1
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Honour JW. The interpretation of immunometric, chromatographic and mass spectrometric data for steroids in diagnosis of endocrine disorders. Steroids 2024; 211:109502. [PMID: 39214232 DOI: 10.1016/j.steroids.2024.109502] [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: 05/31/2024] [Revised: 08/25/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
The analysis of steroids for endocrine disorders is in transition from immunoassay of individual steroids to more specific chromatographic and mass spectrometric methods with simultaneous determination of several steroids. Gas chromatography (GC) and liquid chromatography (LC) coupled with mass spectrometry (MS) offer unrivalled analytical capability for steroid analysis. These specialist techniques were often judged to be valuable only in a research laboratory but this is no longer the case. In a urinary steroid profile up to 30 steroids are identified with concentrations and excretion rates reported in a number of ways. The assays must accommodate the wide range in steroid concentrations in biological fluids from micromolar for dehydroepiandrosterone sulphate (DHEAS) to picomolar for oestradiol and aldosterone. For plasma concentrations, panels of 5-20 steroids are reported. The profile results are complex and interpretation is a real challenge in order to inform clinicians of likely implications. Although artificial intelligence and machine learning will in time generate reports from the analysis this is a way off being adopted into clinical practice. This review offers guidance on current interpretation of the data from steroid determinations in clinical practice. Using this approach more laboratories can use the techniques to answer clinical questions and offer broader interpretation of the results so that the clinician can understand the conclusion for the steroid defect, and can be advised to program further tests if necessary and instigate treatment. The biochemistry is part of the patient workup and a clinician led multidisciplinary team discussion of the results will be required for challenging patients. The laboratory will have to consider cost implications, bearing in mind that staff costs are the highest component. GC-MS and LC-MS/MS analysis of steroids are the choices. Steroid profiling has enormous potential to improve diagnosis of adrenal disorders and should be adopted in more laboratories in favour of the cheap, non-specific immunological methods.
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Affiliation(s)
- John W Honour
- Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, UK.
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2
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Araujo-Castro M, Hanzu FA, Pascual-Corrales E, García Cano AM, Marchan M, Escobar-Morreale HF, Valderrabano P, Casals G. Is the 1mg-dexamethasone suppression test a precise marker of glucocorticoid excess and cardiometabolic risk in patients with adrenal incidentalomas? Endocrine 2023; 82:161-170. [PMID: 37351760 DOI: 10.1007/s12020-023-03429-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/14/2023] [Indexed: 06/24/2023]
Abstract
AIM To analyze if the 1mg-dexamethasone suppression test (DST) is a reliable marker of glucocorticoid excess and cardiometabolic risk in patients with adrenal incidentalomas (AIs). METHODS Cross-sectional study of patients with nonfunctioning adrenal incidentalomas (NFAIs, defined by cortisol post-DST ≤ 1.8 µg/dL) and patients with autonomous cortisol secretion (ACS, defined by cortisol post-DST > 1.8 µg/Dl). The urinary steroid profile (USP) was determined by gas chromatography coupled to mass spectrometry. Both groups were matched by sex, age and body mass index. RESULTS Forty-nine patients with AIs (25 with ACS and 24 with NFAI) were included. As a whole, AIs showed a high excretion of β-cortolone, tetrahydro-11-deoxycortisol (THS), α-cortolone, α-cortol, tetrahydrocortisol (THF) and tetrahydrocortisone (THE). A positive yet modest correlation between post-DST cortisol and total excretion of glucocorticoid metabolites (r = 0.401, P = 0.004) was observed, with the stronger being observed with total THS (r = 0.548, P < 0.001) and THF (r = 0.441, P = 0.002). Some of the metabolites that were elevated in patients with AIs, were higher in patients with ACS-related comorbidities than in those without comorbidities. Post-DST cortisol showed a fair diagnostic accuracy for the prediction of ACS-related comorbidities (AUC 0.767 [95% CI 0.634-0.882]). However, post-DST diagnostic accuracy improved when combined with urinary cortisone, α-cortol, THS and serum DHEAS (0.853 [0.712‒0.954]). CONCLUSION The DST has a positive, but modest, correlation with urinary glucocorticoid excretion. Similarly, the diagnostic accuracy of the DST for the prediction of ACS-related comorbidities is only fair, but it may be improved if combined with the results of the USP and serum DHEAS. SIGNIFICANCE STATEMENT This is the first study aimed to evaluate if 1mg-dexamethasone suppression test (DST) is a reliable marker of glucocorticoid excess and cardiometabolic risk in patients with adrenal incidentalomas (AIs) and if urinary steroid profile was measured by GS-MS could improve such a prediction. We found a positive yet modest correlation between post-DST cortisol and total excretion of glucocorticoid metabolites, with the stronger being observed with total tetrahydro-11-deoxycortisol (THS) and tetrahydrocortisol. Post-DST cortisol showed a fair diagnostic accuracy for the prediction of ACS-related comorbidities (AUC 0.767). However, post-DST diagnostic accuracy improved when combined with urinary cortisone, α-cortol, THS and serum DHEAS (0.853).
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain.
- Universidad de Alcalá, Madrid, Spain.
| | - Felicia A Hanzu
- Department of Endocrinology & Nutrition Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Eider Pascual-Corrales
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Ana M García Cano
- Department of Biochemistry, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Marta Marchan
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Pablo Valderrabano
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Gregori Casals
- Department of Biochemistry and Molecular Genetics, Hospital Clinic, IDIBAPS, Barcelona, Spain
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Turai PI, Herold Z, Nyirő G, Borka K, Micsik T, Tőke J, Szücs N, Tóth M, Patócs A, Igaz P. Tissue miRNA Combinations for the Differential Diagnosis of Adrenocortical Carcinoma and Adenoma Established by Artificial Intelligence. Cancers (Basel) 2022; 14:cancers14040895. [PMID: 35205648 PMCID: PMC8870702 DOI: 10.3390/cancers14040895] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary The histological differential diagnosis of adrenocortical adenoma and carcinoma is difficult and requires great expertise. MiRNAs were shown to be useful for the differential diagnosis of benign and malignant tumors of several organs, and several findings have suggested their utility in adrenocortical tumors as well. Here, we have selected tissue miRNAs based on the literature search, and used machine learning to identify novel clinically applicable miRNA combinations. Combinations with high sensitivity and specificity (both over 90%) have been identified that could be promising for clinical use. Besides being a useful adjunct to histological examination, these miRNA combinations could enable preoperative adrenal biopsy in patients with adrenal tumors suspicious for malignancy. Abstract The histological analysis of adrenal tumors is difficult and requires great expertise. Tissue microRNA (miRNA) expression is distinct between benign and malignant tumors of several organs and can be useful for diagnostic purposes. MiRNAs are stable and their expression can be reliably reproduced from archived formalin-fixed, paraffin-embedded (FFPE) tissue blocks. Our purpose was to assess the potential applicability of combinations of literature-based miRNAs as markers of adrenocortical malignancy. Archived FFPE tissue samples from 10 adrenocortical carcinoma (ACC), 10 adrenocortical adenoma (ACA) and 10 normal adrenal cortex samples were analyzed in a discovery cohort, while 21 ACC and 22 ACA patients were studied in a blind manner in the validation cohort. The expression of miRNA was determined by RT-qPCR. Machine learning and neural network-based methods were used to find the best performing miRNA combination models. To evaluate diagnostic applicability, ROC-analysis was performed. We have identified three miRNA combinations (hsa-miR-195 + hsa-miR-210 + hsa-miR-503; hsa-miR-210 + hsa-miR-375 + hsa-miR-503 and hsa-miR-210 + hsa-miR-483-5p + hsa-miR-503) as unexpectedly good predictors to determine adrenocortical malignancy with sensitivity and specificity both of over 90%. These miRNA panels can supplement the histological examination of removed tumors and could even be performed from small volume adrenal biopsy samples preoperatively.
