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Valizadeh M, Abiri B, Hosseinpanah F, Grossman A. Bilateral inferior petrosal sinus sampling in the differential diagnosis of ACTH-dependent Cushing's syndrome: A reappraisal. J Intern Med 2024; 296:2-23. [PMID: 38606956 DOI: 10.1111/joim.13789] [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] [Indexed: 04/13/2024]
Abstract
Cushing's syndrome (CS) is a rare disorder, once exogenous causes have been excluded. However, when diagnosed, the majority of cases are adrenocorticotropic hormone (ACTH)-dependent, of which a substantial minority are due to a source outside of the pituitary, ectopic ACTH syndrome (EAS). Differentiating among pituitary-dependent CS, Cushing's disease (CD) and an ectopic source can be problematic. Because non-invasive tests in the evaluation of CS patients often lack adequate sensitivity and specificity, bilateral inferior petrosal sinus sampling (BIPSS), a minimally invasive procedure performed during the investigation of ACTH-dependent CS, can be extremely helpful. BIPSS is considered to be the gold standard for differentiating CD from the EAS. Furthermore, although such differentiation may indeed be challenging, BIPSS is itself a complex investigation, especially in recent times due to the widespread withdrawal of corticotrophin-releasing hormone and its replacement by desmopressin. We review current published data on this investigation and, in the light of this and our own experience, discuss its appropriate use in diagnostic algorithms.
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Affiliation(s)
- Majid Valizadeh
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behnaz Abiri
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farhad Hosseinpanah
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ashley Grossman
- Centre for Endocrinology, Barts and the London School of Medicine, QMUL, London, UK
- ENETS Centre of Excellence, Royal Free Hospital, London, UK
- Green Templeton College, University of Oxford, Oxford, UK
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2
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Moctezuma S, Perez JL, Baraban E, Caturegli P, Morris-Wiseman L, Salvatori R. Cushing Syndrome Due to a Corticotropin-Releasing Hormone- and Adrenocorticotropic Hormone-Secreting Silent Pheochromocytoma. AACE Clin Case Rep 2024; 10:84-88. [PMID: 38799040 PMCID: PMC11127585 DOI: 10.1016/j.aace.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 05/29/2024] Open
Abstract
Background/Objective Ectopic cosecretion of corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) in silent (ie, non-catecholamine-secreting) pheochromocytoma is a rare cause of Cushing syndrome. Case Report A 57-year-old woman rapidly developed hypercortisolism, clinically manifesting as fatigue, muscle weakness, weight gain, and worsening hypertension and biochemically characterized by hypokalemia and marked increases in the serum cortisol and plasma ACTH levels. This acute presentation suggested a diagnosis of ectopic ACTH syndrome (EAS). Imaging studies revealed a right adrenal mass that enhanced after administration of the radioisotope gallium-68-DOTATATE. Plasma metanephrines were normal in 2 separate measurements. The possibility of a silent pheochromocytoma was considered. After controlling her hypercortisolism with metyrapone and surgical preparation with alpha blockade, the patient underwent elective right adrenalectomy. Pathology revealed a pheochromocytoma that stained focally for ACTH and CRH. Postoperatively, the cortisol levels normalized, the hypothalamic-pituitary-adrenal axis was not suppressed, and clinical symptoms from hypercortisolism abated. Discussion Patients who exhibit a rapid progression of ACTH-dependent hypercortisolism should be screened for EAS. The use of functional imaging radioisotopes (eg, gallium DOTA-peptides) improves the detection of ACTH-secreting tumors. Preoperative treatment with steroidogenesis inhibitors helps control clinical and metabolic derangements associated with severe hypercortisolemia, whereas alpha blockade prevents the onset of an adrenergic crisis. Conclusion We present a rare case of EAS due to a silent pheochromocytoma that cosecreted ACTH and CRH. Pheochromocytoma should be considered in patients with EAS who have an adrenal mass even in the absence of excessive catecholamine secretion.
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Affiliation(s)
- Sananda Moctezuma
- Division of Endocrinology, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jonathan L. Perez
- Department of Pathology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ezra Baraban
- Department of Pathology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patrizio Caturegli
- Department of Pathology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lilah Morris-Wiseman
- Department of Surgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Roberto Salvatori
- Division of Endocrinology, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Mizutani G, Isshiki M, Shimizu E, Saito D, Shimada A. Pheochromocytoma With High Adrenocorticotropic Hormone Production Capacity Without Pigmentation and Cushingoid Symptoms: A Case Report With a Literature Review. Cureus 2024; 16:e53358. [PMID: 38435205 PMCID: PMC10907887 DOI: 10.7759/cureus.53358] [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] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Pheochromocytoma or paraganglioma (PPGL) originating from chromaffin cells can produce diverse hormones in addition to catecholamines, including adrenocorticotropic hormone (ACTH). In pheochromocytoma, high levels of ACTH might not result in pigmentation as typically observed in Addison's disease, and patients might not exhibit the symptoms of Cushing's syndrome, despite ACTH-dependent hypercortisolism. A 63-year-old male patient with hypertension was admitted to our facility, and computed tomography (CT) revealed a large right adrenal tumor. Despite high plasma ACTH (700-1300 pg/mL) and serum cortisol (90-100 µg/dL) levels, no physical pigmentation or Cushingoid symptoms were observed. Urinary metanephrine and normetanephrine levels reached as high as 16.0 mg and 3.2 mg, respectively. 123I-metaiodobenzylguanidine (MIBG) scintigraphy was negative. Low-dose dexamethasone paradoxically increased ACTH and cortisol levels, indicating the potential positive feedback regulation of both hormones by glucocorticoids. The patient was diagnosed with an ACTH-producing pheochromocytoma and underwent successful laparoscopic surgery to remove the adrenal tumor under the intravenous administration of a high-dose α-blocker and hydrocortisone. The levels of ACTH, cortisol, and urinary metanephrine/normetanephrine returned close to normal after tumor removal. We report a rare case of pheochromocytoma with extremely high ACTH/cortisol production but without pigmentation or Cushingoid symptoms. We also reviewed previous reports of ACTH-producing PPGL regarding the paradoxical regulation of ACTH/cortisol by glucocorticoids, pigmentation, Cushingoid symptoms, and negativity of 123I-MIBG scintigraphy.
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Affiliation(s)
- Gen Mizutani
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Masashi Isshiki
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Eisuke Shimizu
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Daigo Saito
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
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Zhang X, Lian P, Su M, Ji Z, Deng J, Zheng G, Wang W, Ren X, Jiang T, Zhang P, Li H. Single-cell transcriptome analysis identifies a unique tumor cell type producing multiple hormones in ectopic ACTH and CRH secreting pheochromocytoma. eLife 2021; 10:68436. [PMID: 34905486 PMCID: PMC8719890 DOI: 10.7554/elife.68436] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 12/13/2021] [Indexed: 01/04/2023] Open
Abstract
Ectopic Cushing’s syndrome due to ectopic ACTH&CRH-secreting by pheochromocytoma is extremely rare and can be fatal if not properly diagnosed. It remains unclear whether a unique cell type is responsible for multiple hormones secreting. In this work, we performed single-cell RNA sequencing to three different anatomic tumor tissues and one peritumoral tissue based on a rare case with ectopic ACTH&CRH-secreting pheochromocytoma. And in addition to that, three adrenal tumor specimens from common pheochromocytoma and adrenocortical adenomas were also involved in the comparison of tumor cellular heterogeneity. A total of 16 cell types in the tumor microenvironment were identified by unbiased cell clustering of single-cell transcriptomic profiles from all specimens. Notably, we identified a novel multi-functionally chromaffin-like cell type with high expression of both POMC (the precursor of ACTH) and CRH, called ACTH+&CRH + pheochromocyte. We hypothesized that the molecular mechanism of the rare case harbor Cushing’s syndrome is due to the identified novel tumor cell type, that is, the secretion of ACTH had a direct effect on the adrenal gland to produce cortisol, while the secretion of CRH can indirectly stimulate the secretion of ACTH from the anterior pituitary. Besides, a new potential marker (GAL) co-expressed with ACTH and CRH might be involved in the regulation of ACTH secretion. The immunohistochemistry results confirmed its multi-functionally chromaffin-like properties with positive staining for CRH, POMC, ACTH, GAL, TH, and CgA. Our findings also proved to some extent the heterogeneity of endothelial and immune microenvironment in different adrenal tumor subtypes.
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Affiliation(s)
- Xuebin Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Penghu Lian
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mingming Su
- Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Zhigang Ji
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jianhua Deng
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Guoyang Zheng
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wenda Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xinyu Ren
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Taijiao Jiang
- Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Jiangsu, China
| | - Peng Zhang
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hanzhong Li
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Karin O, Raz M, Tendler A, Bar A, Korem Kohanim Y, Milo T, Alon U. A new model for the HPA axis explains dysregulation of stress hormones on the timescale of weeks. Mol Syst Biol 2021; 16:e9510. [PMID: 32672906 PMCID: PMC7364861 DOI: 10.15252/msb.20209510] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 12/29/2022] Open
Abstract
Stress activates a complex network of hormones known as the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is dysregulated in chronic stress and psychiatric disorders, but the origin of this dysregulation is unclear and cannot be explained by current HPA models. To address this, we developed a mathematical model for the HPA axis that incorporates changes in the total functional mass of the HPA hormone-secreting glands. The mass changes are caused by HPA hormones which act as growth factors for the glands in the axis. We find that the HPA axis shows the property of dynamical compensation, where gland masses adjust over weeks to buffer variation in physiological parameters. These mass changes explain the experimental findings on dysregulation of cortisol and ACTH dynamics in alcoholism, anorexia, and postpartum. Dysregulation occurs for a wide range of parameters and is exacerbated by impaired glucocorticoid receptor (GR) feedback, providing an explanation for the implication of GR in mood disorders. These findings suggest that gland-mass dynamics may play an important role in the pathophysiology of stress-related disorders.
