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Rahimi L, Kittithaworn A, Gregg Garcia R, Saini J, Dogra P, Atkinson EJ, Achenbach SJ, Kattah A, Bancos I. Kidney Function in Patients With Adrenal Adenomas: A Single-Center Retrospective Cohort Study. J Clin Endocrinol Metab 2024; 109:e1750-e1758. [PMID: 38157409 PMCID: PMC11318994 DOI: 10.1210/clinem/dgad765] [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: 08/13/2023] [Revised: 11/27/2023] [Accepted: 12/28/2023] [Indexed: 01/03/2024]
Abstract
CONTEXT Patients with nonfunctioning adrenal adenomas (NFA) and mild autonomous cortisol secretion (MACS) demonstrate an increased risk of chronic kidney disease (CKD); however, factors associated with CKD are unknown. OBJECTIVE We aimed to identify the factors associated with CKD and assess the effect of adrenalectomy on kidney function in patients with NFA or MACS. METHODS A single-center cohort study of patients with NFA and MACS, 1999 to 2020, was conducted. MACS was diagnosed based on post dexamethasone suppression test (DST) cortisol greater than or equal to 1.8 mcg/dL. Age, sex, dysglycemia, hypertension, therapy with statin, angiotensin-converting enzyme inhibitor, or angiotensin II receptor blocker were included in the multivariable analysis. Outcomes included estimated glomerular filtration rate (eGFR) at the time of diagnosis with MACS or NFA and postadrenalectomy delta eGFR. RESULTS Of 972 patients, 429 (44%) had MACS and 543 (56%) had NFA. At the time of diagnosis, patients with MACS had lower eGFR (median 79.6 vs 83.8 mL/min/1.73 m2; P < .001) than patients with NFA. In a multivariable analysis, factors associated with lower eGFR were older age, hypertension, and higher DST. In 204 patients (MACS: 155, 76% and NFA: 49, 24%) treated with adrenalectomy, postadrenalectomy eGFR improved in both groups starting at 18 months up to 3.5 years of follow-up. Factors associated with increased eGFR were younger age, lower preadrenalectomy eGFR, and longer follow-up period. CONCLUSION DST cortisol is an independent risk factor for lower eGFR in patients with adrenal adenomas. Patients with both MACS and NFA demonstrate an increase in eGFR post adrenalectomy, especially younger patients with lower eGFR pre adrenalectomy.
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Affiliation(s)
- Leili Rahimi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Annop Kittithaworn
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Raul Gregg Garcia
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jasmine Saini
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Prerna Dogra
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Elizabeth J Atkinson
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Sara J Achenbach
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Sweeney AT, Hamidi O, Dogra P, Athimulam S, Correa R, Blake MA, McKenzie T, Vaidya A, Pacak K, Hamrahian A, Bancos I. Clinical Review: The Approach to the Evaluation and Management of Bilateral Adrenal Masses. Endocr Pract 2024:S1530-891X(24)00642-6. [PMID: 39103149 DOI: 10.1016/j.eprac.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 08/07/2024]
Affiliation(s)
- Ann T Sweeney
- Department of Medicine, Division of Endocrinology, St Elizabeth's Medical Center, Brighton, MA.
