Pathogenesis of glucocorticoid disorders

The history of pituitary surgery for Cushing disease

Although he never performed a pituitary operation for the disease, Harvey Cushing was the first to describe and treat patients with Cushing disease (CD). Other surgeons at the time were reluctant to operate on the pituitary due to the normal sella on skull radiographs in CD and the unclear etiology of the disorder. To better define and understand factors influencing the history of pituitary surgery for CD, the authors analyzed historical texts related to CD biology, diagnosis, and treatment. Cushing's monograph on basophilic pituitary adenomas and cortisol excess appeared in 1932. One year later in 1933, Alfred Pattison performed the first successful pituitary operation for CD by implanting radon seeds in the sella. Resection of a pituitary adenoma for CD was attempted 1 month later in 1933 by Howard Naffziger, resulting in only transient improvement that corresponded to the lack of tumor in the resected tissue. Soon thereafter, Susman in 1935 and Costello in 1936 described pituitary basophilic adenomas at autopsy in patients without premorbid endocrinopathy. They concluded that the adrenal gland was the cause of CD, which resulted in a 3-decade abandonment of pituitary surgery for CD. Jules Hardy in 1963 used the operating microscope to perform the first selective removal of an adrenocorticotropic hormone (ACTH)–secreting microadenoma, which established a pituitary cause and defined the modern treatment of CD. Subsequent reports by Hardy, Laws, and Wilson resulted in widespread acceptance of pituitary surgery for CD. Initial reluctance to operate on the pituitary for CD was multifaceted and included general uncertainty surrounding the etiology of Cushing syndrome as well as a lack of early surgical success, both due to the small size of ACTH-secreting adenomas. Selective removal of ACTH-secreting adenomas identified the source of CD and ended the delay in acceptance of pituitary surgery for CD.

Pituitary tumors: surgical and medical management

The pituitary gland has been termed the 'master gland' because of the myriad of hormones that emanate from it that are vital for normal homeostasis as well as growth and development. Primary tumors of this region are frequent and account for up to 10% of intracranial tumors. Pituitary tumors are monoclonal in origin, and may arise from any of the different cell types of the pituitary gland. Hence, these tumors may be manifest by their hormonal secretions. This may lead to profound and striking physiological changes attributable, for example, to prolactin, growth hormone, or ACTH excess. The central location of the pituitary gland also leads to characteristic compressive symptoms. This review will explore the clinical presentations of growth hormone, ACTH, and prolactin secreting tumors as well as the non-secreting pituitary tumors. Advances in neuroimaging and neuropharmacology have resulted in changes in our treatment of these tumors. Treatment modalities including surgical, medical, and radiation therapy will be addressed. The treatment of choice is dictated by the type of tumor and the nature of the excessive hormonal expression. Outcomes and efficacy of treatment are discussed.

Development of Cushing's disease in a patient with anorexia nervosa

A young woman developed clinical features of anorexia nervosa with a maximal loss of ideal body weight of 54 per cent at the age of 16 yr. A partial recovery from the anorectic symptoms was encountered six years later. At the age of 27 yr pituitary Cushing's disease was diagnosed and corticotroph cell pituitary adenoma subsequently removed by transsphenoidal surgery. Within two years after the operation the clinical and biochemical signs of hypercortisolism had disappeared but some of the anorectic features reappeared. Without neglecting the likelihood of a simple coincidence, the possibility of a common pathogenetic mechanism for anorexia nervosa and Cushing's disease, either affecting the function of the hypothalamic serotonergic pathways or concentration of glucocorticoid receptors, is discussed.

Serum ACTH and adrenal histology in reproductively inhibited male prairie deermice (Peromyscus maniculatus bairdi)

Exogenous ACTH will cause adrenal hypertrophy and gonad dysfunction in reproductively capable male deermice. The ultrastructure of the zona fasciculata of inhibited animals is substantially different from ACTH stimulated animals which suggests that ACTH alone does not produce the inhibition. Although ACTH concentrations were variable, there was no clear demonstration that any differences existed between reproductively capable vs inhibited animals at the time when corticosterone is known to be elevated in the inhibited animals. A contributory role for ACTH in promoting inhibition is not ruled out, but neither is it likely that elevated ACTH alone accounts for the observed reproductive inhibition in animals taken from populations.

Pituitary Cushing's syndrome and Nelson's syndrome: diagnostic criteria, surgical therapy, and results

Eight patients with pituitary Cushing's syndrome and 2 with Nelson's syndrome were followed from one to ten years after removal of pituitary adenomas. A detailed assessment of the pituitary-adrenal axis was obtained in all patients when last seen, save the first, who had undergone a complete hypophysectomy ten years previously. Long-term observations have shown sustained endocrine cure in 7 of 8 patients with pituitary Cushing's syndrome. One patient with Nelson's syndrome was also cured. There was no operative morbidity or mortality. There were no instances of diabetes insipidus. The long-term results in this study indicate that patients with pituitary Cushing's syndrome have a better than 90% chance of being cured after transsphenoidal removal of the pituitary (micro) adenomas. Current diagnostic and therapeutic concepts in the management of pituitary Cushing's syndrome are discussed in detail.

Tumor host relations. I. Increased plasma cortisol in tumor-bearing humans compared with patients with benign surgical diseases

Plasma cortisol was measured by a protein binding technique in 81 patients with malignant tumors of different extent and various sites and in 82 patients with benign surgical diseases. The mean value of the tumor patients (x +/- s = 165 +/- 69 micrograms cortisol/l plasma) was increased significantly compared with the benign surgical disorders (100 +/- 45 micrograms/l). Within the group of patients with benign surgical disorders there was little variation by the type of disease (cortisol mean values given in brackets): benign breast tumors (95), gall stones (107), ulcer of the stomach and duodenum (96), hernia (78), appendicitis acuta (112), and struma (90). The results are in accordance with the hypothesis that glucocorticoids are involved in the increased protein catabolism of skeletal muscles and other signs of cachectic tumor patients.

Cushing's disease. Selective trans-sphenoidal resection of pituitary microadenomas

We undertook trans-sphenoidal microsurgical pituitary exploration in 20 consecutive patients with Cushing's disease, eight of whom had normal sellar polytomography. Pituitary adenomas were selectively resected in 17 and histologically confirmed in 14. In one patient total hypophysectomy revealed a 1.5-mm basophilic adenoma, and in two patients vascular anomalies prevented sellar exploration. Hypercortisolism was corrected in 17 patients (i.e., in 16 of the 17 undergoing selective tumor removal and in the one with total hypophysectomy). Panhypopituitarism occurred only in this patient, and transient diabetes insipidus occurred in five. Most patients became glucocorticoid deficient and required replacement therapy. We conclude that pituitary tumors are present in the great majority of patient with Cushing's disease, even in the absence of demonstrable tomographic changes in the sella turcica, and that selective removal corrects hypercortisolism with little morbidity.

ACTH-secreting 'apudoma' of gallbladder

The case of a 44-year-old woman is reported. The diagnosis after the appropriate tests and laparotomy was ACTH-secreting 'apudoma' of the gallbladder. This is a rare tumour and this case is believed to be the first reported of an ectopic hormone producing tumour from this side.