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Affiliation(s)
- Péter István Turai
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary; (P.I.T.); (G.N.); (J.T.); (N.S.); (M.T.)
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary
- MTA-SE Molecular Medicine Research Group, Eötvös Loránd Research Network, H-1083 Budapest, Hungary
| | - Zoltán Herold
- Division of Oncology, Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary;
| | - Gábor Nyirő
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary; (P.I.T.); (G.N.); (J.T.); (N.S.); (M.T.)
- MTA-SE Molecular Medicine Research Group, Eötvös Loránd Research Network, H-1083 Budapest, Hungary
- Department of Laboratory Medicine, Faculty of Medicine, Semmelweis University, H-1089 Budapest, Hungary;
| | - Katalin Borka
- 2nd Department of Pathology, Semmelweis University, H-1091 Budapest, Hungary;
| | - Tamás Micsik
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1088 Budapest, Hungary;
| | - Judit Tőke
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary; (P.I.T.); (G.N.); (J.T.); (N.S.); (M.T.)
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary
| | - Nikolette Szücs
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary; (P.I.T.); (G.N.); (J.T.); (N.S.); (M.T.)
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary
| | - Miklós Tóth
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary; (P.I.T.); (G.N.); (J.T.); (N.S.); (M.T.)
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary
| | - Attila Patócs
- Department of Laboratory Medicine, Faculty of Medicine, Semmelweis University, H-1089 Budapest, Hungary;
- MTA-SE Hereditary Tumors Research Group, Eötvös Loránd Research Network, H-1122 Budapest, Hungary
- Department of Molecular Genetics, National Institute of Oncology, H-1122 Budapest, Hungary
| | - Peter Igaz
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary; (P.I.T.); (G.N.); (J.T.); (N.S.); (M.T.)
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary
- MTA-SE Molecular Medicine Research Group, Eötvös Loránd Research Network, H-1083 Budapest, Hungary
- Correspondence: ; Tel.: +36-1-266-0816
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Mueller JW, Vogg N, Lightning TA, Weigand I, Ronchi CL, Foster PA, Kroiss M. Steroid Sulfation in Adrenal Tumors. J Clin Endocrinol Metab 2021; 106:3385-3397. [PMID: 33739426 DOI: 10.1210/clinem/dgab182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The adrenal cortex produces specific steroid hormones including steroid sulfates such as dehydroepiandrosterone sulfate (DHEAS), the most abundant steroid hormone in the human circulation. Steroid sulfation involves a multistep enzyme machinery that may be impaired by inborn errors of steroid metabolism. Emerging data suggest a role of steroid sulfates in the pathophysiology of adrenal tumors and as potential biomarkers. EVIDENCE ACQUISITION Selective literature search using "steroid," "sulfat*," "adrenal," "transport," "mass spectrometry" and related terms in different combinations. EVIDENCE SYNTHESIS A recent study highlighted the tissue abundance of estrogen sulfates to be of prognostic impact in adrenocortical carcinoma tissue samples using matrix-assisted laser desorption ionization mass spectrometry imaging. General mechanisms of sulfate uptake, activation, and transfer to substrate steroids are reasonably well understood. Key aspects of this pathway, however, have not been investigated in detail in the adrenal; these include the regulation of substrate specificity and the secretion of sulfated steroids. Both for the adrenal and targeted peripheral tissues, steroid sulfates may have relevant biological actions beyond their cognate nuclear receptors after desulfation. Impaired steroid sulfation such as low DHEAS in Cushing adenomas is of diagnostic utility, but more comprehensive studies are lacking. In bioanalytics, the requirement of deconjugation for gas-chromatography/mass-spectrometry has precluded the study of steroid sulfates for a long time. This limitation may be overcome by liquid chromatography/tandem mass spectrometry. CONCLUSIONS A role of steroid sulfation in the pathophysiology of adrenal tumors has been suggested and a diagnostic utility of steroid sulfates as biomarkers is likely. Recent analytical developments may target sulfated steroids specifically.
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Affiliation(s)
- Jonathan Wolf Mueller
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
| | - Nora Vogg
- Department of Internal Medicine I, Division of Endocrinology and Diabetology, University Hospital Würzburg, University of Würzburg, Würzburg(Germany)
| | - Thomas Alec Lightning
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Isabel Weigand
- Department of Medicine IV, University Hospital München, Ludwig-Maximilians-Universität München, München, Germany
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
- Department of Internal Medicine I, Division of Endocrinology and Diabetology, University Hospital Würzburg, University of Würzburg, Würzburg(Germany)
| | - Paul A Foster
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetology, University Hospital Würzburg, University of Würzburg, Würzburg(Germany)
- Department of Medicine IV, University Hospital München, Ludwig-Maximilians-Universität München, München, Germany
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Abstract
Adrenal tumors are commonly discovered incidentally on cross-sectional abdominal imaging performed for reasons other than adrenal mass. Incidence of adrenal tumors increased 10-fold in the past 2 decades, with most diagnosed in older adults. In any patient with a newly discovered adrenal mass, determining whether the adrenal mass is malignant and whether it is hormonally active is equally important to guide the best management. Malignancy is diagnosed in 5% to 8% of patients with adrenal tumors, with a higher risk in young patients, if history of extra-adrenal malignancy, in those with large adrenal tumors with indeterminate imaging characteristics, and in bilateral adrenal tumors. Although overt hormone excess is uncommon in adrenal incidentalomas, mild autonomous cortisol secretion can be diagnosed in up to 30% to 50% of patients. Because autonomous cortisol secretion is associated with increased cardiovascular morbidity and metabolic abnormalities, all patients with adrenal incidentalomas require work up with dexamethasone suppression test. Management of adrenal tumors varies based on etiology, associated comorbidities, and patient's preference. This article reviews the current evidence on the diagnosis and evaluation of patients with adrenal mass and focuses on management of the most common etiologies of adrenal incidentalomas.
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Affiliation(s)
- Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Laboratory Medicine and Pathology Mayo Clinic, Rochester, MN 55905, USA
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TT, UK
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Araujo-Castro M, Valderrábano P, Escobar-Morreale HF, Hanzu FA, Casals G. Urine steroid profile as a new promising tool for the evaluation of adrenal tumors. Literature review. Endocrine 2021; 72:40-48. [PMID: 33219921 DOI: 10.1007/s12020-020-02544-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/31/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To review the literature assessing the diagnostic performance of urinary steroid profiling (USP) by high-performance liquid chromatography (LC-MS) or gas chromatography (GC) coupled to mass spectrometry (MS) in the evaluation of adrenal lesions, both in terms of functionality and malignancy. RESULTS The evaluation of adrenal incidentalomas (AI) aims to rule out malignancy and hormone excess. Current diagnostic protocols have several limitations and include time consuming and relatively complicated multi-step processes in most cases. On the contrary, USP by LC-MS/MS or LC-GC/MS offer an easy, comprehensive and non-invasive assessment of adrenal steroid secretion. USP complements current workups used in the evaluation of AIs by improving our ability to identify malignancy and/or autonomous hormone secretion. CONCLUSIONS Urine steroid profiling by LC-MS/MS and GC-MS allows a thorough, non-invasive, assessment of adrenal steroidogenesis as a whole which complement the current evaluation of AIs, and holds a promising role in the diagnosis of autonomous cortisol secretion, primary aldosteronism, and adrenal malignancy.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology & Metabolism, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
| | - Pablo Valderrábano
- Department of Endocrinology & Metabolism, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology & Metabolism, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Felicia A Hanzu
- Department of Endocrinology & Metabolism, Hospital Clinic, Barcelona, Spain
| | - Gregori Casals
- Department of Biochemistry and Molecular Genetics, Hospital Clinic, IDIBAPS, Barcelona, Spain.