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Affiliation(s)
- Omer Karin
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Moriya Raz
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Avichai Tendler
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Alon Bar
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Yael Korem Kohanim
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Tomer Milo
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Uri Alon
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
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Perlman JE, Johnston PC, Hui F, Mulligan G, Weil RJ, Recinos PF, Yogi-Morren D, Salvatori R, Mukherjee D, Gallia G, Kennedy L, Hamrahian AH. Pitfalls in Performing and Interpreting Inferior Petrosal Sinus Sampling: Personal Experience and Literature Review. J Clin Endocrinol Metab 2021; 106:e1953-e1967. [PMID: 33421066 PMCID: PMC8599872 DOI: 10.1210/clinem/dgab012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Indexed: 02/13/2023]
Abstract
CONTEXT Inferior petrosal sinus sampling (IPSS) helps differentiate the source of ACTH-dependent hypercortisolism in patients with inconclusive biochemical testing and imaging, and is considered the gold standard for distinguishing Cushing disease (CD) from ectopic ACTH syndrome. We present a comprehensive approach to interpreting IPSS results by examining several real cases. EVIDENCE ACQUISITION We performed a comprehensive review of the IPSS literature using PubMed since IPSS was first described in 1977. EVIDENCE SYNTHESIS IPSS cannot be used to confirm the diagnosis of ACTH-dependent Cushing syndrome (CS). It is essential to establish ACTH-dependent hypercortisolism before the procedure. IPSS must be performed by an experienced interventional or neuroradiologist because successful sinus cannulation relies on operator experience. In patients with suspected cyclical CS, it is important to demonstrate the presence of hypercortisolism before IPSS. Concurrent measurement of IPS prolactin levels is useful to confirm adequate IPS venous efflux. This is essential in patients who lack an IPS-to-peripheral (IPS:P) ACTH gradient, suggesting an ectopic source. The prolactin-adjusted IPS:P ACTH ratio can improve differentiation between CD and ectopic ACTH syndrome when there is a lack of proper IPS venous efflux. In patients who have unilateral successful IPS cannulation, a contralateral source cannot be excluded. The value of the intersinus ACTH ratio to predict tumor lateralization may be improved using a prolactin-adjusted ACTH ratio, but this requires further evaluation. CONCLUSION A stepwise approach in performing and interpreting IPSS will provide clinicians with the best information from this important but delicate procedure.
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Affiliation(s)
- Jordan E Perlman
- Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, Baltimore, MD, USA
| | - Philip C Johnston
- Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - Ferdinand Hui
- Johns Hopkins University, Department of Radiology, Baltimore, MD, USA
| | - Guy Mulligan
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Pablo F Recinos
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Divya Yogi-Morren
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Roberto Salvatori
- Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, Baltimore, MD, USA
| | - Debraj Mukherjee
- Johns Hopkins University, Department of Neurosurgery, Baltimore, MD, USA
| | - Gary Gallia
- Johns Hopkins University, Department of Neurosurgery, Baltimore, MD, USA
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Amir H Hamrahian
- Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, Baltimore, MD, USA
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7
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Karin O, Raz M, Alon U. An opponent process for alcohol addiction based on changes in endocrine gland mass. iScience 2021; 24:102127. [PMID: 33665551 PMCID: PMC7903339 DOI: 10.1016/j.isci.2021.102127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/17/2020] [Accepted: 01/27/2021] [Indexed: 12/03/2022] Open
Abstract
Consuming addictive drugs is often initially pleasurable, but escalating drug intake eventually recruits physiological anti-reward systems called opponent processes that cause tolerance and withdrawal symptoms. Opponent processes are fundamental for the addiction process, but their physiological basis is not fully characterized. Here, we propose an opponent processes mechanism centered on the endocrine stress response, the hypothalamic-pituitary-adrenal (HPA) axis. We focus on alcohol addiction, where the HPA axis is activated and secretes β-endorphin, causing euphoria and analgesia. Using a mathematical model, we show that slow changes in the functional mass of HPA glands act as an opponent process for β-endorphin secretion. The model explains hormone dynamics in alcohol addiction and experiments on alcohol preference in rodents. The opponent process is based on fold-change detection (FCD) where β-endorphin responses are relative rather than absolute; FCD confers vulnerability to addiction but has adaptive roles for learning. Our model suggests gland mass changes as potential targets for intervention in addiction. Addiction involves tolerance and withdrawal over weeks Model of the HPA-axis and β-endorphins explains tolerance and withdrawal Effects due to changes in the functional mass of endocrine glands Fold-change detection makes circuit prone to addiction but boosts learning
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Affiliation(s)
- Omer Karin
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot 76100, Israel
| | - Moriya Raz
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot 76100, Israel
| | - Uri Alon
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot 76100, Israel
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Elliott PF, Berhane T, Ragnarsson O, Falhammar H. Ectopic ACTH- and/or CRH-Producing Pheochromocytomas. J Clin Endocrinol Metab 2021; 106:598-608. [PMID: 32710791 DOI: 10.1210/clinem/dgaa488] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT The characteristics of catecholamine-secreting pheochromocytomas have been well studied. However, less is known about the characteristics, management and outcome in patients with ectopic adrenocorticotropic hormone (ACTH) and/or corticotrophin-releasing hormone (CRH)-secreting pheochromocytomas. OBJECTIVE To review the characteristics and outcomes of ACTH- and/or CRH-secreting pheochromocytomas. DATA SOURCE A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 February 2020. STUDY SELECTION Original articles, including case reports and case series, reporting individual patient data from patients with ACTH- and/or CRH-secreting pheochromocytomas. DATA EXTRACTION Information on sex, age, symptoms at presentation, comorbidities, biochemistry, imaging, histopathology, and outcomes was extracted. DATA SYNTHESIS We identified 91 articles reporting on 99 cases of ACTH- and/or CRH-secreting pheochromocytomas (CRH-secreting n = 4). Median age at diagnosis was 49 years (interquartile range 38-59.5) with a 2:1 female to male ratio. Most patients presented with clinical Cushing syndrome (n = 79; 81%), hypertension (n = 87; 93%), and/or diabetes (n = 50; 54%). Blood pressure, glucose control, and biochemical parameters improved in the vast majority of patients postoperatively. Infections were the most common complication. Most cases (n = 70, 88%) with reported long-term outcome survived to publication (median follow-up 6 months). CONCLUSION Ectopic ACTH- and/or CRH-secreting pheochromocytoma should be considered in patients presenting with ACTH-dependent Cushing syndrome and adrenal mass. Despite the challenge in diagnosis, patient outcomes appear favorable.
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Affiliation(s)
| | - Thomas Berhane
- Department of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, Australia
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Abstract
Pheochromocytomas are rare neuroendocrine tumors. Extra-adrenal lesions arising from the autonomic neural ganglia are termed paraganglioma. Clinical symptoms are common between the adrenal and extra-adrenal forms and are determined by excess secretion of catecholamines. Hypertension is a critical and often dramatic feature of pheochromocytoma/paraganglioma, and its most prevalent reported symptom. However, given the rare occurrence of this cancer, in patients undergoing screening for hypertension, the prevalence ranges from 0.1% to 0.6%. Still, patients frequently come to the attention of endocrinologist when pheochromocytoma/paraganglioma is suspected as a secondary cause of hypertension. This article summarizes current clinical approaches in patients with pheochromocytoma/paraganglioma.
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Affiliation(s)
- Sergei G Tevosian
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, 1600 Southwest Archer Road, Suite H-2, Gainesville, FL 32608, USA
| | - Hans K Ghayee
- Department of Medicine, Division of Endocrinology, University of Florida, Malcom Randall VA Medical Center, Gainesville, FL 32610, USA.
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Nakhjavani M, Amirbaigloo A, Rabizadeh S, Rotondo F, Kovacs K, Ghazi AA. Ectopic cushing's syndrome due to corticotropin releasing hormone. Pituitary 2019; 22:561-568. [PMID: 31041631 DOI: 10.1007/s11102-019-00965-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cushing's syndrome (CS) secondary to corticotropin releasing hormone (CRH) producing tumors is rare. In this paper we present an Iranian patient who was admitted to our hospital with classic signs and symptoms of CS. Laboratory evaluation revealed high serum and urine cortisol which could not be suppressed with dexamethasone. Abdominal CT scan revealed a mass in abdominal cavity. A percutaneous needle biopsy was performed and histopathologic evaluation revealed that the mass was a neuroendocrine tumor. A multi-disciplinary approach including resection of the mass, bilateral adrenalectomy somatostatin analogue and chemotherapy was applied for management of the disease. Extensive review of English literature focusing on the topic from 1971 to 2018 revealed that there have been only 75 similar cases. Clinical, laboratory, imaging, histopathologic characteristics and managements of these patients will also be discussed in this paper.
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Affiliation(s)
- Manouchehr Nakhjavani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Soghra Rabizadeh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fabio Rotondo
- Department of Laboratory Medicine, Division of Pathology, Toronto, Canada
- The Keenan Research Centre for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Kalman Kovacs
- Department of Laboratory Medicine, Division of Pathology, Toronto, Canada
- The Keenan Research Centre for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Ali A Ghazi
- Endocrine Research Center, Research Institute for Endocrine Sciences (RIES), Shahid Beheshti University of Medical Sciences, P.O. Box: 19395-4763, Tehran, Iran.
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11
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Angelousi A, Peppa M, Chrisoulidou A, Alexandraki K, Berthon A, Faucz FR, Kassi E, Kaltsas G. Malignant Pheochromocytomas/Paragangliomas and Ectopic Hormonal Secretion: A Case Series and Review of the Literature. Cancers (Basel) 2019; 11:E724. [PMID: 31137729 PMCID: PMC6563134 DOI: 10.3390/cancers11050724] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/02/2019] [Accepted: 05/17/2019] [Indexed: 12/16/2022] Open
Abstract
Malignant pheochromocytomas (PCs) and paragangliomas (PGLs) are rare neuroendocrine neoplasms defined by the presence of distant metastases. There is currently a relatively paucity of data regarding the natural history of PCs/PGLs and the optimal approach to their treatment. We retrospectively analyzed the clinical, biochemical, imaging, genetic and histopathological characteristics of fourteen patients with metastatic PCs/PGLs diagnosed over 15 years, along with their response to treatment. Patients were followed-up for a median of six years (range: 1-14 years). Six patients had synchronous metastases and the remaining developed metastases after a median of four years (range 2-10 years). Genetic analysis of seven patients revealed that three harbored succinate dehydrogenase subunit B/D gene (SDHB/D) mutations. Hormonal hypersecretion occurred in 70% of patients; normetanephrine, either alone or with other concomitant hormones, was the most frequent secretory component. Patients were administered multiple first and subsequent treatments including surgery (n = 12), chemotherapy (n = 7), radionuclide therapy (n = 2) and radiopeptides (n = 5). Seven patients had stable disease, four had progressive disease and three died. Ectopic hormonal secretion is rare and commonly encountered in benign PCs. Ectopic secretion of interleukin-6 in one of our patients, prompted a literature review of ectopic hormonal secretion, particularly from metastatic PCs/PGLs. Only four cases of metastatic PC/PGLs with confirmed ectopic secretion of hormones or peptides have been described so far.