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Prerna Dogra
- Division of Endocrinology, Diabetes and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health, Detroit, MI
| | - Ricardo Correa
- Division of Endocrinology, Cleveland Clinic, 9300 Euclid Avenue, Cleveland, Ohio 44106
| | - Michael A Blake
- Department of Radiology, Division of Abdominal Imaging, Massachusetts General Hospital, Boston, MA
| | - Travis McKenzie
- Department of Surgery, Division of Endocrine Surgery, Mayo Clinic, Rochester, MN
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Amir Hamrahian
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, MD
| | - Irina Bancos
- Division of Endocrinology, Joint appointment Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905
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Barlas T, Gultekin II, Altintop SE, Cindil E, Yalcin MM, Cerit ET, Sozen TS, Poyraz A, Altinova AE, Toruner FB, Karakoc MA, Akturk M. Beyond symptomatology: A comparative analysis of unilateral and bilateral macronodular mild autonomous cortisol secretion. Clin Endocrinol (Oxf) 2024; 101:99-107. [PMID: 38935859 DOI: 10.1111/cen.15109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE To investigate the clinical, laboratory findings and signal intensity index (SII) on magnetic resonance imaging (MRI) of patients with bilateral and unilateral macronodular mild autonomous cortisol secretion (MACS). PATIENTS AND MEASUREMENTS Clinical and laboratory findings of 81 patients with MACS were examined from retrospective records. SII of adenomas and internodular areas were evaluated by MRI. The unilateral group included patients with an adrenal macronodule (≥1 cm) in a single adrenal gland, while the bilateral group included patients with at least one macronodule in both adrenal glands. RESULTS In total, 46 patients were in the unilateral (57%), while 35 (43%) patients were in the bilateral groups. The dehydroepiandrosterone sulphate (DHEA-S) level was lower in the unilateral than in the bilateral group (p < .001). The presence of type 2 diabetes mellitus (T2DM), glycosylated haemoglobin (HbA1c) and low-density lipoprotein (LDL) concentrations were higher in the bilateral group (p < .05). However, no significant difference was detected in terms of adrenocorticotropic hormone (ACTH) and overnight 1 mg dexamethasone suppression test (DST) between the two groups (p > .05). There was no difference in SII between adenomas within the same patient, as well as between the unilateral and bilateral groups (p > .05). Logistic regression analysis based on the differentiation between unilateral and bilateral macronodular MACS demonstrated that DHEA-S, HbA1c and LDL concentrations were associated factors. CONCLUSION DHEA-S levels may not be as suppressed in patients with bilateral macronodular MACS as compared to those with unilateral adenoma. T2DM and hypercholesterolaemia have a higher frequency in bilateral patients. However, ACTH, overnight 1 mg DST and SII may not provide additional information for differentiation of bilaterality and unilaterality.
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Affiliation(s)
- Tugba Barlas
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Isil Imge Gultekin
- Department of Radiology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Sabri Engin Altintop
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Emetullah Cindil
- Department of Radiology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Mehmet Muhittin Yalcin
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Ethem Turgay Cerit
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Tevfik Sinan Sozen
- Department of Urology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Aylar Poyraz
- Department of Pathology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Alev Eroglu Altinova
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Fusun Balos Toruner
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Mehmet Ayhan Karakoc
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Mujde Akturk
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
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Prete A, Bancos I. Mild autonomous cortisol secretion: pathophysiology, comorbidities and management approaches. Nat Rev Endocrinol 2024; 20:460-473. [PMID: 38649778 DOI: 10.1038/s41574-024-00984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
The majority of incidentally discovered adrenal tumours are benign adrenocortical adenomas and the prevalence of adrenocortical adenomas is around 1-7% on cross-sectional abdominal imaging. These can be non-functioning adrenal tumours or they can be associated with autonomous cortisol secretion on a spectrum that ranges from rare clinically overt adrenal Cushing syndrome to the much more prevalent mild autonomous cortisol secretion (MACS) without signs of Cushing syndrome. MACS is diagnosed (based on an abnormal overnight dexamethasone suppression test) in 20-50% of patients with adrenal adenomas. MACS is associated with cardiovascular morbidity, frailty, fragility fractures, decreased quality of life and increased mortality. Management of MACS should be individualized based on patient characteristics and includes adrenalectomy or conservative follow-up with treatment of associated comorbidities. Identifying patients with MACS who are most likely to benefit from adrenalectomy is challenging, as adrenalectomy results in improvement of cardiovascular morbidity in some, but not all, patients with MACS. Of note, diagnosis and management of patients with bilateral MACS is especially challenging. Current gaps in MACS clinical practice include a lack of specific biomarkers diagnostic of MACS-related health outcomes and a paucity of clinical trials demonstrating the efficacy of adrenalectomy on comorbidities associated with MACS. In addition, little evidence exists to demonstrate the efficacy and safety of long-term medical therapy in patients with MACS.