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Mizdrak M, Tičinović Kurir T, Božić J. The Role of Biomarkers in Adrenocortical Carcinoma: A Review of Current Evidence and Future Perspectives. Biomedicines 2021; 9:174. [PMID: 33578890 PMCID: PMC7916711 DOI: 10.3390/biomedicines9020174] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/18/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare endocrine malignancy arising from the adrenal cortex often with unexpected biological behavior. It can occur at any age, with two peaks of incidence: in the first and between fifth and seventh decades of life. Although ACC are mostly hormonally active, precursors and metabolites, rather than end products of steroidogenesis are produced by dedifferentiated and immature malignant cells. Distinguishing the etiology of adrenal mass, between benign adenomas, which are quite frequent in general population, and malignant carcinomas with dismal prognosis is often unfeasible. Even after pathohistological analysis, diagnosis of adrenocortical carcinomas is not always straightforward and represents a great challenge for experienced and multidisciplinary expert teams. No single imaging method, hormonal work-up or immunohistochemical labelling can definitively prove the diagnosis of ACC. Over several decades' great efforts have been made in finding novel reliable and available diagnostic and prognostic factors including steroid metabolome profiling or target gene identification. Despite these achievements, the 5-year mortality rate still accounts for approximately 75% to 90%, ACC is frequently diagnosed in advanced stages and therapeutic options are unfortunately limited. Therefore, imperative is to identify new biological markers that can predict patient prognosis and provide new therapeutic options.
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Affiliation(s)
- Maja Mizdrak
- Department of Nephrology and Hemodialysis, University Hospital of Split, 21000 Split, Croatia;
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia;
| | - Tina Tičinović Kurir
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia;
- Department of Endocrinology, Diabetes and Metabolic Disorders, University Hospital of Split, 21000 Split, Croatia
| | - Joško Božić
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia;
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Cheng Y, Kou W, Zhu D, Yu X, Zhu Y. Future Directions in Diagnosis, Prognosis and Disease Monitoring of Adrenocortical Carcinoma: Novel Non-Invasive Biomarkers. Front Endocrinol (Lausanne) 2021; 12:811293. [PMID: 35178030 PMCID: PMC8844185 DOI: 10.3389/fendo.2021.811293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with frequent metastatic spread and poor prognosis. The disease can occur at any age with unexpected biological behavior. Recent genome-wide studies of ACC have contributed to our understanding of the disease, but diagnosis of ACC remains a challenge, even for multidisciplinary expert teams. Patients with ACC are frequently diagnosed in advanced stages and have limited therapeutic options. Therefore, for earlier diagnosis and better clinical management of adrenocortical carcinoma, specific, sensitive, and minimal invasive markers are urgently needed. Over several decades, great efforts have been made in discovering novel and reliable diagnostic and prognostic biomarkers including microRNAs, steroid profilings, circulating tumor cells, circulating tumor DNAs and radiomics. In this review, we will summarize these novel noninvasive biomarkers and analyze their values for diagnosis, predicting prognosis, and disease monitoring. Current problems and possible future application of these non-invasive biomarkers will also be discussed.
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Kiseljak-Vassiliades K, Bancos I, Hamrahian A, Habra M, Vaidya A, Levine AC, Else T. American Association of Clinical Endocrinology Disease State Clinical Review on the Evaluation and Management of Adrenocortical Carcinoma in an Adult: a Practical Approach. Endocr Pract 2020; 26:1366-1383. [PMID: 33875173 DOI: 10.4158/dscr-2020-0567] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this Disease State Clinical Review is to provide a practical approach to patients with newly diagnosed adrenocortical carcinoma, as well as to follow-up and management of patients with persistent or recurrent disease. METHODS This is a case-based clinical review. The provided recommendations are based on evidence available from randomized prospective clinical studies, cohort studies, cross-sectional and case-based studies, and expert opinions. RESULTS Adrenocortical carcinoma is a rare malignancy, often with poor outcomes. For any patient with an adrenal mass suspicious for adrenocortical carcinoma, the approach should include prompt evaluation with detailed history and physical exam, imaging, and biochemical adrenal hormone assessment. In addition to adrenal-focused imaging, patients should be evaluated with chest-abdomen-pelvis cross-sectional imaging to define the initial therapy plan. Patients with potentially resectable disease limited to the adrenal gland should undergo en bloc open surgery by an expert surgeon. For patients presenting with advanced or recurrent disease, a multidisciplinary approach considering curative repeat surgery, local control with surgery, radiation therapy or radiofrequency ablation, or systemic therapy with mitotane and/or cytotoxic chemotherapy is recommended. CONCLUSION As most health care providers will rarely encounter a patient with adrenocortical carcinoma, we recommend that patients with suspected adrenocortical carcinoma be evaluated by an expert multidisciplinary team which includes clinicians with expertise in adrenal tumors, including endocrinologists, oncologists, surgeons, radiation oncologists, pathologists, geneticists, and radiologists. We recommend that patients in remote locations be followed by the local health care provider in collaboration with a multidisciplinary team at an expert adrenal tumor program. ABBREVIATIONS ACC = adrenocortical carcinoma; ACTH = adrenocorticotropic hormone; BRACC = borderline resectable adrenocortical carcinoma; CT = computed tomography; DHEAS = dehydroepiandrosterone sulfate; EDP = etoposide, doxorubicin, cisplatin; FDG = 18F-fluorodeoxyglucose; FNA = fine-needle aspiration; HU = Hounsfield units; IVC = inferior vena cava; LFS = Li-Fraumeni syndrome; MEN1 = multiple endocrine neoplasia type 1; MRI = magnetic resonance imaging; OAC = oncocytic adrenocortical carcinoma; PC = palliative care; PET = positron emission tomography.
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Affiliation(s)
- Katja Kiseljak-Vassiliades
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Amir Hamrahian
- Division of Endocrinology, Johns Hopkins Hospital, Baltimore, Maryland
| | - MouhammedAmir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alice C Levine
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan.