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Affiliation(s)
- Anna Angelousi
- Department of Internal Medicine, Unit of Endocrinology, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Greece.
| | - Melpomeni Peppa
- Endocrine Unit, 2nd Department of Internal Medicine Propaedeutic, Research Institute and Diabetes Center, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Haidari, Greece.
| | - Alexandra Chrisoulidou
- Unit of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007 Thessaloniki, Greece.
| | - Krystallenia Alexandraki
- st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Athens, Greece.
| | - Annabel Berthon
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Fabio Rueda Faucz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Eva Kassi
- Department of Internal Medicine, Unit of Endocrinology, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Greece.
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 11527 Goudi, Athens, Greece.
| | - Gregory Kaltsas
- st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Athens, Greece.
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Gabi JN, Milhem MM, Tovar YE, Karem ES, Gabi AY, Khthir RA. Severe Cushing Syndrome Due to an ACTH-Producing Pheochromocytoma: A Case Presentation and Review of the Literature. J Endocr Soc 2018; 2:621-630. [PMID: 29942926 PMCID: PMC6007244 DOI: 10.1210/js.2018-00086] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/21/2018] [Indexed: 01/01/2023] Open
Abstract
Adrenocorticotropic hormone (ACTH)-dependent Cushing syndrome is rarely caused by a pheochromocytoma. We present a case of a 46-year-old woman who developed severe hypertension, hypokalemia, and typical Cushingoid features. Investigations revealed extremely high metanephrine, cortisol, and ACTH levels. Imaging showed a 3.8-cm left adrenal mass. Preoperative control of hypertension and hypokalemia was very challenging. The patient was cured after surgical removal of the adrenal mass. We followed this by a review of the literature using the databases Google Scholar and PubMed. A total of 58 cases have been reported to date. In summary, ACTH-producing pheochromocytoma is a rare condition that poses a clinical challenge in the perioperative period. It is important that physicians be aware of such a condition because early recognition and treatment are crucial to decrease morbidity and mortality.
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Affiliation(s)
- Jenan N Gabi
- Division of Endocrinology and Metabolism, Internal Medicine Department, John C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Maali M Milhem
- Division of Endocrinology and Metabolism, Internal Medicine Department, John C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Yara E Tovar
- Division of Endocrinology and Metabolism, Internal Medicine Department, John C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Emhemmid S Karem
- Department of Internal Medicine, John C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Alaa Y Gabi
- Department of Cardiovascular Disease, John C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Rodhan A Khthir
- Division of Endocrinology and Metabolism, Internal Medicine Department, John C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
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13
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Wang BP, Yang LL, Wang H, He Q, Ma ZS, Lin Y, Jiang CX, Sun HR, Liu M. An unusual case of ectopic corticotrophin-releasing hormone syndrome caused by an adrenal noncatecholamine-secreting pheochromocytoma: a case report. BMC Endocr Disord 2018; 18:41. [PMID: 29921267 PMCID: PMC6009975 DOI: 10.1186/s12902-018-0269-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 06/08/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Pheochromocytoma, especially for noncatecholamine-secreting pheochromocytoma, is an extremely rare cause of ectopic corticotrophin-releasing hormone (CRH) syndrome. CASE PRESENTATION A 27-year-old Chinese woman was administered dexamethasone for a skin allergy, but her general condition rapidly deteriorated over a month. She was subsequently hospitalized for typical clinical features of Cushing's syndrome. Endocrinological investigation confirmed severe hypercortisolism along with elevated plasma adrenocorticotropin hormone (ACTH). However, magnetic resonance imaging (MRI) revealed no pituitary adenoma. Abdominal contrast-enhanced computed tomography (CT) revealed a 6.5 cm heterogeneous right adrenal mass with mildly contrast enhancement. The tumor was found during a routine physical check-up at a local hospital 16 months ago; however, the patient did not have any symptoms and did not seek further medical attention at that time. Laparoscopic resection of the right adrenal tumor led to a rapid remission of Cushing's syndrome. Based on pathological findings and the presence of normal catecholamine metabolites in her serum and urine, the patient was diagnosed with noncatecholamine-secreting pheochromocytoma. Immunohistochemical staining of the adrenal tumor revealed positive staining for CRH and negative staining for ACTH. CONCLUSIONS This is an extremely rare case of ectopic CRH syndrome caused by an adrenal noncatecholamine-secreting pheochromocytoma. Both ectopic ACTH syndrome and ectopic CRH syndrome should be considered in patients presenting with ACTH-dependent Cushing's syndrome caused by extrapituitary diseases.
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Affiliation(s)
- Bao-Ping Wang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
| | - Lei-Lei Yang
- Department of Gerontology, Beijing ChuiYangLiu Hospital (Chui Yang Liu Hospital affiliated to TsingHua University), Beijing, 100022 China
| | - Hao Wang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
| | - Qing He
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
| | - Zhong-Shu Ma
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
| | - Yi Lin
- Department of Urology, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
| | - Chang-Xin Jiang
- Department of Pathology, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
| | - Hao-Ran Sun
- Department of Medical Imaging, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
| | - Ming Liu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No 154 Anshan Road, Heping District, Tianjin, 300052 China
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14
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Abstract
This review focuses on discussing the main changes on the upcoming fourth edition of the WHO Classification of Tumors of the Pituitary Gland emphasizing histopathological and molecular genetics aspects of pituitary neuroendocrine (i.e., pituitary adenomas) and some of the non-neuroendocrine tumors involving the pituitary gland. Instead of a formal review, we introduced the highlights of the new WHO classification by answering select questions relevant to practising pathologists. The revised classification of pituitary adenomas, in addition to hormone immunohistochemistry, recognizes the role of other immunohistochemical markers including but not limited to pituitary transcription factors. Recognizing this novel approach, the fourth edition of the WHO classification has abandoned the concept of "a hormone-producing pituitary adenoma" and adopted a pituitary adenohypophyseal cell lineage designation of the adenomas with subsequent categorization of histological variants according to hormone content and specific histological and immunohistochemical features. This new classification does not require a routine ultrastructural examination of these tumors. The new definition of the Null cell adenoma requires the demonstration of immunonegativity for pituitary transcription factors and adenohypophyseal hormones Moreover, the term of atypical pituitary adenoma is no longer recommended. In addition to the accurate tumor subtyping, assessment of the tumor proliferative potential by mitotic count and Ki-67 index, and other clinical parameters such as tumor invasion, is strongly recommended in individual cases for consideration of clinically aggressive adenomas. This classification also recognizes some subtypes of pituitary neuroendocrine tumors as "high-risk pituitary adenomas" due to the clinical aggressive behavior; these include the sparsely granulated somatotroph adenoma, the lactotroph adenoma in men, the Crooke's cell adenoma, the silent corticotroph adenoma, and the newly introduced plurihormonal Pit-1-positive adenoma (previously known as silent subtype III pituitary adenoma). An additional novel aspect of the new WHO classification was also the definition of the spectrum of thyroid transcription factor-1 expressing pituitary tumors of the posterior lobe as representing a morphological spectrum of a single nosological entity. These tumors include the pituicytoma, the spindle cell oncocytoma, the granular cell tumor of the neurohypophysis, and the sellar ependymoma.
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Affiliation(s)
- Ozgur Mete
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th Floor, Toronto, ON, M5G 2C4, Canada.
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - M Beatriz Lopes
- Department of Pathology and Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
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15
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Streuli R, Krull I, Brändle M, Kolb W, Stalla G, Theodoropoulou M, Enzler-Tschudy A, Bilz S. A rare case of an ACTH/CRH co-secreting midgut neuroendocrine tumor mimicking Cushing's disease. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170058. [PMID: 28680643 PMCID: PMC5488327 DOI: 10.1530/edm-17-0058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022] Open
Abstract
Ectopic ACTH/CRH co-secreting tumors are a very rare cause of Cushing’s syndrome and only a few cases have been reported in the literature. Differentiating between Cushing’s disease and ectopic Cushing’s syndrome may be particularly difficult if predominant ectopic CRH secretion leads to pituitary corticotroph hyperplasia that may mimic Cushing’s disease during dynamic testing with both dexamethasone and CRH as well as bilateral inferior petrosal sinus sampling (BIPSS). We present the case of a 24-year-old man diagnosed with ACTH-dependent Cushing’s syndrome caused by an ACTH/CRH co-secreting midgut NET. Both high-dose dexamethasone testing and BIPSS suggested Cushing’s disease. However, the clinical presentation with a rather rapid onset of cushingoid features, hyperpigmentation and hypokalemia led to the consideration of ectopic ACTH/CRH-secretion and prompted a further workup. Computed tomography (CT) of the abdomen revealed a cecal mass which was identified as a predominantly CRH-secreting neuroendocrine tumor. To the best of our knowledge, this is the first reported case of an ACTH/CRH co-secreting tumor of the cecum presenting with biochemical features suggestive of Cushing’s disease.
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Affiliation(s)
- Regina Streuli
- Division of Endocrinology and Diabetes, Department of Internal Medicine
| | - Ina Krull
- Division of Endocrinology and Diabetes, Department of Internal Medicine
| | - Michael Brändle
- Division of Endocrinology and Diabetes, Department of Internal Medicine
| | - Walter Kolb
- Department of Surgery, Kantonsspital St Gallen, St GallenSwitzerland
| | - Günter Stalla
- Clinical Neuroendocrinology, Max Planck Institute of Psychiatry, MunichGermany
| | | | | | - Stefan Bilz
- Division of Endocrinology and Diabetes, Department of Internal Medicine
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16
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Wang BY, Gabrilove L, Pertsemlidis D, Gordon RE, Unger PD. Oncocytic Pheochromocytoma with Cytokeratin Reactivity. Int J Surg Pathol 2016. [DOI: 10.1177/106689699700500110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A large hemorrhagic pheochromocytoma (275 g) is described in a 38-year-old obese woman who had no history of sustained or sporadic hypertension. The tumor was unusual histologically because of the striking presence of oncocytic cells. Immunohistochemical studies revealed the positivity for neuron-specific enolase, synaptophysin, and cytokeratin CAM 5.2. Electron microscopy demonstrated neurosecretory dense core granules characteristic of a pheochromocytoma. Oncocytic pheochromocytoma was briefly documented in previous case reports but has not been well recognized. The expression of cytokeratin by pheochromocytoma is also very rare and has been described in a single study in the literature. This case had both unusual clinical and pathologic manifestations and is the first report of a pheochromocytoma with coexistence of oncocytic changes and cytokeratin immunoreactivity.
