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Lopez-Montoya V, Gutierrez-Restrepo J, Grajales JLT, Aristizabal N, Pantoja D, Roman-Gonzalez A, Jimenez C. Ectopic Cushing syndrome in Colombia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 64:687-694. [PMID: 34033277 PMCID: PMC10528621 DOI: 10.20945/2359-3997000000271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 05/04/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim was to describe the clinical features of patients with ectopic Cushing syndrome (ECS) from Colombia and compare these findings with other series to provide the best management for these patients. METHODS Records of patients with ECS from 1986 to 2017 were retrospectively reviewed; patients with a diagnosis of adrenal or pituitary Cushing syndrome (CS) were excluded. RESULTS Fourteen patients with ECS were analyzed in this study. The mean age was 54.4 (SD 17.1) years, and the female to male ratio was 1.33:1. Regarding the etiology of ECS, four patients had lung carcinoids (28.6%), three had small-cell lung carcinoma (21.4%), three had pancreatic neuroendocrine tumors (21.4%), one had medullary thyroid cancer (7.1%), one had non-metastatic pheochromocytoma (7.1%), one had metastatic thymoma (7.1%) and one patient had an occult source of ACTH (7.1%). The most common clinical features at presentation were moon-face, muscle weakness, diabetes mellitus and hypertension. Hyperpigmentation was present in 36% of patients, and 12 patients had hypokalemia with a mean value of 2.3 mEq/L (SD 0.71). The median basal cortisol, 24-hour urinary free cortisol (UFC) and ACTH were 30.5 ug/dL (IQR 21-59 ug/dL), 2,600 ug/24 h (IQR 253-6,487 ug/24 h) and 91 pg/mL (IQR 31.9-141.9), respectively. Thirteen patients (92.8%) had the site of the primary lesion identified. Six patients had undergone a surgical intervention to address the primary tumor. Resection was curative in 28.5% of patients. Death occurred in 57.1% of patients, and the median overall survival was 27 months. Intrathoracic tumors had the most aggressive behavior. CONCLUSION ECS is a rare disease; however, it is associated with high morbidity and mortality. A rapid intervention supported by an interdisciplinary group is required to improve overall survival and quality of life.
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Affiliation(s)
| | | | - Jose Luis Torres Grajales
- Clínica Las Américas, Departamento de Endocrinología, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Natalia Aristizabal
- Clínica Las Américas, Departamento de Endocrinología, Universidad Pontificia Bolivariana, Medellín, Colombia
| | | | - Alejandro Roman-Gonzalez
- Departamento de Endocrinología, Universidad de Antioquia, Medellín, Colombia
- Departamento de Endocrinología, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Camilo Jimenez
- Departamento de Neoplasia Endocrina y Trastornos Hormonales, Universidad de Texas, MD Anderson Cancer Center, Houston Texas
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Qiang W, Song S, Chen T, Wang Z, Feng J, Zhang J, Guo H. A rare case of ectopic ACTH syndrome with rhabdomyolysis. BMC Endocr Disord 2021; 21:98. [PMID: 33971870 PMCID: PMC8111963 DOI: 10.1186/s12902-021-00755-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 04/19/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Manifestations of hypokalaemia in ectopic adrenocorticotropic hormonesyndrome(EAS) vary from mild muscle weakness to life-threatening arrhythmia. Herein, we present a rare case of EAS with concomitant rhabdomyolysis(RM) as a result of intractable hypokalaemia. CASE PRESENTATION A 64-year-old man was admitted for limb weakness and facial hyperpigmentation for 2 weeks. Lab tests revealed intractable hypokalaemia (lowest at 1.8 mmol/L) and metabolic alkalosis. The diagnosis of RM was based on a creatine kinase(CK)level of 5 times the upper limit. The elevated CK and myohemoglobin (Mb) levels returned to within the normal range after the alleviation of hypokalaemia. The patient was diagnosed with ACTH-dependent Cushing's syndrome (CS) based on unsuppressed serum cortisol after a low-dose dexamethasone suppression test(LDDST) and remarkably elevated ACTH levels. The diagnosis of EAS was made based on the results of a high-dose dexamethasone suppression test(HDDST) and bilateral inferior petrosal sinus sampling(BIPSS). Multiple lymph nodes in the left supraclavicular fossa, right root of neck, mediastinum and bilateral hili of the lung were found with abnormal uptake of 68Ga-DOTA-NOC. Mediastinoscopic lymph node biopsy was performed. The pathological diagnosis was small-cell and large-cell neuroendocrine carcinoma with positive ACTH staining. The patient was prescribed mifepristone and received one cycle of chemotherapy. The patient could not tolerate subsequent chemotherapy and died of dyscrasia. CONCLUSIONS RM is a rare complication of EAS with insidious onset and atypical clinical manifestations. Serum potassium levels should be vigilantly monitored to avoid RM in EAS.