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10
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Newman M, Curran DA, Mayfield BP. Dried urine and salivary profiling for complete assessment of cortisol and cortisol metabolites. J Clin Transl Endocrinol 2020; 22:100243. [PMID: 33354516 PMCID: PMC7744704 DOI: 10.1016/j.jcte.2020.100243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/06/2020] [Accepted: 11/19/2020] [Indexed: 10/29/2022] Open
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Sherlock M, Scarsbrook A, Abbas A, Fraser S, Limumpornpetch P, Dineen R, Stewart PM. Adrenal Incidentaloma. Endocr Rev 2020; 41:bnaa008. [PMID: 32266384 PMCID: PMC7431180 DOI: 10.1210/endrev/bnaa008] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup, and clinical symptoms and signs are required in every case. Adrenocortical carcinoma remains a real concern but is restricted to <2% of all cases. Functional adrenal incidentaloma lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Afroze Abbas
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Sheila Fraser
- Department of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Padiporn Limumpornpetch
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Rosemary Dineen
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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Suzuki S, Minamidate T, Shiga A, Ruike Y, Ishiwata K, Naito K, Ishida A, Deguchi H, Fujimoto M, Koide H, Tatsuno I, Ikeda JI, Yamazaki Y, Sasano H, Yokote K. Steroid metabolites for diagnosing and predicting clinicopathological features in cortisol-producing adrenocortical carcinoma. BMC Endocr Disord 2020; 20:173. [PMID: 33228607 PMCID: PMC7686776 DOI: 10.1186/s12902-020-00652-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/16/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Approximately 60% of adrenocortical carcinomas (ACC) are functional, and Cushing's syndrome is the most frequent diagnosis that has been revealed to have a particularly poor prognosis. Since 30% of ACC present steroid hormone-producing disorganization, measurement of steroid metabolites in suspected ACC is recommended. Previous reports demonstrated that steroid hormone precursors or their urine metabolites, which can be assessed using liquid chromatography tandem mass spectrometry (LC-MS/MS) or gas chromatography mass spectrometry (GC-MS) respectively, are useful for distinguishing ACC from cortisol-producing adenomas (CPA); however, despite high precision, LC-MS/MS and GC-MS require a highly trained team, are expensive and have limited capacity. METHODS Here, we examined 12 serum steroid metabolites using an immunoassay, which is a more rapid and less costly method than LC-MS/MS, in cortisol-producing ACC and CPA. Further, the correlation of each steroid metabolite to the classification stage and pathological status in ACC was analyzed. RESULTS Reflecting disorganized steroidogenesis, the immunoassay revealed that all basal levels of steroid precursors were significantly increased in cortisol-producing ACC compared to CPA; in particular, 17-hydroxypregnenolone (glucocorticoid and androgen precursor) and 11-deoxycorticosterone (mineralocorticoid precursor) showed a large area under the ROC curve with high sensitivity and specificity when setting the cut-off at 1.78 ng/ml and 0.4 mg/ml, respectively. Additionally, a combination of androstenedione and DHEAS also showed high specificity with high accuracy. In cortisol-producing ACC, 11-deoxycortisol (glucocorticoid precursor) showed significant positive correlations with predictive prognostic factors used in ENSAT classification, while testosterone showed significant positive correlations to the Ki67-index in both men and women. CONCLUSION Less expensive and more widely available RIA and ECLIA may also biochemically distinguish ACC from CPA and may predict the clinicopathological features of ACC.
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Affiliation(s)
- Sawako Suzuki
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan.
| | - Tomoki Minamidate
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Akina Shiga
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Yutarou Ruike
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Kazuki Ishiwata
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Kumiko Naito
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Akiko Ishida
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Hanna Deguchi
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Masanori Fujimoto
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Hisashi Koide
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
| | - Ichiro Tatsuno
- Center for Diabetes, Metabolism and Endocrinology, Toho University Sakura Medical Center, Sakura, Japan
| | - Jun-Ichiro Ikeda
- Department of Diagnostic Pathology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University School of Medicine, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University School of Medicine, Sendai, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Diabetes, Metabolism and Endocrinology, Chiba University hospital, Chiba, Japan
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Bancos I, Taylor AE, Chortis V, Sitch AJ, Jenkinson C, Davidge-Pitts CJ, Lang K, Tsagarakis S, Macech M, Riester A, Deutschbein T, Pupovac ID, Kienitz T, Prete A, Papathomas TG, Gilligan LC, Bancos C, Reimondo G, Haissaguerre M, Marina L, Grytaas MA, Sajwani A, Langton K, Ivison HE, Shackleton CHL, Erickson D, Asia M, Palimeri S, Kondracka A, Spyroglou A, Ronchi CL, Simunov B, Delivanis DA, Sutcliffe RP, Tsirou I, Bednarczuk T, Reincke M, Burger-Stritt S, Feelders RA, Canu L, Haak HR, Eisenhofer G, Dennedy MC, Ueland GA, Ivovic M, Tabarin A, Terzolo M, Quinkler M, Kastelan D, Fassnacht M, Beuschlein F, Ambroziak U, Vassiliadi DA, O'Reilly MW, Young WF, Biehl M, Deeks JJ, Arlt W. Urine steroid metabolomics for the differential diagnosis of adrenal incidentalomas in the EURINE-ACT study: a prospective test validation study. Lancet Diabetes Endocrinol 2020; 8:773-781. [PMID: 32711725 PMCID: PMC7447976 DOI: 10.1016/s2213-8587(20)30218-7] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cross-sectional imaging regularly results in incidental discovery of adrenal tumours, requiring exclusion of adrenocortical carcinoma (ACC). However, differentiation is hampered by poor specificity of imaging characteristics. We aimed to validate a urine steroid metabolomics approach, using steroid profiling as the diagnostic basis for ACC. METHODS We did a prospective multicentre study in adult participants (age ≥18 years) with newly diagnosed adrenal masses. We assessed the accuracy of diagnostic imaging strategies based on maximum tumour diameter (≥4 cm vs <4 cm), imaging characteristics (positive vs negative), and urine steroid metabolomics (low, medium, or high risk of ACC), separately and in combination, using a reference standard of histopathology and follow-up investigations. With respect to imaging characteristics, we also assessed the diagnostic utility of increasing the unenhanced CT tumour attenuation threshold from the recommended 10 Hounsfield units (HU) to 20 HU. FINDINGS Of 2169 participants recruited between Jan 17, 2011, and July 15, 2016, we included 2017 from 14 specialist centres in 11 countries in the final analysis. 98 (4·9%) had histopathologically or clinically and biochemically confirmed ACC. Tumours with diameters of 4 cm or larger were identified in 488 participants (24·2%), including 96 of the 98 with ACC (positive predictive value [PPV] 19·7%, 95% CI 16·2-23·5). For imaging characteristics, increasing the unenhanced CT tumour attenuation threshold to 20 HU from the recommended 10 HU increased specificity for ACC (80·0% [95% CI 77·9-82·0] vs 64·0% [61·4-66.4]) while maintaining sensitivity (99·0% [94·4-100·0] vs 100·0% [96·3-100·0]; PPV 19·7%, 16·3-23·5). A urine steroid metabolomics result indicating high risk of ACC had a PPV of 34·6% (95% CI 28·6-41·0). When the three tests were combined, in the order of tumour diameter, positive imaging characteristics, and urine steroid metabolomics, 106 (5·3%) participants had the result maximum tumour diameter of 4 cm or larger, positive imaging characteristics (with the 20 HU cutoff), and urine steroid metabolomics indicating high risk of ACC, for which the PPV was 76·4% (95% CI 67·2-84·1). 70 (3·5%) were classified as being at moderate risk of ACC and 1841 (91·3%) at low risk (negative predictive value 99·7%, 99·4-100·0). INTERPRETATION An unenhanced CT tumour attenuation cutoff of 20 HU should replace that of 10 HU for exclusion of ACC. A triple test strategy of tumour diameter, imaging characteristics, and urine steroid metabolomics improves detection of ACC, which could shorten time to surgery for patients with ACC and help to avoid unnecessary surgery in patients with benign tumours. FUNDING European Commission, UK Medical Research Council, Wellcome Trust, and UK National Institute for Health Research, US National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.
