufficiency. Optimal cut-offs were calculated via receiver operating characteristic (ROC) analysis using CD as reference. RESULTS 469 patients were analyzed [78% females; median age 43 years (IQR 19)]. CRH test and overnight 8 mg DST were performed in 420 [CD, n=394 (94%); ECS, n=26 (6%)] and 237 patients [228 CD (96%), 9 ECS (4%)]. Both tests were performed in 205 patients (44%). The post-CRH %-increase at 30 minutes of both ACTH (cut-off ≥31%, sensitivity 83%, specificity 85%, AUC 0.81) and cortisol (cut-off ≥12%, sensitivity 82%, specificity 89%, AUC 0.86) discriminated best between CD and ECS. A test duration of >60 minutes did not improve diagnostic performance of the CRH test. The optimal cortisol cut-off for the %-suppression during the 8 mg DST was ≥55% (sensitivity 80%, specificity 78%, AUC 0.75). CONCLUSION The CRH test has equivalent sensitivity but higher specificity than the 8 mg DST and is therefore the test of first choice. The diagnostic outcome of ACTH and cortisol is well comparable, however, sampling beyond 60 minutes post-CRH does not provide diagnostic benefits.
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Affiliation(s)
- Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | | | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Marco Losa
- Department of Neurosurgery, Instituto Scientifico San Raffaele, University Vita-Salute, Milan, Italy
| | - Viola Tröger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Greisa Vila
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
- *Correspondence: Timo Deutschbein,
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19
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Application of Contrast-Enhanced 3-Dimensional T2-Weighted Volume Isotropic Turbo Spin Echo Acquisition Sequence in the Diagnosis of Prolactin-Secreting Pituitary Microadenomas. J Comput Assist Tomogr 2021; 46:116-123. [PMID: 35099143 PMCID: PMC8763247 DOI: 10.1097/rct.0000000000001237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Deep learning-based thin-section MRI reconstruction improves tumour detection and delineation in pre- and post-treatment pituitary adenoma. Sci Rep 2021; 11:21302. [PMID: 34716372 PMCID: PMC8556421 DOI: 10.1038/s41598-021-00558-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/08/2021] [Indexed: 11/08/2022] Open
Abstract
Even a tiny functioning pituitary adenoma could cause symptoms; hence, accurate diagnosis and treatment are crucial for management. However, it is difficult to diagnose a small pituitary adenoma using conventional MR sequence. Deep learning-based reconstruction (DLR) using magnetic resonance imaging (MRI) enables high-resolution thin-section imaging with noise reduction. In the present single-institution retrospective study of 201 patients, conducted between August 2019 and October 2020, we compared the performance of 1 mm DLR MRI with that of 3 mm routine MRI, using a combined imaging protocol to detect and delineate pituitary adenoma. Four readers assessed the adenomas in a pairwise fashion, and diagnostic performance and image preferences were compared between inexperienced and experienced readers. The signal-to-noise ratio (SNR) was quantitatively assessed. New detection of adenoma, achieved using 1 mm DLR MRI, was not visualised using 3 mm routine MRI (overall: 6.5% [13/201]). There was no significant difference depending on the experience of the readers in new detections. Readers preferred 1 mm DLR MRI over 3 mm routine MRI (overall superiority 56%) to delineate normal pituitary stalk and gland, with inexperienced readers more preferred 1 mm DLR MRI than experienced readers. The SNR of 1 mm DLR MRI was 1.25-fold higher than that of the 3 mm routine MRI. In conclusion, the 1 mm DLR MRI achieved higher sensitivity in the detection of pituitary adenoma and provided better delineation of normal pituitary gland than 3 mm routine MRI.
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22
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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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23
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Shukla J, Vatsa R, Walia R, Chhabra A, Rana N, Singh H, Kumar R, Mittal BR. Development of Ga-68 DOTA-CRH for PET/CT Imaging of ACTH-Dependent Cushing's Disease: Initial Study. Cancer Biother Radiopharm 2021; 36:642-650. [PMID: 34191604 DOI: 10.1089/cbr.2020.4686] [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] [Indexed: 11/13/2022] Open
Abstract
Purpose: Adrenocorticotropic hormone (ACTH)-dependent Cushing's disease accounts for 75% cases of the endogenous Cushing's syndrome. The size of lesion is usually very small, which results in false-negative magnetic resonance imaging (MRI) even after biochemical confirmation of the disease. Corticotrophin-releasing hormone (CRH) the key controller of hypothalamus-pituitary--adrenal axis binds to CRH receptor R1 and R2. CRH R1 is overexpressed in pituitary adenomas. The present study aims to target these overexpressed receptors with Ga-68-DOTA-CRH for noninvasive imaging of ACTH-dependent pituitary adenomas. Materials and Methods: Custom-synthesized 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-CRH peptide was purified by high performance liquid chromatography (HPLC) and characterized by mass spectra. Postradiolabeling optimization with Ga-68, quality control tests were carried out to ensure the suitability of Ga-68 DOTA-CRH for intravenous administration. A pilot study consisting of 15 patients including 6 known cases of macroadenoma underwent Ga-68-DOTA-CRH regional brain positron emission tomography/computed tomography (PET/CT). The optimal imaging time and biodistribution studies were performed in five patients' whole-body and serial brain PET/CT imaging. Lesion activity was determined as SUVmax and correlated with CE-MRI and histopathology of excised tissue. Results: A retention time of 11.3 min and mass of 5145 Da was observed on HPLC and mass spectra. Radiolabeling yield of >98% was achieved under optimized conditions using 25-100 μg of conjugated peptide for 10-22 mCi of Ga-68. The quality control results were in agreement with acceptable criteria. Ga-68-DOTA-CRH was able to delineate ACTH secreting corticotropinoma in all 15 patients. Physiological uptake of radiotracer was observed in liver and spleen with diffused marrow activity. Excretion was noted by renal route. Imaging results were in correlation with CE-MRI and histopathology of excised tissue. Conclusion: Ga-68-DOTA-CRH PET/CT is a promising molecular imaging modality for detection of ACTH-dependent microadenoma.