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Ren X, Nan M, Zhang X. Evaluating the efficacy of surgical and conservative approaches in mild autonomous cortisol secretion: a meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1399311. [PMID: 39086899 PMCID: PMC11288901 DOI: 10.3389/fendo.2024.1399311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction The management of Mild Autonomous Cortisol Secretion (MACS) remains a topic of debate among clinicians, with differing opinions on the effectiveness of surgical intervention compared to conservative treatment methods. This meta-analysis provides a comprehensive assessment of available literature to determine the most effective approach for treating this condition. Methods On December 1, 2023, an exhaustive literature search of English databases Embase, PubMed, the Cochrane Library, Scopus, Web of Science, as well as the Chinese databases China HowNet, Wanfang Database, SinoMed Database, and Weipu Database using the keywords "Mild Autonomous Cortisol Secretion", "Subclinical Cushing's Syndrome", "Subclinical Hypercortisolism", "Mild Cortisol Autonomous Secretion", "Adrenal Incidentaloma", "Surgical Treatment" and "Adrenalectomy". The data were statistically analyzed using STATA version 15.0. Results In this comprehensive analysis involving 629 patients with MACS, the therapeutic efficacy of adrenalectomy was evident. The meta-analysis results indicate that compared to conservative treatment, surgical intervention more effectively improves obesity indicators in patients: waist circumference (SMD=-0.62, 95% CI: -1.06 to -0.18), BMI (SMD=-0.41, 95% CI: -0.62 to -0.20), enhances glycemic control: fasting blood glucose (SMD=-0.47, 95% CI: -0.68 to -0.26), glycated hemoglobin (SMD=-0.66, 95% CI: -0.95 to -0.38), improves lipid metabolism: triglycerides (SMD=-0.45, 95% CI: -0.73 to -0.16), lowers blood pressure: systolic blood pressure (SMD=-1.04, 95% CI: -1.25 to -0.83), diastolic blood pressure (SMD=-0.89, 95% CI: -1.12 to -0.65), and ameliorates hormonal metabolic disorder: 24h urinary free cortisol (SMD=-1.10, 95% CI: -1.33 to -0.87), ACTH (SMD=2.30, 95% CI: 1.63 to 2.97). All these differences are statistically significant. Conclusion This meta-analysis shows that, compared to conservative treatment, surgical treatment is more effective in improving obesity indicators, glycemic control, lipid metabolism, reducing blood pressure, and ameliorating hormonal metabolic disorders in patients with MACS. These statistically significant results highlight the importance of considering surgical intervention in the management of patients with MACS. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42023492527.
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Affiliation(s)
| | | | - Xiaomei Zhang
- Department of Endocrinology, Peking University International Hospital, Beijing, China
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Birtolo MF, Armignacco R, Benanteur N, Baussart B, Villa C, De Murat D, Guignat L, Groussin L, Libé R, Zennaro MC, Saidi M, Perlemoine K, Letourneur F, Amar L, Bertherat J, Jouinot A, Assié G. Whole blood transcriptomic signature of Cushing's syndrome. Eur J Endocrinol 2024; 191:55-63. [PMID: 38970559 DOI: 10.1093/ejendo/lvae083] [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: 12/12/2023] [Revised: 04/15/2024] [Accepted: 05/20/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE Cushing's syndrome is characterized by high morbidity and mortality with high interindividual variability. Easily measurable biomarkers, in addition to the hormone assays currently used for diagnosis, could reflect the individual biological impact of glucocorticoids. The aim of this study is to identify such biomarkers through the analysis of whole blood transcriptome. DESIGN Whole blood transcriptome was evaluated in 57 samples from patients with overt Cushing's syndrome, mild Cushing's syndrome, eucortisolism, and adrenal insufficiency. Samples were randomly split into a training cohort to set up a Cushing's transcriptomic signature and a validation cohort to assess this signature. METHODS Total RNA was obtained from whole blood samples and sequenced on a NovaSeq 6000 System (Illumina). Both unsupervised (principal component analysis) and supervised (Limma) methods were used to explore the transcriptome profile. Ridge regression was used to build a Cushing's transcriptome predictor. RESULTS The transcriptomic profile discriminated samples with overt Cushing's syndrome. Genes mostly associated with overt Cushing's syndrome were enriched in pathways related to immunity, particularly neutrophil activation. A prediction model of 1500 genes built on the training cohort demonstrated its discriminating value in the validation cohort (accuracy .82) and remained significant in a multivariate model including the neutrophil proportion (P = .002). Expression of FKBP5, a single gene both overexpressed in Cushing's syndrome and implied in the glucocorticoid receptor signaling, could also predict Cushing's syndrome (accuracy .76). CONCLUSIONS Whole blood transcriptome reflects the circulating levels of glucocorticoids. FKBP5 expression could be a nonhormonal marker of Cushing's syndrome.