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Affiliation(s)
- Beverly Y. Wang
- The Lillian and Henry M. Stratton-Hans Popper Department of Pathology, The Mount Sinai Medical Center, New York, N.Y
| | - Lester Gabrilove
- Department of Medicine, The Mount Sinai Medical Center, New York, N.Y
| | | | | | - Pamela D. Unger
- The Lillian and Henry M. Stratton-Hans Popper Department of Pathology, The Mount Sinai Medical Center, New York, N.Y
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17
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Lois KB, Santhakumar A, Vaikkakara S, Mathew S, Long A, Johnson SJ, Peaston R, Neely RDG, Richardson DL, Graham J, Lennard TWJ, Bliss R, Miller M, Ball SG, Pearce SHS, Woods DR, Quinton R. Phaeochromocytoma and ACTH-dependent cushing's syndrome: tumour crf secretion can mimic pituitary cushing's disease. Clin Endocrinol (Oxf) 2016; 84:177-184. [PMID: 26433209 DOI: 10.1111/cen.12960] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 04/28/2015] [Accepted: 09/26/2015] [Indexed: 12/01/2022]
Abstract
INTRODUCTION 10% of corticotrophin (ACTH)-dependent Cushing's syndrome arises from secretion by extrapituitary tumours, with phaeochromocytoma implicated in a few cases. Ectopic secretion by phaeochromocytoma of corticotropin-releasing hormone (CRF), with secondary corticotroph hyperplasia, is even rarer, with only five cases in the literature hitherto. However, such cases may be classified as 'ectopic ACTH' due to incomplete verification. CLINICAL CASES We describe three patients with phaeochromocytoma and ACTH-dependent Cushing's syndrome in whom biochemical cure was achieved following unilateral adrenalectomy. Although unable to access a validated CRF assay within the timeframe for sample storage, we nevertheless inferred CRF secretion in 2 of 3 cases by tumour immunostaining (positive for CRF; negative for ACTH), supported in one case by pre-operative inferior petrosal sinus sampling (IPSS) indicative of pituitary ACTH source. Both cases were characterized by rapid postoperative wean off glucocorticoids, presumed to reflect the pituitary stimulatory-effect of CRF outweighing central negative feedback inhibition by hypercortisolaemia. By contrast, the tumour excised in a third case exhibited positive immunostaining for ACTH - negative for CRF - and postoperative recovery of hypothalamic-pituitary-adrenal axis took significantly longer. DISCUSSION Ectopic CRF production is biochemically indistinguishable from ectopic ACTH secretion, except that IPSS mimics pituitary Cushing's disease and cortisol dynamics may normalize rapidly postadrenalectomy. CRF secretion can be inferred through tumour immunohistochemistry, even if no CRF assay is available. Unrecognized phaeochromocytoma ACTH secretion may underpin some cases of cardiovascular collapse postadrenalectomy through acute hypocortisolaemia. Despite advances in phaeochromocytoma genetics since previous reports, we were unable to identify somatic DNA defects associated with either ACTH or CRF secretion.
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Affiliation(s)
- Konstantinos B Lois
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Anjali Santhakumar
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Suresh Vaikkakara
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati (MP), India
| | - Sajjan Mathew
- Department of Surgery, Oman Health Services, Sohar Hospital, Muscat, Oman
| | - Anna Long
- Department of Cellular Pathology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Sarah J Johnson
- Department of Cellular Pathology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Rovert Peaston
- Department of Clinical Biochemistry, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - R Dermot G Neely
- Department of Clinical Biochemistry, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - David L Richardson
- Department of Radiology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - James Graham
- Department of Radiology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Thomas W J Lennard
- Department of Endocrine Surgery, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Newcastle Bioscience, University of Newcastle-upon-Tyne, Newcastle Upon Tyne, UK
| | - Richard Bliss
- Department of Endocrine Surgery, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Margaret Miller
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Stephen G Ball
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Newcastle Bioscience, University of Newcastle-upon-Tyne, Newcastle Upon Tyne, UK
| | - Simon H S Pearce
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Newcastle Bioscience, University of Newcastle-upon-Tyne, Newcastle Upon Tyne, UK
| | - David R Woods
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Royal Centre for Defence Medicine, Birmingham, UK
- Department of Endocrinology & Diabetes, Northumbria NHS Trust, UK
- Carnegie Research Institute, Leeds Beckett University, UK
| | - Richard Quinton
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Newcastle Bioscience, University of Newcastle-upon-Tyne, Newcastle Upon Tyne, UK
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18
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Fountas A, Giotaki Z, Ligkros N, Tsakiridou ED, Tigas S, Saeger W, Tsatsoulis A. Cushing's Syndrome Due to CRH and ACTH Co-secreting Pancreatic Tumor--Presentation of a New Case Focusing on Diagnostic Pitfalls. Endocr Pathol 2015. [PMID: 26202047 DOI: 10.1007/s12022-015-9384-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cushing's syndrome (CS) due to a corticotropin-releasing hormone (CRH) and adrenocorticotropin hormone (ACTH) co-secreting tumor is very rare, and diagnosis can be difficult. We describe a case of CS caused by ectopic CRH and ACTH production from a pancreatic neuroendocrine tumor (pNET) and discuss possible pitfalls in the diagnosis. A 48-year-old woman presented with gradual increase in body weight, muscle weakness, and difficult to control hypertension. Laboratory and imaging investigations revealed ACTH-dependent hypercortisolemia and a 3-cm mass at the head of the pancreas. The patient underwent partial pancreatoduodenectomy. Histological examination revealed a well-differentiated pNET, expressing both CRH and ACTH. After a follow-up period of 18 months, she remains asymptomatic with no metastatic disease. This is the fourth case report of CS in adults due to an ectopic ACTH- and CRH-secreting pNET. Co-secretion of ACTH and CRH by the same tumor may cause diagnostic problems since investigation depends on which of the two hormones is secreted in greater amounts. Measurement of plasma CRH may help in establishing the diagnosis, especially in patients in whom endocrine tests are indicative of ectopic CS, whereas imaging findings are suggestive of pituitary hyperplasia.
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Affiliation(s)
- Athanasios Fountas
- Department of Endocrinology, University Hospital of Ioannina, Stavros Niarchos Avenue, 45110, Ioannina, Greece,
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19
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Tsirlin A, Oo Y, Sharma R, Kansara A, Gliwa A, Banerji MA. Pheochromocytoma: a review. Maturitas 2014; 77:229-38. [PMID: 24472290 DOI: 10.1016/j.maturitas.2013.12.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/14/2013] [Indexed: 12/19/2022]
Abstract
Pheochromocytomas are catecholamine producing neuroendocrine tumors that can be adrenal or extra-adrenal in origin. The classic symptoms of pheochromocytoma are headache, palpitation, anxiety and diaphoresis and the tumor can occur at any age with equal gender distribution. In patients with an established mutation or hereditary syndrome the condition may manifest at a younger age than in those with sporadic disease. Pheochromocytoma can be associated with certain genetic syndromes such as multiple endocrine neoplasia type 2 (MEN 2), neurofibromatosis (NF) and von Hippel-Lindau (VHL) syndrome. Pheochromocytoma is diagnosed with biochemical confirmation of hormonal excess followed by anatomical localization (CT or MRI). The mainstay of definitive therapy is surgical resection. In this review, we discuss in detail about the symptomatology, diagnosis, genetic aspects and management of pheochromocytoma.
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Affiliation(s)
- A Tsirlin
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - Y Oo
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - R Sharma
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States.
| | - A Kansara
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - A Gliwa
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - M A Banerji
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
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20
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Lefebvre H, Prévost G, Louiset E. Autocrine/paracrine regulatory mechanisms in adrenocortical neoplasms responsible for primary adrenal hypercorticism. Eur J Endocrinol 2013; 169:R115-38. [PMID: 23956298 DOI: 10.1530/eje-13-0308] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A wide variety of autocrine/paracrine bioactive signals are able to modulate corticosteroid secretion in the human adrenal gland. These regulatory factors, released in the vicinity of adrenocortical cells by diverse cell types comprising chromaffin cells, nerve terminals, cells of the immune system, endothelial cells, and adipocytes, include neuropeptides, biogenic amines, and cytokines. A growing body of evidence now suggests that paracrine mechanisms may also play an important role in the physiopathology of adrenocortical hyperplasias and tumors responsible for primary adrenal steroid excess. These intra-adrenal regulatory systems, although globally involving the same actors as those observed in the normal gland, display alterations at different levels, which reinforce the capacity of paracrine factors to stimulate the activity of adrenocortical cells. The main modifications in the adrenal local control systems reported by now include hyperplasia of cells producing the paracrine factors and abnormal expression of the latter and their receptors. Because steroid-secreting adrenal neoplasms are independent of the classical endocrine regulatory factors angiotensin II and ACTH, which are respectively suppressed by hyperaldosteronism and hypercortisolism, these lesions have long been considered as autonomous tissues. However, the presence of stimulatory substances within the neoplastic tissues suggests that steroid hypersecretion is driven by autocrine/paracrine loops that should be regarded as promising targets for pharmacological treatments of primary adrenal disorders. This new potential therapeutic approach may constitute an alternative to surgical removal of the lesions that is classically recommended in order to cure steroid excess.
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Affiliation(s)
- H Lefebvre
- Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Institut National de la Santé et de la Recherche Médicale Unité 982, 76821 Mont-Saint-Aignan, France
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21
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Kirkby-Bott J, Brunaud L, Mathonet M, Hamoir E, Kraimps JL, Trésallet C, Amar L, Rault A, Henry JF, Carnaille B. Ectopic hormone-secreting pheochromocytoma: a francophone observational study. World J Surg 2012; 36:1382-8. [PMID: 22362045 DOI: 10.1007/s00268-012-1488-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ectopic hormone-secreting pheochromocytomas are rare; only case reports exist in the literature. This condition has been linked with increased malignancy, familial syndromes, and ACTH secretion. We wanted to test these hypotheses and shed light on the nature of ectopic hormone-secreting pheochromocytomas. METHODS This is a multicenter (francophone) observational study. Inclusion was based upon abnormal preoperative hormone tests in patients with pheochromocytoma that normalized after removal of the tumor. Where possible, immunohistochemistry was performed to confirm that ectopic secretion came from the tumor. RESULTS Sixteen cases were found: nine female and seven male patients. Median age was 50.5 (range 31-89) years. Most presented with hypertension, diabetes, or cushingoid features. Ten patients had specific symptoms from the ectopic hormone secretion. Two had a familial syndrome. Of eight patients with excess cortisol secretion, three died as a result of the tumor resection: two had pheochromocytomas >15 cm and their associated cortisol hypersecretion complicated their postoperative course. The other died from a torn subhepatic vein. The 13 survivors did not develop any evidence of malignancy during follow-up (median 50 months). Symptoms from the ectopic secretion resolved after removal of the tumor. Immunohistochemistry was performed and was positive in eight tumors: five ACTH, three calcitonins, and one VIP. CONCLUSIONS Most pheochromocytomas with ectopic secretion are neither malignant nor familial. Most ectopic hormone-secreting pheochromocytoma cause hypercortisolemia. Patients with a pheochromocytoma should be worked up for ectopic hormones, because removal of the pheochromocytoma resolves those symptoms. Associated cortisol secretion needs careful attention.