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Affiliation(s)
- Jaya Shukla
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakhee Vatsa
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupriya Chhabra
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nivedita Rana
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmandeep Singh
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajender Kumar
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Zhang K, Shen M, Qiao N, Chen Z, He W, Ma Z, Shou X, Li S, Zhao Y, Pan L, Liu D, He M, Zhang Z, Li Y, Yao Z, Ye H, Wang Y. Surgical outcomes and multidisciplinary management strategy of Cushing's disease: a single-center experience in China. Neurosurg Focus 2021; 48:E7. [PMID: 32480378 DOI: 10.3171/2020.3.focus2067] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/05/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary aim of this study was to investigate the value of multidisciplinary team (MDT) management in treating patients with Cushing's disease (CD). The secondary aim was to assess the concordance of bilateral inferior petrosal sinus sampling (BIPSS) lateralization with intraoperative observations. METHODS The authors recruited 124 consecutive patients (128 procedures) who had undergone endoscopic endonasal resection of adrenocorticotropic hormone-secreting pituitary adenomas from May 2014 to April 2018 and assessed their clinical characteristics, surgical outcomes, and adjuvant therapies. The criteria for surgical remission were normalized serum and urinary cortisol levels, which could be suppressed by a low-dose dexamethasone suppression test at 3-months' follow-up without adjuvant treatment. RESULTS The remission rates of the 113 patients with long-term follow-up (20.3 ± 12.2 months) were 83.2% after surgery alone and 91.2% after adjuvant therapy. The surgical remission rates of macroadenomas, MRI-visible microadenomas, and MRI-negative tumors were 66.7% (12/18), 89.3% (67/75), and 75% (15/20), respectively (p = 0.039). The surgical remission rates had a trend of improvement during the study period (87.5% in 2017-2018 vs 76.5% in 2014, p = 0.517). Multivariate regression analysis showed that a history of previous pituitary surgery (OR 0.300, 95% CI 0.100-0.903; p = 0.032) and MRI-visible microadenoma (OR 3.048, 95% CI 1.030-9.019; p = 0.044) were independent factors influencing surgical remission. The recurrence rate was 3.2% after a mean of 18 months after surgery. The remission rate of postoperative MDT management in patients with persistent disease was higher than non-MDT management (66.7% vs 0%, p = 0.033). In cases with preoperative BIPSS lateralization, 84.6% (44/52) were concordant with intraoperative findings. CONCLUSIONS MRI-visible microadenoma and primary surgery were independent predictors of surgical remission in CD. The MDT management strategy helps to achieve a better overall outcome. BIPSS may help to lateralize the tumor in MRI-negative/equivocal microadenomas.
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Affiliation(s)
| | | | | | | | | | | | | | - Shiqi Li
- 1Department of Neurosurgery, and
| | - Yao Zhao
- 1Department of Neurosurgery, and
| | - Li Pan
- 1Department of Neurosurgery, and.,2CyberKnife Center, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University; and
| | - Dan Liu
- Departments of3Endocrinology and
| | - Min He
- Departments of3Endocrinology and
| | | | | | - Zhenwei Yao
- 4Radiology, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
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25
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Bestepe N, Ozdemir D, Polat B, Topaloglu O, Algin O, Bal E, Ersoy R, Cakir B. The role of bilateral inferior petrosal sinus sampling in determining the preoperative localization of ACTH-secreting pituitary microadenomas in Cushing's disease: Experience of a tertiary center. Clin Neurol Neurosurg 2021; 207:106724. [PMID: 34102422 DOI: 10.1016/j.clineuro.2021.106724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Bilateral inferior petrosal sinus sampling (BIPSS) is an important procedure in the diagnostic work-up of Cushing's syndrome (CS). In this study, we investigated the diagnostic performance of BIPSS in detecting the source of adrenocorticotropic hormone (ACTH) secretion in Cushing's disease (CD) without radiological evidence. METHODS Thirty-five consecutive patients who underwent BIPSS due to ACTH-dependent CS between 2010 and 2019 in our clinic and subsequently underwent transsphenoidal surgery were included. The indication for BIPSS was biochemically proven ACTH-dependent CS but normal or ≤6 mm pituitary lesion in pituitary magnetic resonance imaging (MRI). Corticotropin releasing hormone (CRH) stimulation was applied to all patients during the BIPSS procedure. BIPSS data, MRI results, pathological findings, and follow-up results were analyzed. The diagnostic performance of BIPSS was calculated. RESULTS A total of 35 patients, 6 (17%) males and 29 (83%) females, were included in the study. Pituitary MRI was normal in 12 (34.3%) and revealed lesions ≤ 6 mm in 23 (65.7%) patients. BIPSS lateralized the right side in 13 (37.1%) and left side in 18 (51.4%) patients, while no lateralization was observed in the remaining 4 (11.5%) patients. BIPSS showed lateralization in the same direction with pituitary adenoma in 21 (60%) patients before CRH injection and in 29 (83%) patients after CRH injection (p = 0.034). The sensitivity of the BIPSS procedure was 88%. Accurate localization of the pituitary lesion was more frequent when based on BIPSS results than on MRI (83% vs. 51%, P = 0.005). CONCLUSION BIPSS appears to be a valuable and safe diagnostic tool in patients who are diagnosed with CD biochemically but do not have clear radiological evidence of ACTH-producing lesion.
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Affiliation(s)
- Nagihan Bestepe
- Ankara City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Didem Ozdemir
- Yildirim Beyazit University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Burcak Polat
- Yildirim Beyazit University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Oya Topaloglu
- Yildirim Beyazit University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Oktay Algin
- Yildirim Beyazit University Faculty of Medicine, Department of Radiology, Ankara, Turkey.
| | - Ercan Bal
- Yildirim Beyazit University Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey.
| | - Reyhan Ersoy
- Yildirim Beyazit University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Bekir Cakir
- Yildirim Beyazit University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey.