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Affiliation(s)
- Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alice J Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Carl Jenkinson
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Katharina Lang
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Magdalena Macech
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Riester
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Ivana D Pupovac
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Thomas G Papathomas
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Cristian Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | - Magalie Haissaguerre
- Department of Endocrinology, Hôpital Haut Lévêque, CHU de Bordeaux, Pessac, France
| | - Ljiljana Marina
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marianne A Grytaas
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ahmed Sajwani
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Katharina Langton
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - Hannah E Ivison
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Cedric H L Shackleton
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; UCSF Benioff Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Miriam Asia
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sotiria Palimeri
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Agnieszka Kondracka
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Ariadni Spyroglou
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Bojana Simunov
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ioanna Tsirou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Martin Reincke
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stephanie Burger-Stritt
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Harm R Haak
- Department of Internal Medicine, Maxima Medisch Centrum, Eindhoven, Netherlands; Department of Health Services Research and CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - M Conall Dennedy
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Grethe A Ueland
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Miomira Ivovic
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Antoine Tabarin
- Department of Endocrinology, Hôpital Haut Lévêque, CHU de Bordeaux, Pessac, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | | | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, University of Würzburg, Würzburg, Germany; Central Laboratory, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Michael W O'Reilly
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Michael Biehl
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.
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Vaduva P, Bonnet F, Bertherat J. Molecular Basis of Primary Aldosteronism and Adrenal Cushing Syndrome. J Endocr Soc 2020; 4:bvaa075. [PMID: 32783015 PMCID: PMC7412855 DOI: 10.1210/jendso/bvaa075] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
This review reports the main molecular alterations leading to development of benign cortisol- and/or aldosterone-secreting adrenal tumors. Causes of adrenal Cushing syndrome can be divided in 2 groups: multiple bilateral tumors or adenomas secreting cortisol. Bilateral causes are mainly primary pigmented nodular adrenocortical disease, most of the time due to PRKAR1A germline-inactivating mutations, and primary bilateral macronodular adrenal hyperplasia that can be caused in some rare syndromic cases by germline-inactivating mutations of MEN1, APC, and FH and of ARMC5 in isolated forms. PRKACA somatic-activating mutations are the main alterations in unilateral cortisol-producing adenomas. In primary hyperaldosteronism (PA), familial forms were identified in 1% to 5% of cases: familial hyperaldosteronism type I (FH-I) due to a chimeric CYP11B1/CYP11B2 hybrid gene, FH-II due to CLCN-2 germline mutations, FH-III due to KCNJ5 germline mutations, FH-IV due to CACNA1H germline mutations and PA, and seizures and neurological abnormalities syndrome due to CACNA1D germline mutations. Several somatic mutations have been found in aldosterone-producing adenomas in KCNJ5, ATP1A1, ATP2B3, CACNA1D, and CTNNB1 genes. In addition to these genetic alterations, genome-wide approaches identified several new alterations in transcriptome, methylome, and miRnome studies, highlighting new pathways involved in steroid dysregulation.
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Affiliation(s)
- Patricia Vaduva
- Reference Center for Rare Adrenal Diseases, Department of Endocrinology, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France
| | - Fideline Bonnet
- Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France.,Hormonal Biology Laboratory, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Jérôme Bertherat
- Reference Center for Rare Adrenal Diseases, Department of Endocrinology, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France
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15
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Vassiliadi DA, Partsalaki E, Tsagarakis S. Approach to patients with bilateral adrenal incidentalomas. Curr Opin Endocrinol Diabetes Obes 2020; 27:125-131. [PMID: 32209820 DOI: 10.1097/med.0000000000000536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW The current review provides a summary on the most recent developments regarding the cause, work-up and management of bilateral adrenal incidentalomas (BAI). RECENT FINDINGS The recent ENS@T/ESE guidelines provide comprehensive directions on the evaluation and management of patients with adrenal incidentalomas with special focus on those with bilateral tumours. Intraadrenal ACTH synthesis that may locally stimulate cortisol secretion challenging the traditionally used term 'ACTH-independent'. Inactivating mutations of a new tumour suppressor gene, armadillo repeat containing 5 (ARMC5), are implicated in a number of patients, especially those with multiple macronodules (bilateral macronodular hyperplasia) and evidence of hypercortisolism. Loss-of-function mutations of the glucocorticoid receptor gene (NR3C1) consist a new possible genetic cause of BAIs. Regarding management an increasing number of studies provide data on the benefits and safety of unilateral rather than bilateral adrenalectomy. There is also emerging data on the beneficial use of steroidogenesis inhibitors in a dosing schedule that aims to mimic the normal cortisol rhythm with promising short-term results, but the long-term clinical benefits of this approach remain to be demonstrated. SUMMARY The diagnostic approach consists of imaging and hormonal evaluation. Imaging characterization should be done separately for each lesion. Hormonal evaluation includes testing for primary aldosteronism, pheochromocytoma and evaluation for autonomous cortisol secretion, using the 1-mg overnight dexamethasone suppression test. Midnight cortisol or 24-h urinary-free cortisol may aid in establishing the degree of cortisol excess. In patients with hypercortisolism ACTH levels should be measured to establish ACTH-independency. The appropriate management of BAI associated with cortisol excess remains controversial. Bilateral adrenalectomy results in lifetime steroid dependency and is better reserved only for patients with overt and severe hypercortisolism. Unilateral adrenalectomy might be considered in selected patients. Medical therapy is not an established approach yet but it may be considered when control of hypercortisolism is desired, but surgery is not an option.
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Affiliation(s)
- Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes, and Metabolism, National Expertise Center for Rare Endocrine Disorders, Evangelismos Hospital, Athens, Greece
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16
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Lenders NF, Greenfield JR. Urinary steroid profiling in diagnostic evaluation of an unusual adrenal mass. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190090. [PMID: 31778357 PMCID: PMC6893307 DOI: 10.1530/edm-19-0090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022] Open
Abstract
SUMMARY Adrenal oncocytomas are rare tumours, with only approximately 160 cases reported in the literature. We report the use of urinary steroid profiling as part of their diagnostic evaluation and prognostication. A 45-year-old woman presented with clinical features of hyperandrogenism. Serum biochemistry confirmed androgen excess and computed tomography (CT) demonstrated a 3.2 cm adrenal tumour with density 39 HU pre-contrast. Urine steroid profiling showed elevated tetrahydro-11 deoxycortisol (THS), which is associated with adrenal malignancy. Laparoscopic adrenalectomy was performed, and histopathology diagnosed adrenal oncocytoma. Serum and urinary biochemistry resolved post-operatively and remained normal at 1-year follow-up. LEARNING POINTS Differential diagnosis of adrenal masses is challenging. Current techniques for differentiating between tumour types lack sensitivity and specificity. 24-h urinary steroid profiling is a useful tool for reflecting steroid output from adrenal glands. Gas chromatography-mass spectrometry (GC-MS) of urinary steroid metabolites has sensitivity and specificity of 90% for diagnosing adrenocortical carcinoma. Adrenal oncocytoma are rare tumours. Differentiating between benign and malignant types is difficult. Data guiding prognostication and management are sparse.