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Affiliation(s)
- James Kirkby-Bott
- Service de Chirurgie Endocrinienne, Université Lille Nord, CHU, 59037 Lille Cedex, France
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22
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Yarman S, Soyluk O, Altunoglu E, Tanakol R. Interleukin-6-producing pheochromocytoma presenting with fever of unknown origin. Clinics (Sao Paulo) 2011; 66:1843-5. [PMID: 22012062 PMCID: PMC3180162 DOI: 10.1590/s1807-59322011001000028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Sema Yarman
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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23
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Nijhoff MF, Dekkers OM, Vleming LJ, Smit JWA, Romijn JA, Pereira AM. ACTH-producing pheochromocytoma: clinical considerations and concise review of the literature. Eur J Intern Med 2009; 20:682-5. [PMID: 19818286 DOI: 10.1016/j.ejim.2009.08.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 07/09/2009] [Accepted: 08/10/2009] [Indexed: 11/25/2022]
Abstract
We present a patient with a rare cause of ectopic ACTH-dependent Cushing's syndrome, caused by a pheochromocytoma. The case provides clues for a detailed discussion on the pitfalls and diagnostic difficulties in establishing the correct underlying cause of ACTH-dependent Cushing's syndrome. It clearly demonstrates that the relative contributions of clinical, biochemical, and radiological clues in establishing the correct underlying cause of Cushing's syndrome may differ considerably between Cushing's disease and Cushing's syndrome due to ectopic overproduction of ACTH. In addition, the literature concerning ACTH-producing pheochromocytomas is reviewed.
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Affiliation(s)
- M F Nijhoff
- Department of Endocrinology & Metabolism, Leiden University Medical Center, Leiden, The Netherlands
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24
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Ruggeri RM, Ferraù F, Campennì A, Simone A, Barresi V, Giuffrè G, Tuccari G, Baldari S, Trimarchi F. Immunohistochemical localization and functional characterization of somatostatin receptor subtypes in a corticotropin releasing hormone-secreting adrenal phaeochromocytoma: review of the literature and report of a case. Eur J Histochem 2009; 53:e1. [PMID: 30256857 PMCID: PMC3167276 DOI: 10.4081/ejh.2009.e1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2008] [Indexed: 11/25/2022] Open
Abstract
Somastostatin receptors are frequently expressed in phaeochromocytoma but data on somatostatin receptor subtyping are scanty and the functional response to the somatostatin analogue octretide is still debated.We report an unusual case of pheochromocytoma, causing ectopic Cushing’s syndrome due to CRH production by the tumour cells, in a 50-yr-old woman. Abdominal computed tomography revealed an inhomogeneous, 9-cm mass in the right adrenal gland, and [111In-DTPA0] octreotide scintigraphy showed an abnormal uptake of the radiotracer in the right perirenal region, corresponding to the adrenal mass. The patient underwent laparoscopic surgery and formalin-fixed and paraffin-embedded samples were studied. The tumour was extensively characterized by immunohistochemistry and somatostatin receptor (SSTRs) subtypes expression was analyzed. Histological and immunohistochemical examination of the surgical specimens displayed a typical pheochromocytoma, which was found to be immunoreative to S-100, chromogranin A and neurofilaments. Immunostaining for SSTR subtypes showed a positive reaction for SSTR1, SSTR2A, SSTR2B, antisera on tumour cells. The intense and diffuse immunostaining for corticotropin releasing hormone (CRH) antiserum indicated that Cushing’s disease was dependent on CRH overproduction by the pheochromocytoma, in which no immunostaining for adrenocorticotropic hormone was found. Our report confirms the heterogeneity of the pattern of SSTR expression in pheochromocytomas, and provide further evidence for functional SSTR subtype SSTR2a in a subgroup of pheochromocytomas, suggesting that these tumours may represent potential target for octreotide treatment.
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Affiliation(s)
- R M Ruggeri
- Department of Medicine and Pharmacology, Section of Endocrinology
| | - F Ferraù
- Department of Medicine and Pharmacology, Section of Endocrinology
| | - A Campennì
- Department of Radiology, Section of Nuclear Medicine
| | - A Simone
- Department of Pathology, University of Messina, Messina, Italy
| | - V Barresi
- Department of Pathology, University of Messina, Messina, Italy
| | - G Giuffrè
- Department of Pathology, University of Messina, Messina, Italy
| | - G Tuccari
- Department of Pathology, University of Messina, Messina, Italy
| | - S Baldari
- Department of Radiology, Section of Nuclear Medicine
| | - F Trimarchi
- Department of Medicine and Pharmacology, Section of Endocrinology
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Lahera Vargas M, da Costa CV. Prevalencia, etiología y cuadro clínico del síndrome de Cushing. ACTA ACUST UNITED AC 2009; 56:32-9. [DOI: 10.1016/s1575-0922(09)70191-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 10/27/2008] [Indexed: 01/09/2023]
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Jehle S, Walsh JE, Freda PU, Post KD. Selective use of bilateral inferior petrosal sinus sampling in patients with adrenocorticotropin-dependent Cushing's syndrome prior to transsphenoidal surgery. J Clin Endocrinol Metab 2008; 93:4624-32. [PMID: 18796519 PMCID: PMC2626443 DOI: 10.1210/jc.2008-0979] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Few data are available on the selective use of bilateral inferior petrosal sinus sampling (BIPSS) in the presurgical evaluation of patients with ACTH-dependent Cushing's syndrome, so we investigated whether its use only in patients without a clear adenoma on magnetic resonance imaging and/or inconsistent biochemical testing affected remission and long-term outcome after surgery in patients with Cushing's disease (CD). SETTING This was a retrospective review of patients treated for CD by one pituitary neurosurgeon at tertiary medical centers in New York City. PATIENTS A total of 193 consecutive adult patients who underwent initial transsphenoidal surgery (TS) for presumed CD between 1987 and 2005 were included. MAIN OUTCOME MEASURES We examined preoperative pituitary imaging and biochemical data, results of BIPSS and surgical pathology, and outcome based on biochemical tests after initial TS and long term after subsequent therapies. RESULTS Remission rate after the first TS was 80.8% overall, 79.1% in the BIPSS group (n = 105), and 83.0% in the No-BIPSS group (n = 88). Recurrences occurred in 13.5% after the first TS at a mean of 4.8 +/- 3.5 yr (range, 0.7-12.4 yr) with no difference between BIPSS and No-BIPSS groups. Long-term remission was achieved after surgeries and radiotherapy in 85% (86.7% of BIPSS group, 83.0% of No-BIPSS group). CD was ultimately confirmed in all but one patient in each group. CONCLUSIONS Selective use of BIPSS in the preoperative evaluation of patients with presumed CD did not lead to misdiagnosis in the No-BIPSS group or adversely affect remission rates or long-term outcome.
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Affiliation(s)
- Sigrid Jehle
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, New York 10029, USA
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Coexistence of Adrenal Cushing Syndrome and Pheochromocytoma in a “Corticomedullary Adenoma”. ACTA ACUST UNITED AC 2007. [DOI: 10.1097/ten.0b013e3181596219] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tsagarakis S, Vassiliadi D, Kaskarelis IS, Komninos J, Souvatzoglou E, Thalassinos N. The application of the combined corticotropin-releasing hormone plus desmopressin stimulation during petrosal sinus sampling is both sensitive and specific in differentiating patients with Cushing's disease from patients with the occult ectopic adrenocorticotropin syndrome. J Clin Endocrinol Metab 2007; 92:2080-6. [PMID: 17356045 DOI: 10.1210/jc.2006-2691] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Although bilateral inferior petrosal sinus sampling (BIPSS) with CRH stimulation is the most accurate procedure for the differential diagnosis of ACTH-dependent Cushing's syndrome (CS), 4-15% of patients with Cushing's disease (CD) fail to demonstrate diagnostic gradients. Preliminary data suggest that a more potent stimulation by the combined administration of CRH plus desmopressin during BIPSS may provide some diagnostic advantage. A crucial issue, however, is whether such an amplified stimulation may affect the specificity of the procedure, and this was the main aim of the present study. OBJECTIVE We investigated the diagnostic accuracy of BIPSS performed by CRH plus desmopressin stimulation. DESIGN AND SETTING A retrospective analysis was conducted at a single tertiary care center. PARTICIPANTS Fifty-four patients were admitted for the investigation of ACTH-dependent CS. CD was diagnosed in 47 patients; occult ectopic ACTH syndrome (oEAS) was histologically confirmed in seven patients. INTERVENTION(S) All patients underwent BIPSS with CRH plus desmopressin administration. Additional noninvasive tests included CRH test, high-dose dexamethasone suppression test, desmopressin test, and pituitary magnetic resonance imaging. MAIN OUTCOME MEASURES Gradients of inferior petrosal sinus (IPS) to peripheral (IPS/P) ACTH were calculated before and after stimulation with CRH plus desmopressin. RESULTS The sensitivity for a basal IPS/P gradient greater than 2 was 61.7%, with 100% specificity and a diagnostic accuracy of 66.7%. After stimulation with CRH plus desmopressin, receiver operating characteristic (ROC) curve analysis showed that a cutoff gradient of more than 2 offers the best test performance. In total, 46 of 47 patients with CD had an IPS/P gradient greater than 2, but none of the patients with oEAS, resulting in a sensitivity of 97.9%. The specificity was 100%, diagnostic accuracy was 98.2%, and the positive and negative predictive values were 100 and 87.5%, respectively. A subgroup of 18 patients (16 with CD and two with oEAS) had contradictory responses to routine tests with CRH and/or high-dose dexamethasone suppression test; sensitivity, specificity, and accuracy of BIPSS in this subgroup were 100%. CONCLUSIONS The application of a combined stimulation with CRH plus desmopressin during BIPSS is associated with a high sensitivity but no loss of specificity.