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Reginelli A, Vacca G, Belfiore M, Sangiovanni A, Nardone V, Vanzulli A, Grassi R, Cappabianca S. Pitfalls and differential diagnosis on adrenal lesions: current concepts in CT/MR imaging: a narrative review. Gland Surg 2021; 9:2331-2342. [PMID: 33447584 DOI: 10.21037/gs-20-559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The purpose of this pictorial essay is to review the imaging findings of adrenal lesions. Adrenal lesions could be divided into functioning or non-functioning masses, primary or metastatic, and benign or malignant. Imaging techniques have undergone significant advances in recent years. The most significant objective of adrenal imaging is represented by the detection and, when possible, characterization of adrenal lesions in order to direct patient management correctly. The detection and management of adrenal lesions is based on cross-sectional imaging obtained with non-contrast CT (tumour density), contrast-enhanced CT including delayed washout (either absolute percentage washout or relative percentage one) and finally with MR chemical shift analysis (loss of signal intensity between in-phase and out-of-phase images including both qualitative and quantitative estimates of signal loss). The small incidental adrenal nodules are benign, in most of cases; some tumors such as lipid-rich adenoma and myelolipoma have characteristic features that can be diagnosed accurately in CT. On contrary, if the presenting contrast-enhanced CT shows an adrenal mass with uncertain or malignant morphologic features, particularly in patients with a known history of malignancy, further evaluations should be considered. The most significative implications for radiologists are represented by how to assess risk of malignancy on imaging and what follow-up to indicate if an adrenal incidentaloma is not surgically removed.
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Affiliation(s)
- Alfonso Reginelli
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Giovanna Vacca
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Mariapaola Belfiore
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Angelo Sangiovanni
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Valerio Nardone
- Unit of Radiation Oncology, Ospedale del Mare, Naples, Italy
| | - Angelo Vanzulli
- Department of Radiology, University "La Statale" of Milan, Milan, Italy
| | - Roberto Grassi
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
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Mathai C, Anolik J. Cushing's Disease as a Result of Two ACTH-Secreting Pituitary Tumors. AACE Clin Case Rep 2020; 7:149-152. [PMID: 34095475 PMCID: PMC8053624 DOI: 10.1016/j.aace.2020.12.002] [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] [Indexed: 11/29/2022] Open
Abstract
Objective Our objective is to present a case of Cushing’s disease (CD) with 2 adrenocorticotropic hormone (ACTH)-secreting pituitary tumors. Multiple monohormonal pituitary tumors are rare. This case supports a consideration of repeat transsphenoidal surgery (TSS) in patients with initial surgical failure. Methods Salivary, 24-h urine, serum cortisol testing, and magnetic resonance imaging (MRI) were used to diagnose CD. Treatment included TSS and postoperative hydrocortisone. Results A 36-year-old woman followed for hypothyroidism presented with a new left supraclavicular fossa swelling and underwent Cushing’s syndrome screening. The levels of late-night salivary cortisol were 0.636 and 0.316 μg/dL, 24-h urine cortisol was 162 μg/24 h, cortisol after 1-mg dexamethasone suppression was 14.0 μg/dL, and serum morning cortisol was 26.4 μg/dL with ACTH of 66.7 pg/mL. A 7-mm hypoenhancing anterior pituitary lesion was noted on pituitary MRI. The cortisol level was 2.7 μg/dL after an 8-mg dexamethasone suppression. She underwent TSS, and her histopathology read as pituitary adenoma staining positive for ACTH. No residual tumor was seen intraoperatively. Postoperative morning serum cortisol was 17.9 μg/dL, and ACTH level was 79 pg/mL. Repeat TSS revealed a second adenoma previously unseen on MRI, which also stained positive for ACTH. Postoperative morning cortisol was 0.7 μg/dL, and ACTH was <9 pg/mL. Hydrocortisone, which was started for her central adrenal insufficiency, was tapered and stopped 1 year postoperatively. Late-night salivary cortisol levels were 0.016 and 0.012 μg/dL. Conclusion We conclude that surgical failure in CD after initial TSS should warrant the consideration of a second ACTH-secreting pituitary adenoma and possible repeat TSS.
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Affiliation(s)
- Christine Mathai
- Section of Endocrinology, Diabetes and Metabolism, Temple University Hospital, Philadelphia, Pennsylvania
| | - Jonathan Anolik
- Section of Endocrinology, Diabetes and Metabolism, Temple University Hospital, Philadelphia, Pennsylvania
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Tortora F, Negro A, Briganti F, Del Basso De Caro ML, Cavallo LM, Solari D, Somma T, Brunese L, Caranci F. Pituitary magnetic resonance imaging vs. bilateral inferior petrosal sinus sampling: comparison between non-invasive and invasive diagnostic techniques for Cushing's disease-a narrative review. Gland Surg 2020; 9:2260-2268. [PMID: 33447578 DOI: 10.21037/gs-20-654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cushing's syndrome is a pathological clinical condition caused by an exposure of elevated cortisol levels over a long period of time. It is therefore essential to establish what the cause of hypercortisolism is. In most cases (about 80%) the pathological process is due to adrenocorticotropic hormone (ACTH), while in a minor part of the cases (about 20%) the cause is represented by a pathology of the adrenal glands and therefore not related to ACTH. Most patients with ACTH dependent Cushing's syndrome have a pituitary microadenoma; in the remaining cases (30%), the high level of cortisol is linked to an ectopic secretion of ACTH. Surgical removal of the pituitary adenoma represents the treatment of choice in Cushing's disease (CD) patients; it is therefore necessary to identify and precisely locate the pituitary tumour responsible for the secretion of ACTH. Adequate diagnostic information is very often, even with magnetic resonance imaging (MRI), and in these cases we rely on bilateral inferior petrosal sinuses sampling (BIPSS). This procedure is considered the gold standard method for the diagnosis, but like any other diagnostic method it is not free from erroneous results such as false positives or false negatives.