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Affiliation(s)
- Maria Francesca Birtolo
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy
| | - Roberta Armignacco
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Nesrine Benanteur
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Bertrand Baussart
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Department of Neurosurgery, Hôpital Universitaire Pitié-Salpêtrière, APHP, Sorbonne Université, 75013 Paris, France
| | - Chiara Villa
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Department of Neuropathology, Hôpital Universitaire Pitié-Salpêtrière, APHP, Sorbonne Université, 75013 Paris, France
| | - Daniel De Murat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Laurence Guignat
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Lionel Groussin
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Rossella Libé
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Maria-Christina Zennaro
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
- Service de Génétique, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
| | - Meriama Saidi
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Karine Perlemoine
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Franck Letourneur
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Laurence Amar
- Hypertension Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
| | - Jérôme Bertherat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Anne Jouinot
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Guillaume Assié
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
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Fuß CT, Megerle F, Fassnacht M. [Adrenal tumors: current standards in clinical management]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:632-641. [PMID: 38864873 DOI: 10.1007/s00108-024-01727-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/13/2024]
Abstract
Adrenal tumors are among the most common tumors in humans. They are most frequently discovered incidentally during abdominal imaging for other reasons or due to clinical symptoms (e.g. Conn's or Cushing's syndrome, pheochromocytoma or androgen excess). Although over 80% of adrenal tumors are benign, in cases of hormone excess, they are associated with significantly increased morbidity. In highly malignant adrenocortical carcinoma (ACC), early diagnosis is of particular prognostic relevance. Therefore, this review presents the diagnostic procedure for what are referred to as adrenal incidentalomas and provide recommendations for the management of ACC and pheochromocytomas/paragangliomas (PPGL). In primary diagnosis, sufficient hormone diagnostics is required for all adrenal tumors, as this is the only way to identify all patients with relevant hormone excess. Imaging has increasingly improved in recent years and allows a reliable assessment of the tumor's malignancy in most cases. Imaging of first choice is unenhanced computed tomography (CT), while magnetic resonance imaging (MRI) and fluorodeoxyglucose-18 positron emission tomography (FDG-PET/CT) are reserved for special situations, as published evidence on these procedures is more limited. The treatment of ACC and PPGL is complex and is carried out on an interdisciplinary basis at specialized centers. In the case of localized disease, surgery is the only curative treatment option. There are now clear recommendations for individualized adjuvant therapy for ACC. In metastatic disease, mitotane with or without platinum-containing chemotherapy is the standard. Other lines of therapy should be discussed with a reference center. Over 35% of PPGL have a germline mutation; therefore, genetic testing should be offered. In metastatic PPGL, an individual decision is required between active surveillance, radionuclide therapy, sunitinib or chemotherapy.
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Affiliation(s)
- Carmina Teresa Fuß
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Felix Megerle
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Martin Fassnacht
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
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Di Dalmazi G, Goi J, Burrello J, Tucci L, Cicero AFG, Mancusi C, Coletti Moia E, Iaccarino G, Borghi C, Muiesan ML, Ferri C, Mulatero P. Screening of hypercortisolism among patients with hypertension: an Italian nationwide survey. J Endocrinol Invest 2024:10.1007/s40618-024-02387-2. [PMID: 38913251 DOI: 10.1007/s40618-024-02387-2] [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: 02/21/2024] [Accepted: 04/25/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE Screening of Cushing Syndrome (CS) and Mild Autonomous Cortisol Secretion (MACS) in hypertensive patients is crucial for proper treatment. The aim of the study was to investigate screening and management of hypercortisolism among patients with hypertension in Italy. METHODS A 10 item-questionnaire was delivered to referral centres of European and Italian Society of Hypertension (ESH and SIIA) in a nationwide survey. Data were analyzed according to type of centre (excellence vs non-excellence), geographical area, and medical specialty. RESULTS Within 14 Italian regions, 82 centres (30% excellence, 78.790 patients during the last year, average 600 patients/year) participated to the survey. Internal medicine (44%) and cardiology (31%) were the most prevalent medical specialty. CS and MACS were diagnosed in 313 and 490 patients during the previous 5 years. The highest number of diagnoses was reported by internal medicine and excellence centres. Screening for hypercortisolism was reported by 77% in the presence of specific features of CS, 61% in resistant hypertension, and 38% in patients with adrenal mass. Among screening tests, the 24 h urinary free cortisol was the most used (66%), followed by morning cortisol and ACTH (54%), 1 mg-dexamethasone suppression test (49%), adrenal CT or MRI scans (12%), and late night salivary cortisol (11%). Awareness of referral centres with expertise in management of CS was reported by 67% of the participants, which reduced to 44% among non-excellence centres. CONCLUSIONS Current screening of hypercortisolism among hypertensive patients is unsatisfactory. Strategies tailored to different medical specialties and type of centres should be conceived.
