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Prete A, Bancos I. Mild autonomous cortisol secretion: pathophysiology, comorbidities and management approaches. Nat Rev Endocrinol 2024; 20:460-473. [PMID: 38649778 DOI: 10.1038/s41574-024-00984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
The majority of incidentally discovered adrenal tumours are benign adrenocortical adenomas and the prevalence of adrenocortical adenomas is around 1-7% on cross-sectional abdominal imaging. These can be non-functioning adrenal tumours or they can be associated with autonomous cortisol secretion on a spectrum that ranges from rare clinically overt adrenal Cushing syndrome to the much more prevalent mild autonomous cortisol secretion (MACS) without signs of Cushing syndrome. MACS is diagnosed (based on an abnormal overnight dexamethasone suppression test) in 20-50% of patients with adrenal adenomas. MACS is associated with cardiovascular morbidity, frailty, fragility fractures, decreased quality of life and increased mortality. Management of MACS should be individualized based on patient characteristics and includes adrenalectomy or conservative follow-up with treatment of associated comorbidities. Identifying patients with MACS who are most likely to benefit from adrenalectomy is challenging, as adrenalectomy results in improvement of cardiovascular morbidity in some, but not all, patients with MACS. Of note, diagnosis and management of patients with bilateral MACS is especially challenging. Current gaps in MACS clinical practice include a lack of specific biomarkers diagnostic of MACS-related health outcomes and a paucity of clinical trials demonstrating the efficacy of adrenalectomy on comorbidities associated with MACS. In addition, little evidence exists to demonstrate the efficacy and safety of long-term medical therapy in patients with MACS.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Denham SG, Simpson JP, Diez F, Lee P, Kyle C, Morgan R, Homer NZM. A practical approach to supported liquid extraction and measurement of 18 steroids in plasma and serum by targeted liquid chromatography tandem mass spectrometry. MethodsX 2024; 12:102728. [PMID: 38948242 PMCID: PMC11214409 DOI: 10.1016/j.mex.2024.102728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/20/2024] [Indexed: 07/02/2024] Open
Abstract
Chromatography combined with mass spectrometry is a gold standard technique for steroid measurement, however the type of sample preparation, the dynamic range and reliability of the calibration curve, the chromatographic separation and mass spectrometry settings ultimately determine the success of the method. The steroid biosynthetic pathway is conserved in higher mammals and literature demonstrates that the concentration ranges of different steroid groups are relatively comparable across species. We sought to develop a robust and reliable multi steroid targeted analysis method for blood that would have wide application across higher mammals. The method was developed following bioanalytical method validation guidelines to standards typically applied to human clinical studies, including isotopically labelled internal standards where at all possible. Here we describe the practical approach to a 96-well supported liquid extraction (SLE) method of extraction from plasma (200 µL) using an Extrahera liquid handling robot (Biotage, Sweden), including quality control samples, followed by a comprehensive separation and targeted LC-MS/MS analysis of 18 steroids in plasma (pregnenolone, progesterone, 17α-hydroxyprogesterone, 11-deoxycorticosterone, corticosterone, 11-dehydrocorticosterone, aldosterone, 11-deoxycortisol, 21-deoxycortisol, cortisol, cortisone, androstenedione, testosterone, 5α-dihydrotestosterone, dehydroepiandrosterone, estrone, 17β-estradiol and estriol). •SLE in a 96-well format of up to 74 biological plasma samples, enriched with multiple isotopically labelled internal standards, a 12-point aqueous calibration curve, and 6 serum quality controls, designed to monitor long-term performance of the method•Chromatographic separation of multiple steroids along the gradient, with ammonium fluoride mobile phase additive to improve sensitivity, followed by electrospray ionisation and constant polarity switching•Aqueous calibration standards that cover physiologically relevant ranges - high nanomolar glucocorticoids, low nanomolar androgens and picomolar ranges for estrogens and steroid intermediates.