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Affiliation(s)
- Fabio Tortora
- Unit of Interventional Neuroradiology, Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - Alberto Negro
- Neuroradiology Unit, Ospedale del Mare, Naples, Italy
| | - Francesco Briganti
- Unit of Interventional Neuroradiology, Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | | | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Ferdinando Caranci
- Department of Precision Medicine, School of Medicine "Luigi Vanvitelli", University of Campania, Naples, Italy
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29
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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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30
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Astafyeva LI, Kadashev BA, Sidneva YG, Chernov IV, Kalinin PL. [Pituitary microadenomas - current diagnostic and treatment methods]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2020; 84:110-120. [PMID: 32412200 DOI: 10.17116/neiro202084021110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
According to previously accepted criteria, pituitary microadenoma is characterized by a diameter of less than 10 mm. Improvement and widespread use of MRI are accompanied by increased incidence of diagnosis of these neoplasms. Pituitary microadenomas is an extremely heterogeneous group of tumors with different biological behavior, endocrine secretion and clinical symptoms despite the common MR characteristics. Treatment is mainly determined by endocrine secretion. Endocrine-active microadenoma requires medication (in case of microprolactinoma) and surgical treatment (in case of microsomatotropinoma and ACTH-releasing tumor). Follow-up is advisable for endocrine-inactive microadenoma (microincidentaloma). Modern data on the incidence, clinical and endocrine features, diagnosis and treatment of various pituitary microadenomas are discussed in the article.
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Affiliation(s)
| | | | | | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P L Kalinin
- Burdenko Neurosurgical Center, Moscow, Russia
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31
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Hasenmajer V, Sbardella E, Sciarra F, Minnetti M, Isidori AM, Venneri MA. The Immune System in Cushing's Syndrome. Trends Endocrinol Metab 2020; 31:655-669. [PMID: 32387195 DOI: 10.1016/j.tem.2020.04.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/10/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022]
Abstract
Cushing's syndrome (CS), or chronic hypercortisolism, induces a variety of alterations in the immune system, often leading to severe clinical complications such as sepsis and opportunistic infections. Prolonged exposure to high levels of glucocorticoids (GC), changes in the circadian rhythm, and the comorbidities associated therewith all combine to cause profound changes in the immune profile of affected patients. While traditionally associated with generalized immune suppression, such changes actually comprise a much more complex scenario, sharing traits with chronic inflammatory disorders. Persistently increased levels of interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNFα) and adipose tissue infiltration by immune cells lead to a chronic, nonresolving, inflammatory state. The combination of low-grade inflammation and selectively impaired immune response is thought to play a major role in the pathogenesis of clinical complications of CS, including diabetes, lipodystrophy, visceral adiposity, atherosclerosis, osteoporosis, and cognitive impairment. This dysregulation also explains rebound phenomena when CS is treated, involving new clinical complications sustained by an excessive immune response and autoimmunity. The aim of this review is to summarize the available evidence on the immune system in chronic hypercortisolism, while describing the main mechanisms of immune derangement and their role in the increased mortality and morbidity seen in this complex disease. A better understanding of immune system alterations in CS could help improve risk stratification, offer novel biomarkers, and provide the basis for more tailored therapies and post-remission follow-up.
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Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Sciarra
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Mary Anna Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
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32
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A Case of Recurrent Hemorrhagic Corpus Luteum with Elevated Follicle-Stimulating Hormone, Controlled by Estrogen/Gestagen Therapy. Case Rep Obstet Gynecol 2020; 2020:4098085. [PMID: 32774957 PMCID: PMC7399774 DOI: 10.1155/2020/4098085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 04/21/2020] [Accepted: 07/16/2020] [Indexed: 11/17/2022] Open
Abstract
A high secretion of follicle-stimulating hormone (FSH) in reproductive-aged women is unusual. We report a case of recurrent corpus luteum hemorrhage and subsequent ovarian torsion with markedly elevated FSH levels in a reproductive-aged woman in the absence of functional gonadotroph adenoma (FGA) or premature ovarian failure (POF). A 22-year-old nulligravid woman with a history of bilateral hemorrhagic corpus luteum and subsequent ovarian torsion presented with acute abdominal pain. An emergency salpingo-oophorectomy of the right side was performed, and the right ovarian torsion due to hemorrhagic corpus luteum was diagnosed. Laboratory tests revealed markedly elevated FSH levels (77.6 mIU/mL). FGA was suspected, but no evidence of tumor was identified. The left ovary enlarged again at one-month follow-up. Estrogen/gestagen therapy (EGT) was started, which reduced the enlarged ovary to normal size. Two years later, her pituitary hormonal status was evaluated in detail. Besides markedly elevated FSH level, slightly elevated LH (31.2 mIU/mL), normal total inhibin B (35.3 pg/ml), abnormally low anti-Müllerian hormone (AMH) (<0.03 ng/mL), and poor FSH response to gonadotropin-releasing hormone stimulation test were found. In the absence of FGA, we conclude that certain disorders of inhibitory factors for FSH function, including inhibin and AMH may exist, which could attribute to the patient's symptoms. EGT was very effective in suppressing the ovarian hyperactivity.
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33
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Sbardella E, Crocco M, Feola T, Papa F, Puliani G, Gianfrilli D, Isidori AM, Grossman AB. GH deficiency in cancer survivors in the transition age: diagnosis and therapy. Pituitary 2020; 23:432-456. [PMID: 32488760 DOI: 10.1007/s11102-020-01052-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Survival rates among childhood cancer survivors (CCSs) have significantly risen in the last 40 years due to substantial improvements in treatment protocols. However, this improvement has brought with it serious late effects that frequently involve the endocrine system. Of the endocrine disorders, GH deficiency (GHD) is the most common among CCSs as a consequence of a history of cancers, surgery, and/or radiotherapy involving the hypothalamo-pituitary region. METHODS A comprehensive search of English language articles regardless of age was conducted in the MEDLINE database between December 2018 and October 2019. We selected all studies on GH therapy in CCSs during the transition age regarding the most challenging topics: when to retest; which diagnostic tests and cut-offs to use; when to start GH replacement therapy (GHRT); what GH dose to use; safety; quality of life, compliance and adherence to GHRT; interactions between GH and other hormonal replacement treatments. RESULTS In the present review, we provide an overview of the current clinical management of challenges in GHD in cancer survivors in the transition age. CONCLUSIONS Endocrine dysfunction among CCSs has a high prevalence in the transition age and increase with time. Many endocrine disorders, including GHD, are often not diagnosed or under-diagnosed, probably due to the lack of specialized centers for the long-term follow-up. Therefore, it is crucial that transition specialized clinics should be increased in terms of number and specific skills in order to manage endocrine disorders in adolescence, a delicate and complex period of life. A multidisciplinary approach, also including psychological counseling, is essential in the follow-up and management of these patients in order to minimize their disabilities and maximize their quality of life.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Marco Crocco
- Department of Pediatrics, IRCCS Giannina Gaslini Institute, University of Genoa, Genoa, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Fortuna Papa
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, EC1M 6BQ, UK
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Barbot M, Zilio M, Scaroni C. Cushing's syndrome: Overview of clinical presentation, diagnostic tools and complications. Best Pract Res Clin Endocrinol Metab 2020; 34:101380. [PMID: 32165101 DOI: 10.1016/j.beem.2020.101380] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cushing's syndrome (CS) is a severe condition that results from chronic exposure to elevated circulating cortisol levels; it is a rare but potentially life-threating condition, especially when not timely diagnosed and treated. Even though the diagnosis can be straightforward in florid cases due to their typical phenotype, milder forms can be missed. Despite the availability of different screening tests, the diagnosis remains challenging as none of the available tools proved to be fully accurate. Due to the ubiquitous effect of cortisol, it is easy understandable that its excess leads to a variety of systemic complications including hypertension, metabolic syndrome, bone damages and neurocognitive impairment. This article discusses clinical presentation of CS with an eye on the most frequent cortisol-related comorbidities and discuss the main pitfalls of first- and second-line tests in endogenous hypercortisolism diagnostic workup.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy.