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Affiliation(s)
- G Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - J Goi
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
| | - J Burrello
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
| | - L Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - A F G Cicero
- Hypertension and Cardiovascular Risk Research Unit, Medical and Surgery Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - C Mancusi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - E Coletti Moia
- ARCA (Associazioni Regionali Cardiologi Ambulatoriali) sezione Piemonte, Turin, Italy
| | - G Iaccarino
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - C Borghi
- Hypertension and Cardiovascular Risk Research Unit, Medical and Surgery Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - C Ferri
- Department of Life, Health and Environmental Sciences University of L'Aquila, L'Aquila, Italy
| | - P Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
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Tizianel I, Barbot M, Ceccato F. Subtyping of Cushing's Syndrome: A Step Ahead. Exp Clin Endocrinol Diabetes 2024. [PMID: 38574761 DOI: 10.1055/a-2299-5065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Cushing's Syndrome (CS) is a rare disease due to chronic endogenous cortisol secretion. In recent years, new developments have broadened the spectrum of differential diagnosis, traditionally categorized as adrenocorticotropic hormone (ACTH)-dependent and ACTH-independent forms. Moreover, increased awareness of the detrimental effects of cortisol on cardiometabolic health and the risk of cardiovascular events lead to increased diagnosis of mild forms, especially in the context of adrenal incidentalomas.This review provides an up-to-date narrative of the most recent literature regarding the challenges of CS diagnosis. After the description of the diagnostic tools available, the functional non-neoplastic hypercortisolism (formerly known as pseudo-Cushing state) is characterized, followed by the subtyping of the different conditions of hypercortisolism, including the differential diagnosis of ACTH-dependent forms and the management of adrenal hypercortisolism, with peculiar attention to the new genetic classification of adrenal CS, mild autonomous cortisol secretion, and bilateral adrenal adenomas.
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Affiliation(s)
- Irene Tizianel
- 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
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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Puglisi S, Barač Nekić A, Morelli V, Alessi Y, Fosci M, Pani A, Zibar Tomsic K, Palmieri S, Ferraù F, Pia A, Chiodini I, Kastelan D, Reimondo G, Terzolo M. Are comorbidities of patients with adrenal incidentaloma tied to sex? Front Endocrinol (Lausanne) 2024; 15:1385808. [PMID: 38808113 PMCID: PMC11130385 DOI: 10.3389/fendo.2024.1385808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024] Open
Abstract
Background A recent cross-sectional study showed that both comorbidities and mortality in patients with adrenal incidentaloma (AI) are tied to sex. However, few longitudinal studies evaluated the development of arterial hypertension, hyperglycemia, dyslipidemia and bone impairment in patients with AI. The aim of this study is to analyze the impact of sex in the development of these comorbidities during long-term follow-up. Methods We retrospectively evaluated 189 patients (120 females, 69 males) with AI, from four referral centers in Italy and Croatia. Clinical characteristics, comorbidities and cortisol after 1-mg dexamethasone suppression test (1-mg DST) were assessed at baseline and at last follow-up visit (LFUV). Median follow-up was 52 (Interquartile Range 25-86) months. Results The rates of arterial hypertension and hyperglycemia increased over time both in females (65.8% at baseline versus 77.8% at LFUV, p=0.002; 23.7% at baseline versus 39.6% at LFUV, p<0.001; respectively) and males (58.0% at baseline versus 69.1% at LFUV, p=0.035; 33.8% at baseline versus 54.0% at LFUV, p<0.001; respectively). Patients were stratified in two groups using 1.8 µg/dl as cut-off of cortisol following 1-mg DST: non-functional adrenal tumors (NFAT) and tumors with mild autonomous cortisol secretion (MACS). In the NFAT group (99 patients, females 62.6%), at baseline, we did not observe any difference in clinical characteristics and comorbidities between males and females. At LFUV, males showed a higher frequency of hyperglycemia than females (57.6% versus 33.9%, p=0.03). In the MACS group (89 patients, females 64.0%), at baseline, the prevalence of hypertension, hyperglycemia and dyslipidemia was similar between sexes, despite females were younger (60, IQR 55-69 versus 67.5, IQR 61-73, years; p=0.01). Moreover, females presented higher rates of bone impairment (89.3% versus 54.5%, p=0.02) than males. At LFUV, a similar sex-related pattern was observed. Conclusion Patients with AI frequently develop arterial hypertension and hyperglycemia and should be periodically checked for these comorbidities, regardless of sex. In patients with MACS, the lack of difference between sexes in the frequency of cardiometabolic comorbidities despite that females are younger, and the higher frequency of bone impairment in females, suggest a sex-specific effect of cortisol.