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Affiliation(s)
- N F Lenders
- Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- Department of Endocrinology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - J R Greenfield
- Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- Department of Endocrinology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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17
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Jouinot A, Armignacco R, Assié G. Genomics of benign adrenocortical tumors. J Steroid Biochem Mol Biol 2019; 193:105414. [PMID: 31207362 DOI: 10.1016/j.jsbmb.2019.105414] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 04/25/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022]
Abstract
Benign adrenocortical adenomas and hyperplasia are relatively common and include a spectrum of distinct entities, which diagnosis depends on the macroscopic aspect and the secretion profile. Recent advances in genomics have proposed high-throughput molecular characterization of adrenal tumors, thereby improving our knowledge on the pathophysiology and tumorigenesis of these tumors. Genomic (exome and chromosome alteration profiles), epigenomic (micro-RNAs expression and methylation profiles) and transcriptomic (gene expression profiles) studies highlighted the major roles of intracellular calcium signaling in aldosterone-producing adenomas (APA), of protein kinase A (PKA)/cAMP pathway in cortisol-producing tumors, and of Wnt/beta-catenin pathway in non-secreting tumors. Exome sequencing revealed new major drivers in all tumor types, including KCNJ5, ATP1A1, ATP2B3, CACNA1D and CACNA1H mutations in APA, PRKACA mutations in cortisol-producing adenomas (CPA) and ARMC5 mutations in primary macronodular adrenocortical hyperplasia (PMAH). The clinical impact of these findings is just starting to evolve. The identification of genetic syndromes, such as germline ARMC5 mutations in PMAH, has allowed genetic counseling. Key molecular alterations could serve as a basis for the development of targeted medical treatments for benign adrenal tumors. The recent developments in genomics, including single-cell technologies, and in proteomics and metabolomics will probably offer new perspectives for characterizing benign adrenal tumorigenesis.
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Affiliation(s)
- Anne Jouinot
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France; Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France
| | - Roberta Armignacco
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France
| | - Guillaume Assié
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France; Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France.
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18
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Abstract
Adrenocortical carcinoma (ACC) is an aggressive and rare neoplasm that originates in the cortex of the adrenal gland. The disease is associated with heterogeneous but mostly poor outcomes and lacks effective pharmaceutical treatment options. Multi-omics studies have defined the landscape of molecular alterations in ACC. Specific molecular signatures can be detected in body fluids, potentially enabling improved diagnostic applications for patients with adrenal tumours. Importantly, pan-molecular data sets further reveal a spectrum within ACC, with three major subgroups that have different disease outcomes. These new subgroups have value as prognostic biomarkers. Research has revealed that the p53-RB and the WNT-β-catenin pathways are common disease drivers in ACC. However, these pathways remain difficult to target by therapeutic interventions. Instead, a unique characteristic of ACC is steroidogenic differentiation, which has emerged as a potential treatment target, with several agents undergoing preclinical or clinical investigations. Finally, a large proportion of ACC tumours have genetic profiles that are associated with promising therapeutic responsiveness in other cancers. All these opportunities now await translation from the laboratory into the clinical setting, thereby offering a real potential of improved survival outcomes and increased quality of life for patients with this serious condition.
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Affiliation(s)
- Joakim Crona
- Department of Medical Sciences, Uppsala Universitet, Uppsala, Sweden.
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zurich, Zurich, Switzerland.
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19
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Lopez AG, Fraissinet F, Lefebvre H, Brunel V, Ziegler F. Pharmacological and analytical interference in hormone assays for diagnosis of adrenal incidentaloma. ANNALES D'ENDOCRINOLOGIE 2019; 80:250-258. [DOI: 10.1016/j.ando.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/27/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
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20
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Delivanis DA, Athimulam S, Bancos I. Modern Management of Mild Autonomous Cortisol Secretion. Clin Pharmacol Ther 2019; 106:1209-1221. [PMID: 31206616 DOI: 10.1002/cpt.1551] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
Incidentally discovered adrenal tumors are reported in ~ 5% of adults undergoing cross-sectional imaging. Mild autonomous cortisol secretion (MACS) from the adrenal mass is demonstrated in 5-48% of patients with adrenal tumors. The diagnosis of MACS represents a challenge due to limitations of the currently used diagnostic tests, differences in the definitions of the clinically relevant MACS, and heterogeneity in an individual's susceptibility to abnormal cortisol secretion from the adrenal mass. Patients with MACS present with increased risk of cardiovascular risk factors, cardiovascular events, metabolic bone disease, and mortality. Adrenalectomy improves or reverses MACS-associated comorbidities in selected patients. The current review will address diagnostic and management challenges in the care of patients with MACS, discuss data on emerging biomarkers, and suggest future directions in the field of MACS.
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Affiliation(s)
- Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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21
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Abstract
PURPOSE OF REVIEW Circulating microRNAs represent promising minimally invasive markers of several diseases including tumors. As the preoperative diagnosis of different adrenal tumors is difficult, for example, diagnosis of adrenocortical or adrenomedullary malignancy, circulating microRNAs might be helpful in their clinical management. RECENT FINDINGS Observations regarding the applicability of circulating microRNAs isolated both from unfractionated plasma or serum and from extracellular vesicle preparations for the diagnosis of adrenocortical malignancy have been published. Data show that circulating microRNA might be exploited for monitoring adrenocortical cancer progression. Circulating microRNA profiles of adrenal myelolipoma have also been published that might be useful for differentiating adrenocortical cancer and adrenal myelolipoma in dubious cases. SUMMARY In this review, recent advances in the field of circulating microRNAs in adrenal tumors are discussed.
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Affiliation(s)
- Peter Igaz
- 2nd Department of Internal Medicine, Faculty of Medicine
- MTA-SE Molecular Medicine Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary
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22
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Comparison of plasma and urinary microRNA-483-5p for the diagnosis of adrenocortical malignancy. J Biotechnol 2019; 297:49-53. [PMID: 30940435 DOI: 10.1016/j.jbiotec.2019.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Minimally invasive circulating microRNAs might be used for the preoperative differentiation of adrenocortical carcinoma (ACC) and adrenocortical adenoma (ACA). So far, the best blood-borne microRNA biomarker of ACC is circulating hsa-miR-483-5p. The expression of urinary hsa-miR-483-5p as a non-invasive marker of malignancy and its correlation with plasma hsa-miR-483-5p, has not been investigated, yet. AIM Our aim was to investigate the expression of urinary hsa-miR-483-5p and its correlation with its plasma counterpart. METHODS Plasma and urinary samples from 23 ACC and 23 ACA patients were analysed using real-time RT-qPCR. To evaluate the diagnostic applicability of hsa-miR-483-5p, ROC-analysis was performed. RESULTS Significant overexpression of hsa-miR-483-5p was observed in carcinoma patients' plasma samples compared to adenoma patients' (p < 0.0001, sensitivity: 87%, specificity: 78.3%). In urinary samples, however, no significant difference could be detected between ACC and ACA patients. CONCLUSIONS Plasma hsa-miR-483-5p has been confirmed as significantly overexpressed in adrenocortical cancer patients and thus might be exploited as a minimally invasive preoperative marker of malignancy. The applicability of urinary hsa-miR-483-5p for the diagnosis of adrenocortical malignancy could not be confirmed.