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy
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35
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Sbardella E, Minnetti M, Pofi R, Cozzolino A, Greco E, Gianfrilli D, Isidori AM. Late Effects of Parasellar Lesion Treatment: Hypogonadism and Infertility. Neuroendocrinology 2020; 110:868-881. [PMID: 32335548 DOI: 10.1159/000508107] [Citation(s) in RCA: 2] [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: 03/15/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022]
Abstract
Central hypogonadism, also defined as hypogonadotropic hypogonadism, is a recognized complication of hypothalamic-pituitary-gonadal axis damage following treatment of sellar and parasellar masses. In addition to radiotherapy and surgery, CTLA4-blocking antibodies and alkylating agents such as temozolomide can also lead to hypogonadism, through different mechanisms. Central hypogonadism in boys and girls may lead to pubertal delay or arrest, impairing full development of the genitalia and secondary sexual characteristics. Alternatively, cranial irradiation or ectopic hormone production may instead cause early puberty, affecting hypothalamic control of the gonadostat. Given the reproductive risks, discussion of fertility preservation options and referral to reproductive specialists before treatment is essential. Steroid hormone replacement can interfere with other replacement therapies and may require specific dose adjustments. Adequate gonadotropin stimulation therapy may enable patients to restore gametogenesis and conceive spontaneously. When assisted reproductive technology is needed, protocols must be tailored to account for possible long-term gonadotropin insufficiency prior to stimulation. The aim of this review was to provide an overview of the risk factors for hypogonadism and infertility in patients treated for parasellar lesions and to give a summary of the current recommendations for management and follow-up of these dysfunctions in such patients. We have also briefly summarized evidence on the physiological role of pituitary hormones during pregnancy, focusing on the management of pituitary deficiencies.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Ermanno Greco
- Center for Reproductive Medicine, European Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy,
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Caranci F, Leone G, Ponsiglione A, Muto M, Tortora F, Muto M, Cirillo S, Brunese L, Cerase A. Imaging findings in hypophysitis: a review. Radiol Med 2019; 125:319-328. [PMID: 31863360 DOI: 10.1007/s11547-019-01120-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
Hypophysitis (HP) is a rare acute or chronic inflammatory condition of the pituitary gland. The greatest challenge in the management of HP is establishing a diagnosis through clinical criteria and non-invasive methods and predicting the patients' clinical outcome. The aim of this review is to describe the neuroradiological findings of this rare disease, providing some information regarding the possible differential diagnosis in order to avoid unnecessary surgery. Gadolinium-enhanced pituitary magnetic resonance imaging (MRI) is considered the neuroradiological investigation of choice. The features suggestive for HP include an enlarged triangular- or dumbbell-shaped gland with a thickened and not obviously deviated stalk, further supported by the absence of posterior pituitary bright spot on T1weighted images, particularly in patients presenting with diabetes insipidus. Contrast enhancement pattern is quite variable; dural enhancement has been reported in some cases after intravenous contrast administration. The characterization of the unusual sellar mass is not straightforward and generally results in a wide differential. HP should be primarily differentiated from pituitary adenomas (including pituitary apoplexy), from pituitary metastases, and from other sellar and parasellar tumors, e.g., craniopharyngiomas, germinomas, gliomas, lymphomas, meningiomas, pituicytomas, chordomas, teratomas, dermoids and epidermoids, Rathke's cleft cysts, and abscesses. In patients suspected for secondary forms related to systemic pathology, additional imaging is helpful in identifying other involved sites. Neuroradiologists need to know MRI appearance of this rare disease, as well as its typical symptoms and serological markers. A strict collaboration with endocrinologists and neurosurgeons is mandatory in order to reach a definitive diagnosis, allowing to promptly initiating an appropriate treatment.
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Affiliation(s)
- Ferdinando Caranci
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy.
| | - Giuseppe Leone
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Andrea Ponsiglione
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Massimo Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy.,Department of Neuroscience and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Fabio Tortora
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Mario Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Sossio Cirillo
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Alfonso Cerase
- Department of Neurological and Sensorineural Sciences, Azienda ospedaliero-universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
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Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
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Yang W, Pham D, Vierra A, Azam S, Gui D, Yoon J. Pulmonary embolism as the presenting symptom and a confounder in ACTH-secreting bronchial carcinoid. Endocrinol Diabetes Metab Case Rep 2019; 2019. [PMID: 31352698 PMCID: PMC6685091 DOI: 10.1530/edm-19-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ectopic ACTH-secreting pulmonary neuroendocrine tumors are rare and account for less than 5% of endogenous Cushing’s syndrome cases. We describe an unusual case of metastatic bronchial carcinoid tumor in a young woman presenting with unprovoked pulmonary emboli, which initially prevented the detection of the primary tumor on imaging. The source of ectopic ACTH was ultimately localized by a Gallium-DOTATATE scan, which demonstrated increased tracer uptake in a right middle lobe lung nodule and multiple liver nodules. The histological diagnosis was established based on a core biopsy of a hepatic lesion and the patient was started on a glucocorticoid receptor antagonist and a somatostatin analog. This case illustrates that hypercogulability can further aggravate the diagnostic challenges in ectopic ACTH syndrome. We discuss the literature on the current diagnosis and management strategies for ectopic ACTH syndrome.