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Affiliation(s)
- Wei Qiang
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
| | - Sucai Song
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
- Department of Endocrinology, The First Affiliated Hospital of Zhengzhou University, 450052 Zhengzhou, People’s Republic of China
| | - Tianjun Chen
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Zhe Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jun Feng
- Department of Vascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jiaojiao Zhang
- Department of Pathology, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Hui Guo
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
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Moszczyńska E, Pasternak-Pietrzak K, Prokop-Piotrkowska M, Śliwińska A, Szymańska S, Szalecki M. Ectopic ACTH production by thymic and appendiceal neuroendocrine tumors - two case reports. J Pediatr Endocrinol Metab 2021; 34:141-146. [PMID: 33185577 DOI: 10.1515/jpem-2020-0442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Ectopic adrenocorticotropic syndrome (EAS) causes approximately 10-18% of cases of Cushing's syndrome (CS) in adults, while in children it occurs much less frequently. CASE PRESENTATION We report two cases of neuroendocrine tumors (of the thymus and the appendix) in a 12-year-old boy and a 15-year-old girl who presented with the clinical features of CS. Elevated serum cortisol, ACTH, and chromogranin levels were observed in both patients. Diagnoses were made on the basis of a mass in the thymus/appendix region visualized with chest/abdominal CT scan and radiotracer accumulation in scintigraphy in the same areas. Histopathological examinations confirmed the diagnoses of NET. CONCLUSION EAS is an extremely rare endocrine disorder. However, it should be taken into consideration in the diagnostic process of every case of ACTH-dependent CS.
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Affiliation(s)
- Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Monika Prokop-Piotrkowska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Anna Śliwińska
- Department of Nuclear Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Sylwia Szymańska
- Department of Pathology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute, Warsaw, Poland.,Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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Di Ruscio V, Del Baldo G, De Pasquale MD, De Vito R, Miele E, Colafati GS, Deodati A, De Ioris MA, Tornesello A, Milano GM, Mastronuzzi A. Ectopic ACTH Secretion in a Child With Metastatic Ewing's Sarcoma: A Case Report. Front Oncol 2020; 10:574. [PMID: 32411598 PMCID: PMC7198717 DOI: 10.3389/fonc.2020.00574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/30/2020] [Indexed: 11/17/2022] Open
Abstract
Ectopic ACTH syndrome is rare in pediatric age. Sarcomas that cause Ectopic ACTH Syndrome (EAS) are even more uncommon. Currently, only three cases of EAS caused by Ewing' sarcoma have been reported. We detail a 10-year-old boy with Cushing's syndrome symptoms caused by ectopic ACTH production by a metastatic Ewing's sarcoma of the right ischio-pubic and ileo-pubic branches. The rapid appearance of cushingoid symptoms, with significant weight gain, acne, hirsutism, and hypercortisolism were implications of ectopic ACTH production as paraneoplastic Cushing's Syndrome. The very high levels of ACTH and non-suppression at the high dose dexamethasone test confirmed the clinical suspicion. We underline the possibility EAS was caused by an ACTH-secreting tumor, including soft tissue sarcomas.
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Affiliation(s)
- Valentina Di Ruscio
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Department of Paediatric, Sapienza University of Rome, Rome, Italy
| | - Giada Del Baldo
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria Debora De Pasquale
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Rita De Vito
- Department of Pathology, Bambino Gesù Children Hospital (IRCCS), Rome, Italy
| | - Evelina Miele
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Annalisa Deodati
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | | | - Giuseppe Maria Milano
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Angela Mastronuzzi
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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Abstract
BACKGROUND Two types of ectopic Cushing syndrome (ECS) are described: ECS associated with aggressive neoplasms, and ECS with indolent and occult tumors, however, there is a lack of studies that thoroughly review their characteristics. METHODS A systematic review was carried out on PUBMED of all the papers about the ECS, in order to better define the types of this subcategory of Cushing's syndrome, highlighting the differential aspects between these subgroups. RESULTS It was found that in 50% of cases the prototypic "aggressive" ECS is caused by small cell lung carcinomas (SCLC). In these cases, the clinical presentation may be atypical, predominating the signs and symptoms derived from the protein catabolism. Cortisol and ACTH levels are extremely high, the clinical presentation is abrupt (< 3-6 months) and the tumor is usually advanced, being impossible a curative treatment. On the other hand, "indolent" ECS is mainly represented by carcinoid tumors (CT). In these cases the clinical presentation overlaps enormously with that of Cushing's disease (CD). Cortisol and ACTH levels are slightly elevated, the clinical presentation is progressive (> 6 months) and the prognosis is usually good, and a curative treatment is possible in about 75% of the cases. CONCLUSION Although there is no absolute differentiation between the two extremes of ECS, a classification could be established in two groups, guided by its clinical and biochemical characteristics, and mainly by the type and stage of the ACTH-secreting tumor. However, a small percentage of tumors do not fit in this simple grouping, and may present both phenotypes or an intermediate one.
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Affiliation(s)
- Marta Araujo Castro
- Department Endocrinology, Hospital Universitario de la Princesa, Madrid, Spain.
- Department Endocrinology, Hospital Universitario Rey Juan Carlos, Madrid, Spain.