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23
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Kaur RJ, Pichurin PN, Hines JM, Singh RJ, Grebe SK, Bancos I. Adrenal Cortical Carcinoma Associated With Lynch Syndrome: A Case Report and Review of Literature. J Endocr Soc 2019; 3:784-790. [PMID: 30963136 PMCID: PMC6446885 DOI: 10.1210/js.2019-00050] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/27/2019] [Indexed: 12/20/2022] Open
Abstract
Objective Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis. ACC was reported in 3.2% patients with Lynch syndrome (LS), however no particular case-detection strategies have been recommended. Participants We report a case of a 65-year-old woman who was incidentally discovered with a large adrenal mass during work-up of postmenopausal uterine bleeding. She was recently diagnosed with MSH6 germline mutation after her sister presented with uterine carcinoma in the setting of LS. Results Whereas the patient was asymptomatic for overt hormonal excess, biochemical work-up confirmed glucocorticoid autonomy and androgen and estrogen excess. Urine steroid profiling was suggestive of ACC. Adrenalectomy confirmed an oncocytic ACC with focal extracapsular extension into the periadrenal adipose tissue with a Ki-67 of 15% and a peak mitotic count of 40/50 high-power fields. Conclusion ACC can be the only manifestation of LS. A best case-detection approach for ACC in the asymptomatic patient with LS is unclear, however urine steroid profiling could be considered.
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Affiliation(s)
- Ravinder Jeet Kaur
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Pavel N Pichurin
- Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota
| | - Jolaine M Hines
- Immunochemical Core Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Stefan K Grebe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Papathomas TG, Sun N, Chortis V, Taylor AE, Arlt W, Richter S, Eisenhofer G, Ruiz-Babot G, Guasti L, Walch AK. Novel methods in adrenal research: a metabolomics approach. Histochem Cell Biol 2019; 151:201-216. [PMID: 30725173 DOI: 10.1007/s00418-019-01772-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2019] [Indexed: 02/07/2023]
Abstract
Metabolic alterations have implications in a spectrum of tissue functions and disease. Aided by novel molecular biological and computational tools, our understanding of physiological and pathological processes underpinning endocrine and endocrine-related disease has significantly expanded over the last decade. Herein, we focus on novel metabolomics-related methodologies in adrenal research: in situ metabolomics by mass spectrometry imaging, steroid metabolomics by gas and liquid chromatography-mass spectrometry, energy pathway metabologenomics by liquid chromatography-mass spectrometry-based metabolomics of Krebs cycle intermediates, and cellular reprogramming to generate functional steroidogenic cells and hence to modulate the steroid metabolome. All four techniques to assess and/or modulate the metabolome in biological systems provide tremendous opportunities to manage neoplastic and non-neoplastic disease of the adrenal glands in the era of precision medicine. In this context, we discuss emerging clinical applications and/or promising metabolic-driven research towards diagnostic, prognostic, predictive and therapeutic biomarkers in tumours arising from the adrenal gland and extra-adrenal paraganglia as well as modern approaches to delineate and reprogram adrenal metabolism.
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Affiliation(s)
- Thomas G Papathomas
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Research Unit Analytical Pathology, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Na Sun
- Research Unit Analytical Pathology, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Susan Richter
- Faculty of Medicine Carl Gustav Carus, School of Medicine, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Graeme Eisenhofer
- Faculty of Medicine Carl Gustav Carus, School of Medicine, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine III, Technische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Gerard Ruiz-Babot
- Department of Internal Medicine III, Technische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, USA
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Axel Karl Walch
- Research Unit Analytical Pathology, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
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25
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LaVoie M, Constantinides V, Robin N, Kyriacou A. Florid hyperandrogenism due to a benign adrenocortical adenoma. BMJ Case Rep 2018; 2018:bcr-2018-224804. [PMID: 30061126 PMCID: PMC6067132 DOI: 10.1136/bcr-2018-224804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 11/04/2022] Open
Abstract
A 26-year-old woman with a history of polycystic ovarian syndrome presented with secondary amenorrhea, worsening hirsutism, acne, deepening of voice and unexplained 10-20 kg weight gain. Her Ferriman-Gallway hirsutism score was 12 with cystic facial acne and increased masculine phenotype. Urine Beta-Human Chorionic Gonadotropins (bHCG) was negative. She had elevated serum testosterone of 551 ng/dL, androstenedione at 7.46 ng/mL and dehydroepiandrosterone sulfate (DHEAS) at 4243 µg/L. Overnight dexamethasone suppression test showed mildly unsuppressed cortisol (2.89 µg/dL). Urinary free cortisol along with paired serum cortisol and adrenocorticotrophic hormone (ACTH) tests were normal (55.4 µg/24 hours, 13.44 mcg/dL, 30.4 pg/mL respectively). Her leutinizing hormone (LH) was low(<0.1 mIU/mL), follicle stimulating hormone (FSH) low/normal (1.41 mIU/mL) with sex hormone binding globulin (SHBG) level 45nmol/L and the rest of the pituitary and adrenal workup was unremarkable. Thyroid stimulating hormone (TSH) was 2.15mU/mL. MRI revealed a 3.1 cm, indeterminate but well-defined left adrenal lesion and polycystic ovaries without abdominal lymphadenopathy. Given radiological appearances and despite biochemical concerns for adrenocortical malignancy, a multidisciplinary team meeting decision was made to proceed with laparoscopic adrenalectomy. Histology was consistent with a benign adenoma. Postoperatively, there was clinical and biochemical resolution of the disease.
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Affiliation(s)
- Melanie LaVoie
- Internal Medicine Residency, Stamford Hospital, Stamford, Connecticut, USA
| | | | - Noel Robin
- Internal Medicine Department, Stamford Hospital, Stamford, Connecticut, USA
| | - Angelos Kyriacou
- Endocrinologist, Centre of Endocrinology Diabetes & Metabolism, Limassol, Cyprus
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26
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Honour JW, Conway E, Hodkinson R, Lam F. The evolution of methods for urinary steroid metabolomics in clinical investigations particularly in childhood. J Steroid Biochem Mol Biol 2018; 181:28-51. [PMID: 29481855 DOI: 10.1016/j.jsbmb.2018.02.013] [Citation(s) in RCA: 12] [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: 09/26/2017] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 12/15/2022]
Abstract
The metabolites of cortisol, and the intermediates in the pathways from cholesterol to cortisol and the adrenal sex steroids can be analysed in a single separation of steroids by gas chromatography (GC) coupled to MS to give a urinary steroid profile (USP). Steroids individually and in profile are now commonly measured in plasma by liquid chromatography (LC) coupled with MS/MS. The steroid conjugates in urine can be determined after hydrolysis and derivative formation and for the first time without hydrolysis using GC-MS, GC-MS/MS and liquid chromatography with mass spectrometry (LC-MS/MS). The evolution of the technology, practicalities and clinical applications are examined in this review. The patterns and quantities of steroids changes through childhood. Information can be obtained on production rates, from which children with steroid excess and deficiency states can be recognised when presenting with obesity, adrenarche, adrenal suppression, hypertension, adrenal tumours, intersex condition and early puberty, as examples. Genetic defects in steroid production and action can be detected by abnormalities from the GC-MS of steroids in urine. New mechanisms of steroid synthesis and metabolism have been recognised through steroid profiling. GC with tandem mass spectrometry (GC-MS/MS) has been used for the tentative identification of unknown steroids in urine from newborn infants with congenital adrenal hyperplasia. Suggestions are made as to areas for future research and for future applications of steroid profiling. As routine hospital laboratories become more familiar with the problems of chromatographic and MS analysis they can consider steroid profiling in their test repertoire although with LC-MS/MS of urinary steroids this is unlikely to become a routine test because of the availability, cost and purity of the internal standards and the complexity of data interpretation. Steroid profiling with quantitative analysis by mass spectrometry (MS) after chromatography now provides the most versatile of tests of adrenal function in childhood.