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Affiliation(s)
- Wei Yang
- Division of Endocrinology, Department of Internal Medicine
| | - David Pham
- Department of Radiology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Aren Vierra
- Division of Endocrinology, Department of Internal Medicine
| | - Sarah Azam
- Division of Endocrinology, Department of Internal Medicine
| | - Dorina Gui
- Department of Pathology, University of California Davis School of Medicine, Sacramento, California, USA
| | - John Yoon
- Division of Endocrinology, Department of Internal Medicine
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39
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Barbot M, Ceccato F, Lizzul L, Daniele A, Zilio M, Gardiman MP, Denaro L, Emanuelli E, Vianello F, Lombardi G, Rolma G, Scaroni C. Perioperative multidisciplinary management of endoscopic transsphenoidal surgery for sellar lesions: practical suggestions from the Padova model. Neurosurg Rev 2019; 43:1109-1116. [PMID: 31227951 DOI: 10.1007/s10143-019-01132-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/03/2019] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
Abstract
Perioperative management of patients with sellar lesion submitted to endoscopic transsphenoidal neurosurgery (TSS) lacks standardization and therefore it is committed to each center clinical practice. Although neurosurgical procedure remains the same for all sellar lesions, perioperative approach can require different measures depending on the underlying disease. With the aim of standardizing our perioperative procedures and sharing our experience with other centers involved in the management of pituitary disease, we developed a clinical care path for patients with sellar lesions candidate to endoscopic TSS. For the drafting of the following protocol, the national and international guidelines published in the last 5 years have been evaluated and integrated with our center experience accumulated in decades of clinical practice. A steering committee including medical doctors involved in management of patients with pituitary masses at the Padua Hospital reviewed current knowledge on this topic. The committee developed a first draft which was shared with a broader group of medical doctors to reach a preliminary consensus; when it was reached, the clinical care assistance pathway was confirmed, validated, and published in the local web-based health service. We want to present and share our experience with colleagues involved in the perioperative management of pituitary diseases in other centers.
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Affiliation(s)
- M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - L Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - A Daniele
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - M Zilio
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - M P Gardiman
- Surgical Pathology & Cytopathology Unit, Department of Medicine DIMED, University Hospital of Padova, Padua, Italy
| | - L Denaro
- Neurosurgery Unit, Department of Neurosciences, University of Padova, Padua, Italy
| | - E Emanuelli
- Institute of Otorhinolaryngology, Department of Neuroscience, University Hospital of Padova, Padua, Italy
| | - F Vianello
- Radiotherapy Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - G Lombardi
- Clinical and Experimental Oncology, Medical Oncology 1, Veneto Institute of Oncology, Padua, Italy
| | - G Rolma
- Neuroradiology Unit, Department of Radiology, University Hospital of Padova, Padua, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
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Andereggen L, Gralla J, Schroth G, Mordasini P, Andres RH, Widmer HR, Luedi MM, Kellner F, Beck J, Mariani L, Ozdoba C, Christ E. Influence of inferior petrosal sinus drainage symmetry on detection of adenomas in Cushing's syndrome. J Neuroradiol 2019; 48:10-15. [PMID: 31228539 DOI: 10.1016/j.neurad.2019.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Asymmetric inferior petrosal sinuses (IPS) are not infrequently encountered during bilateral IPS sampling. There is little data on whether IPS symmetry influences success in predicting the adenoma side in patients with ACTH-dependent Cushing's syndrome (CS). OBJECTIVE To assess the influence of IPS drainage patterns on detection of an adenoma in CS. METHODS Retrospective single-center cohort analysis reviewing records of patients with CS and negative MRI findings who subsequently underwent BIPSS. RESULTS BIPSS was performed in 38 patients with a mean age of 45±15 years. The overall technical success rate was 97% for bilateral cannulation. Asymmetric IPS were observed in 11 (39%) patients with Cushing's disease (CD). A side-to-side ACTH ratio was not significantly different between patients with symmetric outflow and those with asymmetric outflow at baseline (8.6±2.7 versus 16.4±6.0; P=0.45), but ratios were significantly different after ovine corticotropin-releasing hormone (oCRH) stimulation (6.0±2.5 versus 35.7±22.5; P=0.03). BIPSS correctly predicted the side of the adenoma in 25 (96%) patients with CD. Prediction was better when the venous outflow was symmetric (100%) rather than asymmetric (93%), although the difference was not significant (P=0.42). Remission from CS was achieved in 32 patients (87%), independent of the symmetry of IPS. CONCLUSIONS Bearing in mind the sample size of this audit, asymmetric IPS at least do not seem to diminish the accuracy of diagnosis of ACTH-dependent CS, nor do they influence the clinical outcome.
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Affiliation(s)
- Lukas Andereggen
- Department of neurosurgery, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Robert H Andres
- Department of neurosurgery, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Hans Rudolf Widmer
- Department of neurosurgery, 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
| | - Frauke Kellner
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of neurosurgery, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Luigi Mariani
- Department of neurosurgery, university hospital of Basel, Basel, Switzerland
| | - Christoph Ozdoba
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Emanuel Christ
- Department of endocrinology, diabetology and metabolism, university hospital of Basel, Basel, Switzerland.
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41
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Warszawski L, Esteves GSC, Pagnocelli A, Bouzon BDL, Oliveira SLD. SELLA TURCICA 3T MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF CUSHING'S DISEASE IN CHILDREN: TWO CASE REPORTS. ACTA ACUST UNITED AC 2019; 37:386-391. [PMID: 31090849 PMCID: PMC6868556 DOI: 10.1590/1984-0462/;2019;37;3;00009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/10/2018] [Indexed: 11/22/2022]
Abstract
Objective: To present two clinical cases of pediatric Cushing disease caused by
adrenocorticotropic hormone secreting pituitary adenomas, which were
diagnosed by magnetic resonance imaging using 3 Tesla technology. Case description: Two cases of Cushing disease in 9-year-old children are reported. Both
children presented pituitary adenomas that were smaller than 5 mm at their
largest diameter, and which were not seen by standard 1.5 Tesla resonance.