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Affiliation(s)
- S Tsagarakis
- Department of Endocrinology, Athens Polyclinic Hospital, Athens, Greece.
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Uysal M, Temiz S, Gul N, Yarman S, Tanakol R, Kapran Y. Hypoglycemia due to ectopic release of insulin from a paraganglioma. HORMONE RESEARCH 2007; 67:292-5. [PMID: 17284922 DOI: 10.1159/000099291] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Accepted: 08/09/2006] [Indexed: 11/19/2022]
Abstract
Insulin-secreting pancreatic tumors and insulin-like growth hormone-secreting non-islet cell tumors can cause hypoglycemia. However, insulin-releasing paraganglioma or pheochromocytoma has almost never been reported. A 67-year-old female patient was admitted to our hospital because of headache, palpitation, perspiration, faintness, frequent sense of hunger and absent-mindedness. These intermittent symptoms had begun approximately a year before admission. On physical examination, she had high blood pressure of 150/90 mm Hg. Hormonal studies demonstrated increased urinary norepinephrine levels, and hyperinsulinemic hypoglycemia was confirmed while the patient was symptomatic. Abdominal MRI revealed a retroperitoneal mass measuring 4.5 cm in the pancreatic region. She was treated with an alpha-blocking agent to control blood pressure preceding the removal of the mass. Histopathological diagnosis was paraganglioma, and immunohistochemically insulin staining in the neoplastic cells was demonstrated. Her blood pressure normalized and hypoglycemia relieved after the operation. The patient did not have recurrence of hypoglycemia after a year of follow-up. Paraganglioma is a rare tumor of the neural crest, and co-secretion of insulin and catecholamines has been reported only by a single case report in the literature. The present patient is another case with this co-secretion.
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Affiliation(s)
- M Uysal
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Capa, Istanbul, Turkey.
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Young WF. Secondary Hypertension: Pheochromocytoma. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Eng PH, Tan LH, Wong KS, Cheng CW, Fok AC, Khoo DH. Cushing's syndrome in a patient with a corticotropin-releasing hormone-producing pheochromocytoma. Endocr Pract 2005; 5:84-7. [PMID: 15251695 DOI: 10.4158/ep.5.2.84] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present the first case of Cushing's syndrome attributable solely to ectopic production of corticotropin-releasing hormone by a pheochromocytoma. METHODS We summarize the clinical features and results of laboratory investigations in a patient with symptoms characteristic of Cushing's syndrome. RESULTS Although Cushing's syndrome is usually caused by ectopic production of adrenocorticotropic hormone (ACTH), our current patient had clinical and biochemical evidence of hypercortisolism in conjunction with "normal" ACTH levels and nonsuppressible serum and urinary cortisol levels on low-dose and high-dose dexamethasone suppression testing. An abdominal computed tomographic scan revealed a 7.7-cm mass in the left adrenal gland. Light microscopic examination and immunohistochemical staining showed a pheochromocytoma with mild cortical hyperplasia. Immunostaining was positive for corticotropin-releasing hormone but negative for ACTH. CONCLUSION To our knowledge, this is the first case of Cushing's syndrome in a patient with pheochromocytoma caused only by ectopic secretion of corticotropin-releasing hormone without accompanying secretion of ACTH.
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Affiliation(s)
- P H Eng
- Department of Endocrinology, Singapore General Hospital, Singapore
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Markou A, Manning P, Kaya B, Datta SN, Bomanji JB, Conway GS. [18F]fluoro-2-deoxy-D-glucose ([18F]FDG) positron emission tomography imaging of thymic carcinoid tumor presenting with recurrent Cushing's syndrome. Eur J Endocrinol 2005; 152:521-5. [PMID: 15817906 DOI: 10.1530/eje.1.01839] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report a case of a young woman with Cushing's syndrome (CS), in whom although endocrine investigations and negative pituitary imaging were suggestive of ectopic ACTH secretion, the results of inferior petrosal sinus (IPS) sampling after coricotropin-releasing hormone (CRH) stimulation were suggestive of pituitary ACTH hypersecretion. (111)In-labelled octreotide and high-resolution computer tomography (CT) revealed a lesion possibly responsible for the ACTH source in the thymus. Thymectomy confirmed concomitant ectopic CRH and probable ACTH production by a thymic neuroendocrine carcinoma. After an 8-year remission period the patient developed a clinical and biochemical relapse. A high-resolution computed tomography (CT) scan of the thorax showed a 2-cm nodule in the thymic bed, which was positive on a [(18)F]fluoro-2-deoxy-D-glucose ([(18)F]FDG) positron emission tomography (PET) scan. However, a repeated thymectomy did not result in remission. A repeat [(18)F]FDG PET study showed persistent disease in the thymic bed and also uptake in the adrenals. The patient underwent bilateral adrenalectomy, which resulted in clinical remission. A further [(18)F]FDG PET scan 8 months later showed no progression of the thymic tumor and confirmed complete excision of the adrenals. This is a rare case of concomitant CRH and ACTH secretion from a thymic carcinoid tumor; the case illustrates the usefulness of functional imaging with [(18)F]FDG PET in the diagnosis, management and follow-up of neuroendocrine tumors.
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Affiliation(s)
- Athina Markou
- Department of Endocrinology, Middlesex Hospital, London, UK
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Zangeneh F, Young WF, Lloyd RV, Chiang M, Kurczynski E, Zangeneh F. Cushing's syndrome due to ectopic production of corticotropin-releasing hormone in an infant with ganglioneuroblastoma. Endocr Pract 2004; 9:394-9. [PMID: 14583423 DOI: 10.4158/ep.9.5.394] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the first recognized case of Cushing's syndrome due to a corticotropin-releasing hormone (CRH)-secreting ganglioneuroblastoma, which was found in an 18-month-old boy with hypertensive encephalopathy. METHODS The clinical, biochemical, and immunohistochemical characteristics of this rare syndrome are described, and the relevant literature is reviewed. RESULTS An 18-month-old boy with a history of recent weight gain was admitted because of sudden onset of right fixed esotropia and left facial palsy after episodes of emesis. Magnetic resonance imaging showed old left frontal lobe and right hypothalamic infarcts. The patient had generalized obesity, decelerated linear growth, hypertrichosis, hypertension (144/103 mm Hg), hypokalemia, and proteinuria. The 24-hour urinary excretion of free cortisol, catecholamines, and metanephrines was increased. The serum cortisol concentration after a 1-mg overnight dexamethasone suppression test (DST) was 53.7 mg/dL (normal, <5). The serum adrenocorticotropic hormone (ACTH) concentration was 7 pg/mL (normal, 10 to 60), and the CRH level was 439 pg/mL (normal, 24 to 40). An overnight high-dose DST (8 mg) failed to suppress serum cortisol; however, both cortisol and ACTH were responsive to ovine CRH stimulation. Despite discordant dynamic endocrine testing and negative somatostatin receptor scintigraphy, computed tomography showed a right 3.6- by 3.0-cm extra-adrenal retroperitoneal mass with central calcification extending 7 cm cephalocaudally. The patient underwent exploratory laparotomy, followed by chemotherapy. Findings on light microscopic and immunohistochemical examination of the retroperitoneal mass were consistent with a ganglioneuroblastoma that expressed CRH, pro-opiomelanocortin, and ACTH. CONCLUSION The evaluation of Cushing's syndrome is one of the most complex endocrine challenges. In this case, it was due to ectopic production of CRH by a ganglioneuroblastoma. Because most CRH-producing tumors also secrete ACTH, the ectopic production may represent a paracrine phenomenon in addition to an endocrine phenomenon. The ectopic CRH may also indirectly provoke pituitary ACTH secretion. This dual mechanism may explain the resistance of the tumor to feedback inhibition and a CRH-stimulation response indistinguishable from that observed in pituitary-dependent Cushing's syndrome.
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Affiliation(s)
- Farhad Zangeneh
- Division of Endocrinology, Diabetes, Metabolism, Nutrition and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Oh HC, Koh JM, Kim MS, Park JY, Shong YK, Lee KU, Kim GS, Hong SJ, Koo HL, Kim WB. A case of ACTH-producing pheochromocytoma associated with pregnancy. Endocr J 2003; 50:739-44. [PMID: 14709846 DOI: 10.1507/endocrj.50.739] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ectopic ACTH syndrome is rarely caused by pheochromocytoma. We report a case of a 28-year-old woman with Cushing's syndrome due to ACTH-producing adrenal pheochromocytoma. She had delivered preterm baby at 32nd week of gestation with 'severe preeclampsia'. After delivery, persistent hypertension accompanied by severe headache led her to being misdiagnosed as Cushing's syndrome due to right adrenal adenoma (normal plasma ACTH level) and cerebral vasculitis of unknown etiology. She was referred to our hospital for surgical treatment. Repeated biochemical studies suggested coexistence of ectopic ACTH syndrome and pheochromocytoma. To reverse her clinical deterioration, right total and left subtotal adrenalectomy was performed with presumptive diagnosis of 1) right adrenal pheochromocytoma causing ectopic ACTH syndrome or 2) coexistence of ACTH-dependent Cushing's syndrome and right adrenal pheochromocytoma. Pathologic examination of right adrenal mass revealed pheochromocytoma which showed strong immunostaining for ACTH. Plasma ACTH and urinary cortisol excretion normalized after surgery, but she succumbed to multiple cerebral infarcts and disseminated intravascular coagulation. Pregnancy and inappropriately low plasma ACTH at initial evaluation might have hampered early diagnosis. To our knowledge, this is the first description of a case with ectopic ACTH syndrome due to pheochromocytoma associated with pregnancy.
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Affiliation(s)
- Hyoung Chul Oh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Vrezas I, Willenberg HS, Mansmann G, Hiroi N, Fritzen R, Bornstein SR. Ectopic adrenocorticotropin (ACTH) and corticotropin-releasing hormone (CRH) production in the adrenal gland: basic and clinical aspects. Microsc Res Tech 2003; 61:308-14. [PMID: 12768546 DOI: 10.1002/jemt.10340] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is integrated in the human stress system and controls the metabolism of many cell systems in the body. Therefore, hypofunction or hyperfunction of the HPA axis potentially threatens the life of the whole organism. Noncontrolled overproduction of its key regulators, CRH and ACTH, causes dysfunction of the stress system. Ectopic secretion of these compounds may be part of extraadrenal paraneoplastic syndromes caused by various benign or malignant tumors. However, ectopic ACTH and CRH may originate from the adrenal itself. A local CRH/ACTH system exists in the normal human adrenal medulla. Overproduction of CRH and ACTH has been documented in pheochromocytomas causing Cushing's syndrome. Finally, ectopic production of ACTH causing Cushing's syndrome has also been demonstrated in adrenocortical cells. This suggests a marked plasticity within the HPA axis and the neuroendocrine cell system.