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Affiliation(s)
- John W Honour
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.
| | - E Conway
- Clinical Biochemistry, HSL Analytics LLP, Floor 2, 1 Mabledon Place, London, WC1H 9AX, UK
| | - R Hodkinson
- Clinical Biochemistry, HSL Analytics LLP, Floor 2, 1 Mabledon Place, London, WC1H 9AX, UK
| | - F Lam
- Clinical Biochemistry, HSL Analytics LLP, Floor 2, 1 Mabledon Place, London, WC1H 9AX, UK
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Iñiguez-Ariza NM, Kohlenberg JD, Delivanis DA, Hartman RP, Dean DS, Thomas MA, Shah MZ, Herndon J, McKenzie TJ, Arlt W, Young WF, Bancos I. Clinical, Biochemical, and Radiological Characteristics of a Single-Center Retrospective Cohort of 705 Large Adrenal Tumors. Mayo Clin Proc Innov Qual Outcomes 2018; 2:30-39. [PMID: 30225430 PMCID: PMC6124341 DOI: 10.1016/j.mayocpiqo.2017.11.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To characterize large adrenal tumors (≥4 cm in diameter) and to identify features associated with malignancy. PATIENTS AND METHODS We investigated the clinical, biochemical, and imaging characteristics in a large retrospective single-center cohort of patients with adrenal tumors of 4 cm or more in diameter during the period of January 1, 2000, through December 31, 2014. RESULTS Of 4085 patients with adrenal tumors, 705 (17%) had adrenal masses measuring 4 cm or more in diameter; of these, 373 (53%) were women, with a median age of 59 years (range, 18-91 years) and median tumor size of 5.2 cm (range, 4.0-24.4 cm). Underlying diagnoses were adrenocortical adenomas (n=216 [31%]), pheochromocytomas (n=158 [22%]), other benign adrenal tumors (n=116 [16%]), adrenocortical carcinomas (n=88 [13%]), and other malignant tumors (n=127 [18%]). Compared with benign tumors, malignant tumors were less frequently diagnosed incidentally (45.5% vs 86.7%), were larger (7 cm [range, 4-24.4 cm] vs 5 cm [range, 4-20 cm]), and had higher unenhanced computed tomographic (CT) attenuation (34.5 Hounsfield units [HU] [range, 14.1-75.5 HU] vs 11.5 HU [range, -110 to 71.3 HU]; P<.001). On multivariate analysis, older age at diagnosis, male sex, nonincidental mode of discovery, larger tumor size, and higher unenhanced CT attenuation were all found to be statistically significant predictors of malignancy. CONCLUSION The prevalence of malignancy in patients with adrenal tumors of 4 cm or more in diameter was 31%. Older age, male sex, nonincidental mode of discovery, larger tumor size, and higher unenhanced CT attenuation were associated with an increased risk for malignancy. Clinical context should guide management in patients with adrenal tumors of 4 cm or more in diameter.
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Affiliation(s)
| | | | - Danae A. Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | | | - Diana S. Dean
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Melinda A. Thomas
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Muhammad Z. Shah
- Department of Endocrinology, Diabetes, and Metabolism, University of Minnesota, Minneapolis, MN
| | - Justine Herndon
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | | | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - William F. Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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28
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Perge P, Decmann Á, Pezzani R, Bancos I, Fassina A, Luconi M, Canu L, Tóth M, Boscaro M, Patócs A, Igaz P. Analysis of circulating extracellular vesicle-associated microRNAs in cortisol-producing adrenocortical tumors. Endocrine 2018; 59:280-287. [PMID: 29299796 DOI: 10.1007/s12020-017-1506-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 12/19/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE Circulating microRNAs (miRNA) have been described in patients with adrenocortical tumors, but the expression of miRNAs in non-functioning and cortisol-producing tumors has not been yet compared. Therefore, the objective of this study was to evaluate the expression of plasma extracellular vesicle (EV)-associated microRNAs in patients with non-functioning adrenocortical adenoma (NFA), cortisol-producing adrenocortical adenoma (CPA) and cortisol-producing adrenocortical carcinoma (CP-ACC). METHODS Preoperative plasma EV samples of 13 NFAs, 13 CPAs and 9 CP-ACCs were subjected to extracellular vesicle isolation. miRNAs were investigated by targeted quantitative real-time PCR normalized to cel-miR-39 as reference. Five miRNAs have been selected for this analysis based on the previous studies including hsa-miR-22-3p, hsa-miR-27a-3p, hsa-miR-210-3p, hsa-miR-320b and hsa-miR-375. RESULTS We have observed significant overrepresentation of three miRNAs in both CPA and CP-ACC relative to NFA: hsa-miR-22-3p (p < 0.01 and p < 0.0001, respectively), hsa-miR-27a-3p (p < 0.05 in both comparisons) and hsa-miR-320b (p < 0.05 and p < 0.0001, respectively). Hsa-miR-320b has been significantly overrepresented in CP-ACC relative to CPA (p < 0.01). Hsa-miR-210-3p turned out to be significantly overrepresented only in CP-ACC compared to NFA (p < 0.05). Significant correlation was revealed between circulating miRNA concentrations and urinary free cortisol values for hsa-miR-22-3p, hsa-miR-27a-3p and hsa-miR-320b (p < 0.0001 for all) and cortisol after low-dose dexamethasone test for hsa-miR-22-3p and hsa-miR-320b (p < 0.05). Hsa-miR-27a-3p has been significantly stimulated by low-dose dexamethasone test (p < 0.05). CONCLUSIONS EV-associated miRNAs are differentially expressed in different non-functioning and cortisol-producing adrenocortical tumors.
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Affiliation(s)
- Pál Perge
- 2nd Department of Medicine, Semmelweis University, 1088, Budapest, Szentkiralyi str. 46., Hungary
| | - Ábel Decmann
- 2nd Department of Medicine, Semmelweis University, 1088, Budapest, Szentkiralyi str. 46., Hungary
| | - Raffaele Pezzani
- Endocrinology Unit, Department of Medicine, University of Padua, Via Ospedale, 105, 35128, Padova, Italy
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ambrogio Fassina
- Cytopathology Unit, Department of Medicine, University of Padua, Via Ospedale, 105, 35128, Padova, Italy
| | - Michaela Luconi
- Department of Experimental and Clinical Biomedical Sciences, Endocrinology Unit, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences, Endocrinology Unit, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Miklós Tóth
- 2nd Department of Medicine, Semmelweis University, 1088, Budapest, Szentkiralyi str. 46., Hungary
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine, University of Padua, Via Ospedale, 105, 35128, Padova, Italy
| | - Attila Patócs
- MTA-SE Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, 1088, Budapest, Szentkirályi str. 46., Hungary
- Lendület-2013 Research Group, Hungarian Academy of Sciences and Semmelweis University, 1088, Budapest, Szentkirályi str. 46., Hungary
| | - Peter Igaz
- 2nd Department of Medicine, Semmelweis University, 1088, Budapest, Szentkiralyi str. 46., Hungary.
- MTA-SE Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, 1088, Budapest, Szentkirályi str. 46., Hungary.
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