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Affiliation(s)
- Scott G Denham
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna P Simpson
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Federico Diez
- Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian, EH25 9RG, UK
- SRUC, Roslin Institute Building, Easter Bush Campus, EH25 9RG, UK
| | - Patricia Lee
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Catriona Kyle
- BHF/University Centre for Cardiovascular Sciences, Queen's Medical Research Institute, 47 Little France Crescent, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Ruth Morgan
- BHF/University Centre for Cardiovascular Sciences, Queen's Medical Research Institute, 47 Little France Crescent, University of Edinburgh, Edinburgh, EH16 4TJ, UK
- SRUC, Roslin Institute Building, Easter Bush Campus, EH25 9RG, UK
| | - Natalie ZM Homer
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
- BHF/University Centre for Cardiovascular Sciences, Queen's Medical Research Institute, 47 Little France Crescent, University of Edinburgh, Edinburgh, EH16 4TJ, UK
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Bertherat J, Bourdeau I, Bouys L, Chasseloup F, Kamenicky P, Lacroix A. Clinical, pathophysiologic, genetic and therapeutic progress in Primary Bilateral Macronodular Adrenal Hyperplasia. Endocr Rev 2022:6957368. [PMID: 36548967 DOI: 10.1210/endrev/bnac034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) usually present bilateral benign adrenocortical macronodules at imaging and variable levels of cortisol excess. PBMAH is a rare cause of primary overt Cushing's syndrome, but may represent up to one third of bilateral adrenal incidentalomas with evidence of cortisol excess. The increased steroidogenesis in PBMAH is often regulated by various G-protein coupled receptors aberrantly expressed in PBMAH tissues; some receptor ligands are ectopically produced in PBMAH tissues creating aberrant autocrine/paracrine regulation of steroidogenesis. The bilateral nature of PBMAH and familial aggregation, led to the identification of germline heterozygous inactivating mutations of the ARMC5 gene, in 20-25% of the apparent sporadic cases and more frequently in familial cases; ARMC5 mutations/pathogenic variants can be associated with meningiomas. More recently, combined germline mutations/pathogenic variants and somatic events inactivating the KDM1A gene were specifically identified in patients affected by GIP-dependent PBMAH. Functional studies demonstrated that inactivation of KDM1A leads to GIP-receptor (GIPR) overexpression and over or down-regulation of other GPCRs. Genetic analysis is now available for early detection of family members of index cases with PBMAH carrying identified germline pathogenic variants. Detailed biochemical, imaging, and co-morbidities assessment of the nature and severity of PBMAH is essential for its management. Treatment is reserved for patients with overt or mild cortisol/aldosterone or other steroid excesses taking in account co-morbidities. It previously relied on bilateral adrenalectomy; however recent studies tend to favor unilateral adrenalectomy, or less frequently, medical treatment with cortisol synthesis inhibitors or specific blockers of aberrant GPCR.