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Affiliation(s)
- Soraya Puglisi
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Anja Barač Nekić
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Valentina Morelli
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Ylenia Alessi
- Department of Human Pathology G. Barresi, Endocrine Unit, University Hospital G. Martino, University of Messina, Messina, Italy
| | - Michele Fosci
- Department of Medical Sciences and Public Health, Endocrinology and Obesity Unit, University of Cagliari, Cagliari, Italy
| | - Angelo Pani
- Department of Medical Sciences and Public Health, Endocrinology and Obesity Unit, University of Cagliari, Cagliari, Italy
| | - Karin Zibar Tomsic
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Serena Palmieri
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Ferraù
- Department of Human Pathology G. Barresi, Endocrine Unit, University Hospital G. Martino, University of Messina, Messina, Italy
| | - Anna Pia
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Iacopo Chiodini
- Department of Biotechnology and Translational Medicine, Unit of Endocrinology, Ospedale Niguarda Cà Granda, University of Milan, Milan, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
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Zopp S, Reincke M. [Cushing's syndrome]. MMW Fortschr Med 2024; 166:56-61. [PMID: 38581518 DOI: 10.1007/s15006-024-3637-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2024]
Affiliation(s)
- Stephanie Zopp
- Klinikum der Ludwig-Maximilians-UniversitätMedizinische Klinik & Poliklinik IV, Cushing-Ambulanz, Ziemssenstraße 5, 80336, München, Deutschland
| | - Martin Reincke
- Zentrum endokrine Tumore, Klinikum der LMU München, Campus Innenstadt, Ziemssenstraße 1, 80336, München, Deutschland
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Laulhé M, Kuhn E, Bouligand J, Amazit L, Perrot J, Lebigot E, Kamenickỷ P, Lombès M, Fagart J, Viengchareun S, Martinerie L. A novel mutation in the NR3C1 gene associated with reversible glucocorticoid resistance. Eur J Endocrinol 2024; 190:284-295. [PMID: 38584335 DOI: 10.1093/ejendo/lvae031] [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: 11/22/2023] [Revised: 02/02/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE Glucocorticoid resistance is a rare endocrine disease caused by variants of the NR3C1 gene encoding the glucocorticoid receptor (GR). We identified a novel heterozygous variant (GRR569Q) in a patient with uncommon reversible glucocorticoid resistance syndrome. METHODS We performed ex vivo functional characterization of the variant in patient fibroblasts and in vitro through transient transfection in undifferentiated HEK 293T cells to assess transcriptional activity, affinity, and nuclear translocation. We studied the impact of the variant on the tertiary structure of the ligand-binding domain through 3D modeling. RESULTS The patient presented initially with an adrenal adenoma with mild autonomous cortisol secretion and undetectable adrenocorticotropin hormone (ACTH) levels. Six months after surgery, biological investigations showed elevated cortisol and ACTH (urinary free cortisol 114 µg/24 h, ACTH 10.9 pmol/L) without clinical symptoms, evoking glucocorticoid resistance syndrome. Functional characterization of the GRR569Q showed decreased expression of target genes (in response to 100 nM cortisol: SGK1 control +97% vs patient +20%, P < .0001) and impaired nuclear translocation in patient fibroblasts compared to control. Similar observations were made in transiently transfected cells, but higher cortisol concentrations overcame glucocorticoid resistance. GRR569Q showed lower ligand affinity (Kd GRWT: 1.73 nM vs GRR569Q: 4.61 nM). Tertiary structure modeling suggested a loss of hydrogen bonds between H3 and the H1-H3 loop. CONCLUSION This is the first description of a reversible glucocorticoid resistance syndrome with effective negative feedback on corticotroph cells regarding increased plasma cortisol concentrations due to the development of mild autonomous cortisol secretion.