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Affiliation(s)
- Ilias Vrezas
- Department of Endocrinology, University Hospital of Duesseldorf, 40225 Duesseldorf, Germany.
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37
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Abstract
OBJECTIVE To report an unusual case of Cushing's syndrome caused by an adrenal pheochromocytoma, manifesting as pseudo-central hypothyroidism and diabetic hyperosmolar coma. METHODS A detailed case report is presented, including clinical, laboratory, and radiologic findings as well as results of selective adrenal vein sampling. RESULTS In a 69-year-old woman with weight gain and hypothyroidism, diabetes mellitus with hyperosmolar coma developed precipitously. She had mild hypertension, but no diabetes was noted 2 weeks before the hyperosmolar event. Evaluation revealed Cushing's syndrome due to ectopic secretion of adrenocorticotropic hormone from an adrenal pheochromocytoma. After surgical resection of the tumor, the diabetes and the hypertension resolved. Furthermore, the pseudo-central hypothyroidism was eliminated, but primary hypothyroidism was unmasked. This combination has not been reported previously. CONCLUSION This case illustrates the array of endocrinopathies that can be associated with pheochromocytoma, causing Cushing's syndrome.
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Abstract
Ectopic POMC syndrome remains one of the most challenging differential diagnoses in endocrinology. Recent progress in the understanding of the tissue specific regulation of POMC gene expression and new insights into the processing of the POMC peptide in nonpituitary tissues has helped elucidate some of the molecular events leading to ectopic expression and secretion of POMC peptides. Corticotropin and other POMC-derived peptides have diverse effects on adrenal steroidogenesis, growth, and extra-adrenal tissues. Differences in POMC gene regulation in the corticotrope versus ectopic POMC-producing tumors provides a scientific framework for the clinical distinction between eutopic and ectopic Cushing's syndrome. In an attempt to revisit recent basic and clinical advances in the diagnosis of ectopic POMC syndrome the authors undertook an extensive literature review of 530 cases in 197 published papers and provided a molecular biologic, demographic and diagnostic update. According to this review, the four most common causes of ectopic POMC syndrome are the small cell carcinoma of the lung (27%), bronchial carcinoids (21%), islet cell tumor of the pancreas (16%), and thymic carcinoids (10%). Although the clinical features of patients with ectopic POMC syndrome are similar to those with Cushing's disease, subgroup analysis reveals a broad spectrum of severity and progression of signs and symptoms of hypercortisolism. The endocrine workup of a patient with suspected ectopic POMC syndrome includes the establishment of pathologic hypercortisolism, diagnosis of corticotropin dependency, and the differential diagnosis of corticotropin-dependent Cushing's syndrome. The use of a variety of baseline endocrine values, dynamic endocrine testing, and invasive procedures leads to the correct diagnosis in the majority of patients with ectopic POMC syndrome. Diagnostic imaging, including conventional radiological techniques and somatostatin receptor scintigraphy, aids in the correct localization and eventual treatment of ectopic POMC production.
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Affiliation(s)
- Felix Beuschlein
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Michigan, 5560A MSRB II, 1150 West Medical Center Dr., Ann Arbor, MI 48109-0678, USA
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Mazarakis N, Kontogeorgos G, Kovacs K, Horvath E, Borboli N, Piaditis G. Composite somatotroph--ACTH-immunoreactive pituitary adenoma with transformation of hyperplasia to adenoma. Pituitary 2001; 4:215-21. [PMID: 12501971 DOI: 10.1023/a:1020764013137] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The majority of pituitary adenomas are solitary and monohormonal, producing only one hormone. Double or multiple adenomas are rare. Plurihormonal adenomas may be monomorphous consisting of one cell type producing more than one hormones or plurimorphous composed of two or more distinct cell populations each producing different hormones. Primary pituitary hyperplasia is uncommon and transformation to adenoma has rarely been documented. We describe a unique case of somatotroph adenoma combined with ACTH-immunoreactive cell hyperplasia and focal transformation to adenoma. The 53-yr-old man was presented with a 2-yr history of headaches, enlargement of the hands and feet and coarsening of facial features. His blood GH was 17.5 ng/ml and he had absence of GH suppressional oral glucose tolerance testing. MRI demonstrated a mass with maximum diameter of 1.5 cm, on the left side of the pituitary, without invasion of surrounding tissues. Transsphenoidal surgery was performed. Morphology disclosed a mostly chromophobic tumor, immunoreactive for GH with ultrastructural characteristics of sparsely granulated somatotroph adenoma. The adenoma cell population was focally admixed with hyperplastic PAS positive and ACTH immunoreactive cells showing the electron microscopic features characteristic of corticotrophs. In these areas the acini were enlarged with distorted architecture of the reticulin pattern. Dissolution of the reticulin fiber network and transformation of hyperplastic ACTH-immunoreactive cells to adenoma was evident in small areas. The hyperplastic and adenomatous ACTH-immunoreactive cells were admixed with somatotroph adenoma cells. Due to lack of biochemically obvious cortisol hypersecretion, this ACTH-immunoreactive adenoma was classified as silent "corticotroph" subtype 1. This is an unusual case of composite pituitary adenoma consisting of somatotroph cells and hyperplastic ACTH-immunoreactive cells transforming to a frank adenoma.
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Affiliation(s)
- N Mazarakis
- Department of Endocrinology, Athens General Hospital Athens, Greece
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Aniszewski JP, Young WF, Thompson GB, Grant CS, van Heerden JA. Cushing syndrome due to ectopic adrenocorticotropic hormone secretion. World J Surg 2001; 25:934-40. [PMID: 11572035 DOI: 10.1007/s00268-001-0032-5] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cushing syndrome (CS) caused by ectopic adrenocorticotropic hormone (ACTH) production (EA) poses major challenges diagnostically by mimicking the pituitary-dependent form of CS and therapeutically by producing severe, life-threatening hypercortisolemia. This retrospective follow-up study describes the clinical characteristics and course of EA in a large referral center. Computer-based cross-index codes for EA, CS, and bilateral adrenalectomy were used to identify patients treated at the Mayo Clinic between 1956 and 1998. EA was confirmed in 106 patients. Gender distribution showed a slight female predominance (61:45). Bronchial carcinoid was the most frequent cause of EA (25%), followed by islet cell cancer (16%), small-cell lung carcinoma (11%), medullary thyroid cancer (8%), disseminated neuroendocrine tumor of unknown primary source (7%), thymic carcinoid (5%), pheochromocytoma (3%), disseminated gastrointestinal carcinoid (1%), and other tumors (8%). No tumor was found in 16% of patients. Altogether, 28 patients were managed medically, and the others underwent curative tumor resection (13 patients) or bilateral adrenalectomy (65 patients). Surgically treated patients had longer survival, but this was most likely affected by treatment bias. The diagnoses of CS and ACTH-secreting neoplasm were usually concurrent, although, there were remarkable cases in which the two conditions were diagnosed several years apart. Curative resection of the tumor producing EA was possible in a small proportion of patients (12%). When curative resection is not possible, patients who are reasonable surgical candidates are likely to benefit from adrenalectomy. Additional experience with bilateral laparoscopic adrenalectomy should increase the number of patients who benefit from adrenal-directed surgery.
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Affiliation(s)
- J P Aniszewski
- Division of Endocrinology, Metabolism, Nutrition, and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
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Shimizu C, Kubo M, Takano K, Takano A, Kijima H, Saji H, Katsuyama I, Sasano H, Koike T. Interleukin-6 (IL-6) producing phaeochromocytoma: direct IL-6 suppression by non-steroidal anti-inflammatory drugs. Clin Endocrinol (Oxf) 2001; 54:405-10. [PMID: 11298095 DOI: 10.1046/j.1365-2265.2001.01082.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 35-year-old Japanese woman presented with a phaeochromocytoma and demonstrated marked inflammatory reactions and pyrexia as a result of excessive production of interleukin-6 (IL-6) by the tumour. Serum IL-6 level was 262 ng/l (normal; < 4.0 ng/l). Fever and inflammatory markers were largely overcome by the administration of the nonsteroidal anti-inflammatory drug, naproxen, and all symptoms disappeared soon after the tumour was excised. Immunohistochemical study revealed positive staining using an antihuman IL-6 antibody and Northern analysis showed increased IL-6 mRNA levels in the tumour. Cultured tumour cells showed IL-6 protein synthesis, and nonsteroidal anti-inflammatory drugs such as naproxen and indomethacin directly inhibited IL-6 release. These results indicate that the effects of naproxen in vivo were due, at least in part, to direct suppression of IL-6 secretion from the tumour.
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Affiliation(s)
- C Shimizu
- Department of Medicine II, Hokkaido University School of Medicine, Sapporo, Japan
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42
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Smallridge RC, Czervionke LF, Fellows DW, Bernet VJ. Corticotropin- and thyrotropin-secreting pituitary microadenomas: detection by dynamic magnetic resonance imaging. Mayo Clin Proc 2000; 75:521-8. [PMID: 10807083 DOI: 10.4065/75.5.521] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hormone-secreting pituitary microadenomas are often not visible on magnetic resonance imaging (MRI). Diagnosis requires confirmatory endocrine test results and often an invasive procedure, inferior petrosal sinus sampling (IPSS). Improved pituitary imaging may eliminate the need for IPSS in some patients, as shown in the 2 women in this report. The first patient with hirsutism, weight gain, and hypertension had intermittent elevations of urinary free cortisol, abnormal results on a low-dose dexamethasone suppression test, and positive results on a dexamethasone-suppressed ovine corticotropin-releasing hormone test (corticotropin, increase of 122%; cortisol, increase of 118%). Gadolinium-enhanced MRI showed no focal lesion, but dynamic MRI (sequential images beginning immediately after contrast injection) revealed a right-sided 5-mm microadenoma, confirmed by transsphenoidal surgery. The second patient had a goiter, anxiety, increased free thyroxine and triiodothyronine levels, and a normal thyrotropin value with no response to thyrotropin-releasing hormone. Magnetic resonance imaging showed no lesion, but dynamic MRI detected an 8-mm microadenoma. Although about 8% to 10% of healthy persons have incidental pituitary lesions that are 3 mm or larger on MRI, identification of a distinct lesion and positive results on a dexamethasone-suppressed ovine corticotropin-releasing hormone test should decrease the probability of a false-positive result on an imaging study. We recommend that dynamic MRI be performed in any patient with a suspected microadenoma, before IPSS is performed.