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Ectopic Cushing's syndrome due to adrenocorticotropic hormone secreting atypical thymic carcinoid tumor. North Clin Istanb 2018; 6:85-88. [PMID: 31180388 PMCID: PMC6526992 DOI: 10.14744/nci.2018.53244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 02/01/2018] [Indexed: 01/01/2023] Open
Abstract
Cushing’s syndromes (CS) due to thymic carcinoids are rarely seen. In this text, a case with CS due to ectopic adrenocorticotropic hormone (ACTH) secreting atypical thymic carcinoid tumor is presented. A 50-year-old Turkish male patient was admitted to our emergency department with typical CS features. Basal hormone profile, low- and high-dose dexamethasone suppression tests, and inferior petrosal sinus sampling results were consistent with ectopic ACTH secretion. Thorax computerized tomography showed an upper mediastinal mass, and trans-thoracic biopsy showed atypical thymic carcinoid with positive ACTH staining. Since the vascular invasion was detected, tumor was accepted inoperable; somatostatine receptor analogs, chemotherapy, and radiotherapy were planned. Ectopic CS can be derived from atypical thymic carcinoid. In this case, ACTH staining was used to confirm ACTH secretion from thymic tissue, and positive staining was detected. ACTH staining routinely was not performed for extra hypophyseal tissue tumors. In suspicious and difficult cases, ACTH staining can be helpful to confirm the presence of ACTH in tumor tissues.
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Araujo Castro M, Palacios García N, Aller Pardo J, Izquierdo Alvarez C, Armengod Grao L, Estrada García J. Ectopic Cushing syndrome: Report of 9 cases. ACTA ACUST UNITED AC 2018; 65:255-264. [PMID: 29655957 DOI: 10.1016/j.endinu.2018.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/29/2018] [Accepted: 02/03/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Ectopic Cushing's syndrome (ECS) is a rare condition caused by ACTH secretion by extrapituitary tumors. Its low frequency makes it difficult to acquire experience in its management. The aim of this study was to describe patients with ECS seen at the endocrinology department of a tertiary hospital over 15 years. METHODS This was a retrospective study of the clinical, biochemical and radiographic data, treatment, and course of patients with ECS seen from 2000 to 2015. RESULTS Nine patients (6 of them female) with a mean age of 47 years were included in the study. The clinical syndrome developed in less than 3 months in all cases but one, and most patients also had edema, hyperpigmentation and/or hypokalemia. Mean urinary free cortisol and ACTH levels were 2,840μg/24h and 204pg/mL respectively. The ectopic origin was confirmed by a combination of dynamic non-invasive tests and radiographic studies in most cases. The tumor responsible could be identified in 8 cases, and 7 patients had metastatic dissemination. Primary treatment was surgery in one patient, surgery combined with systemic therapy in 3, and chemotherapy in the other 3 patients. Bilateral adrenalectomy was required in 4 patients to control hypercortisolism. After a mean follow-up of 40 months, 3 patients died, 5 were still alive, and one had been lost to follow-up. CONCLUSIONS Our study confirms that ECS covers a wide spectrum of tumors of different aggressiveness and nature. The ectopic origin of Cushing's syndrome can usually, be suspected and confirmed in most cases without the need for invasive tests. Control of both hypercortisolism and the tumor requires multiple treatment modalities, and multidisciplinary management is recommended.
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Affiliation(s)
- Marta Araujo Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | - Nuria Palacios García
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Javier Aller Pardo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | | | - Laura Armengod Grao
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Javier Estrada García
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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Guilmette J, Nosé V. Hereditary and familial thyroid tumours. Histopathology 2017; 72:70-81. [DOI: 10.1111/his.13373] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 01/16/2023]
Affiliation(s)
| | - Vania Nosé
- Massachusetts General Hospital; Boston MA USA
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Hypercortisolism Manifesting as Severe Weight Loss, Hypokalemia, and Hyperglycemia in the Emergency Department. J Emerg Med 2016; 50:e187-90. [DOI: 10.1016/j.jemermed.2015.06.084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 06/01/2015] [Indexed: 12/25/2022]
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Abstract
Cushing syndrome due to endogenous hypercortisolism may cause significant morbidity and mortality. The source of excess cortisol may be adrenal, pituitary, or ectopic. Ectopic Cushing syndrome is sometimes difficult to localize on conventional imaging like CT and MRI. After performing a multilevel thoracoabdominal imaging with CT, the evidence regarding the use of radiotracers for PET imaging is unclear due to significant molecular and etiological heterogeneity of potential causes of ectopic Cushing's syndrome. In our systematic review of literature, it appears that GalLium-based (Ga68) somatostatin receptor analogs have better sensitivity in diagnosis of bronchial carcinoids causing Cushing syndrome and FDG PET appears superior for small-cell lung cancers and other aggressive tumors. Further large-scale studies are needed to identify the best PET tracer for this condition.
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Affiliation(s)
- Prasanna Santhanam
- Section of Endocrinology, Department of Internal Medicine, Joan C Edwards School of Medicine, Marshall University, Huntington, WV, 25701, USA.
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France.
- Marseille Cancerology Research Center, Institut Paoli-Calmettes, Marseille, France.
| | - Luca Giovanella
- Nuclear Medicine and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, Switzerland.
| | - Giorgio Treglia
- Nuclear Medicine and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, Switzerland.
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