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Affiliation(s)
- Margaux Laulhé
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Emmanuelle Kuhn
- Unité Hypophyse, Hôpital Pitié-Salpêtrière, AP-HP, Paris 75013, France
| | - Jérôme Bouligand
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital Bicêtre APHP Paris Saclay, Le Kremlin Bicêtre 94270, France
| | - Larbi Amazit
- UMS 44/Institut Biomédical du Val de Bièvre, Université Paris-Saclay, Le Kremlin Bicêtre 94276, France
| | - Julie Perrot
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Elise Lebigot
- Service de Biochimie, Hôpital Bicêtre APHP Paris Saclay, Le Kremlin Bicêtre 94270, France
| | - Peter Kamenickỷ
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre APHP Paris Saclay, Le Kremlin-Bicêtre 94270, France
| | - Marc Lombès
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Jérôme Fagart
- Laboratoire de Biologie Structurale de la Cellule, BIOC, Ecole Polytechnique, CNRS, Institut Polytechnique de Paris, 91128 Palaiseau cedex, France
| | - Say Viengchareun
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
- Endocrinologie Pédiatrique, Centre de Référence Maladies Endocriniennes Rares de la Croissance et du Développement, Hôpital Universitaire Robert-Debré APHP Nord, Paris 75019, France
- Faculté de Santé, Université Paris Cité, UFR de Médecine, Paris 75006, France
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Araujo-Castro M, Reincke M, Lamas C. Epidemiology and Management of Hypertension and Diabetes Mellitus in Patients with Mild Autonomous Cortisol Secretion: A Review. Biomedicines 2023; 11:3115. [PMID: 38137336 PMCID: PMC10740610 DOI: 10.3390/biomedicines11123115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
Mild autonomous cortisol secretion (MACS) is associated with a higher cardiometabolic risk than that observed in patients with nonfunctioning adrenal adenomas and in the general population. In patients with MACS, the excess of glucocorticoids affects various metabolic pathways, leading to different manifestations of metabolic syndrome and other comorbidities. Hypertension and diabetes mellitus are two of the most common cardiometabolic comorbidities associated with MACS, reaching a prevalence of up to 80% and up to 40%, respectively. In addition, they are the comorbidities that experienced a greater improvement after adrenalectomy in patients with MACS. Hypertension pathogenesis is multifactorial, including the coexistence of comorbidities such as obesity or diabetes and the role of the different polymorphisms of the glucocorticoid receptor gene, among others. Glucocorticoid-induced diabetes mellitus is mainly related to the detrimental effects of glucocorticoids on insulin-dependent glucose uptake in peripheral tissues, gluconeogenesis and insulin secretion. There are no specific recommendations for hypertension and diabetes treatment in patients with MACS. Thus, considering the similar underlying pathogenesis of hypertension and diabetes mellitus in overt and mild hypercortisolism, our recommendation is to follow this general stepwise approach: surgically remove the adrenal culprit lesion to induce remission from hypercortisolism; control hypercortisolism with steroidogenesis inhibitors; and treat elevated blood pressure or high glucose levels using carefully selected anti-hypertensives and glucose-lowering medications if blood pressure and glucose levels remain uncontrolled, respectively. In this review, we summarize the epidemiology, physiopathology and management of diabetes mellitus and hypertension in patients with MACS.
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal, Colmenar Viejo Street km 9, 28034 Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street km 9, 28034 Madrid, Spain
| | - Martin Reincke
- Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany;
| | - Cristina Lamas
- Endocrinology & Nutrition Department, Complejo Hospitalario Universitario de Albacete, 02006 Albacete, Spain;
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