One of the patients was submitted to bilateral and simultaneous
catheterization of the inferior petrosal sinus, but the result was
undetermined. In both cases, the pituitary adenoma was detected by 3 Tesla
magnetic resonance imaging. Both patients underwent transsphenoidal surgery
and were cured. Comments: Cushing disease presents high morbidity. Therefore, early diagnosis and
prompt treatment are essential. It is usually caused by adenomas that are
smaller than 5 mm in diameter. Surgery is the first line of treatment, and
effective methods of locating the adenoma are necessary for greater
therapeutic success. This report suggests that the 3 Tesla magnetic
resonance imaging is more sensitive, and thus able to detect pituitary
microadenomas (largest diameter <10 mm). This exam may be indicated as a
low-morbidity diagnostic tool for finding pituitary microadenomas in Cushing
disease that are not visualized by 1.5 Tesla magnetic resonance imaging.
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Affiliation(s)
- Leila Warszawski
- Instituto Estadual de Diabetes e Endocrinologia Luis Capriglione, Rio de Janeiro, RJ, Brazil
| | | | - Ariane Pagnocelli
- Instituto Estadual de Diabetes e Endocrinologia Luis Capriglione, Rio de Janeiro, RJ, Brazil
| | - Bruna de Lacerda Bouzon
- Instituto Estadual de Diabetes e Endocrinologia Luis Capriglione, Rio de Janeiro, RJ, Brazil
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Cristante J, Lefournier V, Sturm N, Passagia JG, Gauchez AS, Tahon F, Cantin S, Chabre O, Gay E. Why we should still treat by neurosurgery patients with Cushing's disease and a normal or inconclusive pituitary MRI. J Clin Endocrinol Metab 2019; 104:4101-4113. [PMID: 31087046 DOI: 10.1210/jc.2019-00333] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023]
Abstract
CONTEXT In patients with Cushing's disease (CD) and a typical image of adenoma at MRI, transsphenoidal surgery is consensual. However, when MRI is inconclusive or normal, some authors now advocate medical treatment instead. The implicit assumption is that modern MRI should miss only very small microadenomas, too difficult to visualize at surgery. OBJECTIVE To analyze the evolution with time of the performances of MRI and the outcomes of surgery in CD patients with a typical image of adenoma vs. inconclusive or normal MRI. METHODS AND PATIENTS Retrospective single center study of 195 CD patients treated by transsphenoidal surgery between 1992 and 2018, using first a translabial microscopic and then a transnasal endoscopic approach. Patients with inconclusive or normal MRI were explored by bilateral inferior petrosal sinus sampling (BIPSS). Four MRI groups were defined : microadenomas (n=89), macroadenomas (n=18), or MRI either inconclusive (n=44) or normal (n=44). RESULTS The proportion of inconclusive/normal MRI decreased with time, from 60% (21/35) in 1992-96 to 27% (14/51) in 2012-2018 (p=0.037).In the 4 MRI groups, per-operatory adenoma visualization rate was only slightly lower when MRI was normal (95%; 100%; 86%; 79% ; p=0.012) and postoperative remission rates were not different (85%; 94%; 73%; 75 %; p= 0.11). CONCLUSION The diagnostic performances of MRI have improved but remain inferior to the eye of an expert neurosurgeon, best assisted by endoscopy. We propose that patients with CD and an inconclusive/normal MRI be still addressed to an expert neurosurgeon for transsphenoidal surgery rather than treated medically.
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Affiliation(s)
| | | | - Nathalie Sturm
- Anatomy and pathology department, CHU Grenoble-Alpes, Grenoble, France
| | | | | | - Florence Tahon
- Neuroradiology unit, CHU Grenoble-Alpes, Grenoble France
| | | | - Olivier Chabre
- Endocrinology unit, CHU Grenoble-Alpes, Grenoble, France
| | - Emmanuel Gay
- Neurosurgery unit, CHU Grenoble-Alpes, Grenoble France
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Fukuhara N, Inoshita N, Yamaguchi-Okada M, Tatsushima K, Takeshita A, Ito J, Takeuchi Y, Yamada S, Nishioka H. Outcomes of three-Tesla magnetic resonance imaging for the identification of pituitary adenoma in patients with Cushing's disease. Endocr J 2019; 66:259-264. [PMID: 30760659 DOI: 10.1507/endocrj.ej18-0458] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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
Pituitary adenoma has been reported to be detectable in only 36-63% of Cushing's disease (CD) patients by magnetic resonance imaging (MRI). In this study, we investigate the outcomes and problems associated with tumor identification using 3-Tesla (3-T) MRI, which provides clearer images than ≤1.5-T MRI, in 115 patients who were initially diagnosed with CD. Before surgery, 31 macroadenomas (27%) and 54 microadenomas (47%) were identified by 3-T MRI, but pituitary adenoma was invisible on MRI in the remaining 30 cases (26%). The smallest tumor diameter amenable to a definitive diagnosis was 2 mm, and spoiled gradient-echo was the best sequence for diagnosing microadenomas. In 14 of 30 cases of MRI-invisible CD, the pituitary adenoma was identified during surgery. Nine of these 14 tumors that developed from outside the pituitary gland were retrospectively identified on MRI by comparison with surgical findings. The remaining 16 cases of MRI-invisible CD in which the pituitary adenoma was not identified during surgery involved partial hypophysectomy. Seven cases were hormonally remitted, but another nine cases experienced persistent disease after surgery. The sensitivity and specificity of the pituitary adenoma diagnosis in CD patients after the introduction of 3-T MRI were 80% and 100%, respectively. However, the sensitivity decreased to 72% when macroadenomas were excluded. Some adenomas associated with CD are still undetectable on 3-T MRI due to tumor size, location and intensity. However, sensitivity can be improved by monitoring tumors that develop outside the pituitary gland.