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Affiliation(s)
- Jerôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Fanny Chasseloup
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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Bonnet-Serrano F, Barat M, Vaczlavik A, Jouinot A, Bouys L, Laguillier-Morizot C, Zientek C, Simonneau C, Larger E, Guignat L, Groussin L, Assié G, Guibourdenche J, Nicolis I, Menet MC, Bertherat J. Decreased steroidogenic enzyme activity in benign adrenocortical tumors is more pronounced in bilateral lesions as determined by steroid profiling in LC-MS/MS during ACTH stimulation test. Endocr Connect 2022; 11:EC-22-0063. [PMID: 35731238 PMCID: PMC9346343 DOI: 10.1530/ec-22-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Large response of steroid precursors, including 17-hydroxyprogesterone, to adrenocorticotropic hormone (ACTH) has been described in adrenocortical tumors, suggesting the existence of intra-tumoral enzymatic deficiencies. This study aimed to compare steroidogenesis enzymes activity in unilateral and bilateral benign tumors using serum steroid profiling in liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) in the basal state and after ACTH 1-24 stimulation. DESIGN AND METHODS A serum profile of seven consecutive adrenal steroids was determined in LC-MS/MS in the basal state (T0) and after ACTH 1-24 stimulation (T60) in 35 patients with bilateral adrenocortical tumors (BL), 38 patients with unilateral tumors (UL) and 37 control subjects (CT). Response amplitude of each individual steroid was evaluated by T60/T0 ratio, whereas enzymatic activity was assessed by the downstream/upstream steroid ratio. Adrenal volume was quantified by a semi-automatic segmentation method. RESULTS For the seven steroids assayed, the amplitude of response to ACTH was higher in BL than in UL and in CT. The difference between BL and UL persisted even after matching patients on adrenal volume. On glucocorticoids pathway, enzymatic activity of CYP11B1 was significantly decreased in BL (78.3 (43.1-199.4)) in comparison to both UL (122.7 (13.8-228.4), P = 0.0002) and CT (186.8 (42.1-1236.3), P < 0.0001). On mineralocorticoids and androgens pathways, the enzymatic activity of CYP11B2 and CYP17A1-17,20 lyase was also lower in BL than UL and CT. CONCLUSIONS Decreased activity of distal steroidogenesis enzymes CYP11B1, CYP11B2 and CYP17A1-17,20 lyase, responsible for an explosive response to ACTH of upstream precursors in bilateral tumors, limits the synthesis of bioactive steroids, in particular cortisol, despite the increase in adrenal mass. SIGNIFICANCE STATEMENT Activity of distal steroidogenesis enzymes (CYP11B1, CYP11B2 and CYP17A1 on glucocorticoids, mineralocorticoids and androgens pathways, respectively) is decreased in adrenocortical benign tumors. This decrease is more pronounced in bilateral lesions and seems to depend more on the nature of the lesion than on the increase in adrenal volume. It is responsible for the explosive response to ACTH of steroid precursors located upstream of these enzymes. It probably allows bioactive steroids, particularly cortisol, to stay in the normal range for a long time despite the increase in adrenal mass.
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Affiliation(s)
- Fidéline Bonnet-Serrano
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Hormonology Department, Cochin Hospital, Paris, France
- Correspondence should be addressed to F Bonnet-Serrano:
| | - Maxime Barat
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Radiology Department, Cochin Hospital, Paris, France
| | - Anna Vaczlavik
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Reference Center for Rare Adrenal Diseases, Endocrinology Department, Cochin Hospital, Paris, France
| | | | - Lucas Bouys
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Reference Center for Rare Adrenal Diseases, Endocrinology Department, Cochin Hospital, Paris, France
| | - Christelle Laguillier-Morizot
- Université Paris Cité, Paris, France
- Hormonology Department, Cochin Hospital, Paris, France
- INSERM, Physiopathologie et Pharmacotoxicologie Placentaire Humaine : Microbiote Pré & Post natal, Paris, France
| | | | | | - Etienne Larger
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Diabetology Department, Cochin Hospital, Paris, France
| | - Laurence Guignat