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Affiliation(s)
- R C Smallridge
- Division of Endocrinology, Mayo Clinic Jacksonville, FL 32224, USA
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Affiliation(s)
- J W Findling
- Medical College of Wisconsin, St. Luke's Medical Center, Milwaukee, USA
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44
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Finkenstedt G, Gasser RW, Höfle G, Lhotta K, Kölle D, Gschwendtner A, Janetschek G. Pheochromocytoma and sub-clinical Cushing's syndrome during pregnancy: diagnosis, medical pre-treatment and cure by laparoscopic unilateral adrenalectomy. J Endocrinol Invest 1999; 22:551-7. [PMID: 10475154 DOI: 10.1007/bf03343608] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The coexistence of pheochromocytoma and primary adrenal Cushing's syndrome of the same adrenal gland has rarely been reported. We describe here the case of a female patient presenting with mild Cushing's stigmata, hypertension and diabetes mellitus in whom we diagnosed a pheochromocytoma of the left adrenal gland with coexisting non-ACTH-dependent cortisol hypersecretion. While hormonal work-up was still in progress, the patient became pregnant and wanted to carry her pregnancy to full-term. A laparoscopic adrenalectomy in the 17th week of gestation was decided upon and the patient accordingly prepared for surgery by pre-treatment with phenoxybenzamine. Successful surgery--the first ever reported laparoscopic resection of a pheochromocytoma in pregnancy--without perioperative complications was performed under general anesthesia, with the patient receiving peri- and post-operative hydrocortisone substitution. Pathohistological examination revealed a pheochromocytoma with positive immunostaining for interleukin-6 (IL-6) and negative immunostaining for ACTH, vasoactive intestinal polypeptide (VIP) and cytochrome P450, and with no signs of malignancy. A paracrine stimulation of the ipsilateral adrenal cortex by IL-6 produced by the pheochromocytoma, leading to cortical hyperplasia and subclinical Cushing's syndrome, is suggested by the positive immunostaining for IL-6 and the MRI findings. Post-operatively, secondary adrenal insufficiency ensued, necessitating continuing hydrocortisone replacement over 12 months. Hypertension resolved after surgery, and diabetes after the uncomplicated vaginal delivery at term.
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Affiliation(s)
- G Finkenstedt
- Department of Internal Medicine, University of Innsbruck, Austria.
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45
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Abstract
Comprehensive article summarizing more than 25 years of experience with pituitary hyperplasia in surgical material. Morphologic forms of hyperplasia--diffuse and nodular--are defined and, for comparison, the normal morphology, frequency and intraglandular distribution of cell types are briefly reviewed. All cell types can give rise to hyperplasia, although their frequency, extent and clinical importance widely vary. Somatotroph hyperplasia is rare; it is limited to cases of GHRH overproduction by extrapituitary endocrine neoplasms and sporadic examples of gigantism. Prolactin cells display the highest propensity for non-neoplastic proliferation. Physiologic hyperplasia occurs in pregnancy and lactation. Pathological hyperplasia is mostly secondary to other, neoplastic or non-neoplastic, space occupying processes. Idiopathic lactotroph hyperplasia is very rare. The much-disputed corticotroph hyperplasia is infrequent cause of pituitary dependent Cushing's disease. Despite difficulties of diagnosis in fragmented biopsies, several well-documented cases prove the existence of corticotroph hyperplasia which is nearly always nodular. Thyrotroph hyperplasia, secondary to hypothyroidism, a treatable condition, is not expected to occur in surgical material, yet several cases have been identified. Operated lesions are massive nodular leading to significant pituitary enlargement thereby mimicking TSH- or PRL-producing adenoma. Hyperprolactinemia is a frequent concomitant of severe thyrotroph hyperplasia. Gonadotroph hyperplasia and proliferation of pars intermedia derived POMC cells are not likely to occur in surgical material and have no clinical significance. Adenoma formation may rarely be associated with any type of pituitary hyperplasia.
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Affiliation(s)
- E Horvath
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Ontario, Canada
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46
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Abstract
A norepinephrine producing right adrenal pheochromocytoma was associated with bilateral adrenal hyperplasia and clinically and biochemically evident Cushing's syndrome. Ectopic adrenocorticotropin production was suspected, but the six criteria for proof of ectopic adrenocorticotropin production could not be demonstrated. The diagnosis of Cushing's syndrome from ectopic hormone production by a pheochromocytoma requires a high index of suspicion and extensive biochemical and radiographic testing to confirm Cushing's syndrome, identify the cause of Cushing's syndrome, and localize the pheochromocytoma.
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Affiliation(s)
- A M Amos
- Department of Surgery, University of Kentucky, Chandler Medical Center, Lexington 40536-0084, USA
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47
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Ehrhart-Bornstein M, Hinson JP, Bornstein SR, Scherbaum WA, Vinson GP. Intraadrenal interactions in the regulation of adrenocortical steroidogenesis. Endocr Rev 1998; 19:101-43. [PMID: 9570034 DOI: 10.1210/edrv.19.2.0326] [Citation(s) in RCA: 310] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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48
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Venihaki M, Ain K, Dermitzaki E, Gravanis A, Margioris AN. KAT45, a noradrenergic human pheochromocytoma cell line producing corticotropin-releasing hormone. Endocrinology 1998; 139:713-22. [PMID: 9449645 DOI: 10.1210/endo.139.2.5724] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
KAT45 cells were derived from a human pheochromocytoma, which also caused ectopic Cushing's syndrome, and developed into a cell line spontaneously after the continuous primary culture of the tumor cells. These human pheochromocytoma cells were compared with the extensively characterized PC12 rat pheochromocytoma cell line. KAT45 cells resembled PC12 cells in morphology, proliferation rate, response to cholinergic stimuli, and the development of dendrite-like projections after exposure to nerve growth factor. They produced norepinephrine and epinephrine in a ratio of 50:1, as opposed to production of dopamine by PC12 cells, in amounts 1 order of magnitude higher compared with PC12. Because of the ectopic Cushing's syndrome in our patient, her normal ACTH level, and the knowledge that PC12 cells and even normal rat chromaffin cells appear to produce CRH, we examined whether KAT45 cells also produced this neuropeptide. Indeed, KAT45 cells released authentic CRH and contained an apparently intact CRH transcript. Nicotine and KCl depolarization stimulated the secretion of CRH, whereas interleukin-1beta, glucocorticoids, and nerve growth factor stimulated its synthesis. In addition to the potential systemic effects of CRH, which in our patient produced ectopic Cushing's syndrome, CRH can exert paracrine effects within normal or tumoral adrenals. We used KAT45 cells as a model for the study of the local role of CRH. CRH affected several parameters of KAT45 cell metabolism, including their proliferation rate, synthesis of catecholamines, and production of POMC-derived peptides. KAT45 cells, in addition to the data they provided regarding the in vitro profile of a human CRH-producing pheochromocytoma, may prove to be a valuable auxiliary to the PC12 cell line.
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Affiliation(s)
- M Venihaki
- Department of Clinical Chemistry, University of Crete School of Medicine, Greece
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49
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Venihaki M, Gravanis A, Margioris AN. Comparative study between normal rat chromaffin and PC12 rat pheochromocytoma cells: production and effects of corticotropin-releasing hormone. Endocrinology 1997; 138:698-704. [PMID: 9003004 DOI: 10.1210/endo.138.2.4916] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The adrenal medulla of several species and some human pheochromocytomas contain CRH. The first aim of the present work was to find out whether normal rat adrenal chromaffin cells and the PC12 rat pheochromocytoma cell line produce CRH in vitro and what regulates its production. CRH was measured and characterized in the media of both types of chromaffin cells under basal conditions and after exposure to K+, nicotine, interleukin-1 beta, and nerve growth factor (NGF). The second aim was to examine the biological effect of exogenous CRH (and of its antagonist) on the production of catecholamines from these two types of cells. Our results are as follows: 1) Both types of chromaffin cells contained and secreted comparable amounts of immunoreactive-CRH under basal conditions and after K(+)-induced depolarization, nicotine, and interleukin-1 beta; 2) the physicochemical characteristics of the immunoreactive-CRH in the cells and the media were identical to the putative CRH peptide on both sieve chromatography and RP-HPLC; 3) synthetic CRH induced the production of catecholamines from both cell types in a dose- and time-dependent manner; this effect was abolished by the antagonist, alpha helical CRH; 4) exposure of PC12 cells to NGF (for 1 week) resulted in their neuronal differentiation and the stimulation of their production of CRH by 30 times and of dopamine by 10 times, compared with parallel controls; this effect of NGF was abolished by alpha helical CRH. In conclusion, our data suggest that the production of CRH by PC12 cells represents the preservation of a normal chromaffin cell characteristic rather than a tumor-induced ectopic phenomenon.
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Affiliation(s)
- M Venihaki
- Department of Clinical Chemistry, School of Medicine, University of Crete, Iraklion, Greece
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50
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Borretta G, Terzolo M, Cesario F, Meineri I, Pia A, Angeli A. Coexistence of unilateral adrenal macronodule and Cushing's disease. Report of two cases. J Endocrinol Invest 1996; 19:131-5. [PMID: 8778166 DOI: 10.1007/bf03349849] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The coexistence of an unilateral adrenal macronodule and Cushing's disease is well documented in only few reports. We hereby describe two patients with ACTH-dependent Cushing's syndrome and asymmetric adrenal involvement. In both patients the left-sided adrenal contained a nodule sized 1.5 and 1.4 cm, respectively, while the contralateral gland appeared as normal at abdominal computerized tomography. Adrenal scintiscan revealed a bilateral uptake of the tracer. Dynamic testing of hypothalamic-pituitary-adrenal axis was suggestive of pituitary dependency but neuroradiologic imaging was inconclusive. Inferior petrosal sinus sampling demonstrated a clear center to periphery ACTH gradient and an ACTH-producing pituitary microadenoma was found and removed in both cases. Hypopituitarism ensued postoperatively and Cushing's syndrome resolved but the adrenal nodules regressed only many month after operation. The present cases confirm that the presence of an adrenal mass in a patient with Cushing's syndrome is insufficient to confidently conclude for the adrenal dependency of the syndrome.
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Affiliation(s)
- G Borretta
- Divisione di Endocrinologia, Ospedale S. Croce, Cuneo, Italy
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