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Affiliation(s)
- Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
| | - Naoko Inoshita
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Pathology, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Mitsuo Yamaguchi-Okada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Keita Tatsushima
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Akira Takeshita
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Junko Ito
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Yasuhiro Takeuchi
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Shozo Yamada
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Neurosurgery, Tokyo Neurological Center Hospital, Tokyo 134-0088, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
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Agarwal A, Gupta A. Commentary: Management of central serous chorioretinopathy: Looking beyond the eye. Indian J Ophthalmol 2018; 66:1714-1715. [PMID: 30451171 PMCID: PMC6256893 DOI: 10.4103/ijo.ijo_1412_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Aniruddha Agarwal
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amod Gupta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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45
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Chatain GP, Patronas N, Smirniotopoulos JG, Piazza M, Benzo S, Ray-Chaudhury A, Sharma S, Lodish M, Nieman L, Stratakis CA, Chittiboina P. Potential utility of FLAIR in MRI-negative Cushing's disease. J Neurosurg 2017; 129:620-628. [PMID: 29027863 DOI: 10.3171/2017.4.jns17234] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Accurate presurgical localization of microadenomas in Cushing's disease (CD) leads to improved remission rates and decreased adverse events. Volumetric gradient recalled echo (3D-GRE) MRI detects pituitary microadenomas in CD in up to 50%-80% cases as a focus of hypointensity due to delayed contrast wash-in. The authors have previously reported that postcontrast FLAIR imaging may be useful in detecting otherwise MRI-negative pituitary microadenomas as foci of hyperintensity. This reflects theoretically complementary imaging of microadenomas due to delayed contrast washout. The authors report on the diagnostic accuracy and clinical utility of FLAIR imaging in the detection of microadenomas in patients with CD. METHODS The authors prospectively analyzed imaging findings in 23 patients (24 tumors) with biochemically proven CD who underwent transsphenoidal surgery for CD. Preoperatively, the patients underwent pituitary MRI with postcontrast FLAIR and postcontrast 3D-GRE sequences. RESULTS Postcontrast FLAIR hyperintensity was detected in macroadenomas, and in 3D-GRE-positive or -negative microadenomas. Overall, 3D-GRE was superior in detecting surgically and histopathologically confirmed, location-concordant microadenomas. Of 24 pituitary adenomas, 18 (75%; sensitivity 82%, positive predictive value 95%) were found on 3D-GRE, and 13 (50% [1 was false positive]; sensitivity 55%, positive predictive value 92%) were correctly identified on FLAIR. The stand-alone specificity of 3D-GRE and FLAIR was similar (50%). These results confirm the superiority of 3D-GRE as a stand-alone imaging modality. The authors then tested the utility of FLAIR as a complementary tool to 3D-GRE imaging. All 5 patients with negative 3D-GRE MRI displayed a distinct focus of FLAIR enhancement. Four of those 5 cases (80%) had location-concordant positive histopathological results and achieved postsurgical biochemical remission. The remaining patient was not cured, because resection did not include the region of FLAIR hyperintensity. CONCLUSIONS This study suggests that delayed microadenoma contrast washout may be detected as FLAIR hyperintensity in otherwise MRI-negative CD cases. The authors propose adding postcontrast FLAIR sequences to complement 3D-GRE for surgical planning in patients with CD. Clinical trial registration no.: NIH protocol 03-N-0164, NCT00060541 (clinicaltrials.gov).
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Affiliation(s)
- Grégoire P Chatain
- 1Neurosurgery Unit for Pituitary and Inheritable Diseases, and.,4Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Nicholas Patronas
- 2Diagnostic Radiology, Warren Grant Magnuson Clinical Center, National Institutes of Health
| | | | - Martin Piazza
- 4Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Sarah Benzo
- 4Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Abhik Ray-Chaudhury
- 4Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Susmeeta Sharma
- 5Pituitary Endocrinology Section, MedStar Washington Hospital Center, Washington, DC
| | - Maya Lodish
- 6Section on Endocrinology and Genetics, Pediatric Endocrinology Inter-Institute Training Program
| | - Lynnette Nieman
- 7Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Constantine A Stratakis
- 6Section on Endocrinology and Genetics, Pediatric Endocrinology Inter-Institute Training Program
| | - Prashant Chittiboina
- 1Neurosurgery Unit for Pituitary and Inheritable Diseases, and.,4Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
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Feng M, Liu Z, Liu X, Bao X, Yao Y, Deng K, Xing B, Lian W, Zhu H, Lu L, Wang R. Diagnosis and Outcomes of 341 Patients with Cushing's Disease Following Transsphenoid Surgery: A Single-Center Experience. World Neurosurg 2017; 109:e75-e80. [PMID: 28951275 DOI: 10.1016/j.wneu.2017.09.105] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Transsphenoid surgery (TSS) is a standard treatment modality for Cushing's disease (CD). However, postoperative remission and recurrence rates vary among studies. Here we analyze the diagnosis and outcomes of 341 patients with a preoperative diagnosis of CD undergoing TSS in a single center over a 3-year period. METHODS A total of 341 patients were enrolled. Clinical manifestations, imaging results, laboratory workups, and results of inferior petrosal sinus sampling (IPSS) were obtained. Outcomes were obtained with a follow-up length from 12 to 36 months. RESULTS The tumors were mainly of Knosp level 0 (68.57%). The sensitivity of MRI, combined low-dose and high-dose dexamethasone suppression test and IPSS in the diagnosis were 90.83%, 88.53% and 95.57%. The concordance of lateralization by MRI and by IPSS were 78.96% and 61.34% compared with surgery. 2. OUTCOMES The overall remission rate was 78.89% (N = 289). Patients undergoing the first TSS (N = 234) had a remission rate of 86.36% for macroadenomas (N = 22) and 83.2% for microadenomas (N = 212). Patients undergoing a second TSS (N = 55) had lower rate of remission of 50.00% for macroadenomas (N = 6) and 61.22% for microadenomas (N = 49). For patients with invasive tumors, the overall remission rate was 26.92% (N = 26), 20.0% for macroadenomas (n = 20) and 50.0% for microadenomas (N = 6). The recurrence rate was 2.42%. CONCLUSIONS Pituitary imaging, endocrinological workups and IPSS are sensitive and specific diagnostic modalities for CD, but the lateralization efficacy of MRI and IPSS are unsatisfactory. A higher rate of remission relies on gross resections of tumors.
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Affiliation(s)
- Ming Feng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ziyuan Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China.
| | - Renzhi Wang
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China.
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