- Reference Center for Rare Adrenal Diseases, Endocrinology Department, Cochin Hospital, Paris, France
| | - Lionel Groussin
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Reference Center for Rare Adrenal Diseases, Endocrinology Department, Cochin Hospital, Paris, France
| | - Guillaume Assié
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Reference Center for Rare Adrenal Diseases, Endocrinology Department, Cochin Hospital, Paris, France
| | - Jean Guibourdenche
- Université Paris Cité, Paris, France
- Hormonology Department, Cochin Hospital, Paris, France
- INSERM, Physiopathologie et Pharmacotoxicologie Placentaire Humaine : Microbiote Pré & Post natal, Paris, France
| | - Ioannis Nicolis
- Université Paris Cité, Paris, France
- UR 7537 BioSTM, Paris, France
| | - Marie-Claude Menet
- Institut de Chimie Physique, Université Paris-Saclay-CNRS, UMR8000, Orsay, France
| | - Jérôme Bertherat
- Université Paris Cité, Paris, France
- Inserm U1016-CNRS UMR8104, Paris, France
- Reference Center for Rare Adrenal Diseases, Endocrinology Department, Cochin Hospital, Paris, France
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Costa-Barbosa FA, Carvalho VM, Oliveira KC, Vieira JGH, Kater CE. Reassessment of predictive values of ACTH-stimulated serum 21-deoxycortisol and 17-hydroxyprogesterone to identify CYP21A2 heterozygote carriers and nonclassic subjects. Clin Endocrinol (Oxf) 2021; 95:677-685. [PMID: 34231242 DOI: 10.1111/cen.14550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Heterozygotes (HZs) for 21-hydroxylase deficiency (21OHD) are highly prevalent, ranging from 1:60 to 1:11 for classic and nonclassic (NC) forms, respectively. Detection of HZ and asymptomatic NC by CYP21A2 genotyping is valuable for genetic counselling, but costly, complex and narrowly available. Adrenocorticotropic hormone (ACTH)-stimulated serum 17-hydroxyprogesterone (17P) and 21-deoxycortisol (21DF) discriminate 21OHD phenotypes effectively, notably if measured simultaneously by liquid chromatography-tandem mass spectrometry (LC-MS/MS). OBJECTIVE This study was performed to reassess former LC-MS/MS-defined post-ACTH 21DF, 17P and cortisol (F) cutoffs in family members at risk for 21OHD. DESIGN AND PATIENTS Prospective study in which we screened 58 asymptomatic relatives from families with 21OHD patients and compared post-ACTH steroid phenotypes with subsequent genotypes. RESULTS Post-ACTH 21DF, 17P, F and (21DF + 17P)/F ratio segregate NC, HZ and wild-type (WT) phenotypes (subsequently genotyped) with some overlap. New receiver operating characteristic curve-defined cutoffs for post-ACTH 21DF, 17P and (21DF + 17P)/F ratio are 60 ng/dl, 310 ng/dl and 12 (unitless). Twenty-six of 33 HZ and all 6 NC (82.1%) had post-ACTH 21DF > 60 and 17P > 310 ng/dl, whereas 17/19 WT (89.5%) had values below cutoffs. Post-ACTH 21DF and 17P had a strong positive correlation (r = .9558; p < .001). A (21DF + 17P)/F ratio > 12 correctly identified 36 of 39 HZ plus NC (92.3% sensitivity) with 84.2% specificity (16 of 19 WT). Given the high frequency of 21OHD HZ, the negative prediction of ratio values below 12 excludes heterozygosity in 99.8% and 99.1% for classic and NC mutations, respectively. CONCLUSIONS Reassessed ACTH-stimulated 21DF and 17P cutoffs by LC-MS/MS (60 and 310 ng/dl, respectively) correctly recognised 82.5% HZ plus NC, but combined precursor-to-product ratio ([21DF + 17P]/F) cutoff of 12 was superior, identifying 92.3% HZ plus NC. Since one WT subject is an outlier (potential HZ), these values would be somewhat better reinforcing their utility for screening asymptomatic relatives at risk for 21OHD.
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Affiliation(s)
- Flávia A Costa-Barbosa
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
- Research and Development Division, Fleury Medicina Diagnóstica, São Paulo, Sao Paulo, Brazil
| | - Valdemir M Carvalho
- Research and Development Division, Fleury Medicina Diagnóstica, São Paulo, Sao Paulo, Brazil
| | - Kelly C Oliveira
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
| | - José Gilberto H Vieira
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
- Research and Development Division, Fleury Medicina Diagnóstica, São Paulo, Sao Paulo, Brazil
| | - Claudio E Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
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