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Hanalioglu S, Gurses ME, Gecici NN, Baylarov B, Isikay I, Gürlek A, Berker M. Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent cushing's disease: safety, feasibility, and success. Pituitary 2024; 27:259-268. [PMID: 38748309 PMCID: PMC11150181 DOI: 10.1007/s11102-024-01396-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE The success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing's disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients. METHODS A retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission. RESULTS Among the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission. CONCLUSION Repeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.
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Affiliation(s)
- Sahin Hanalioglu
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Muhammet Enes Gurses
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Neslihan Nisa Gecici
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Baylar Baylarov
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ilkay Isikay
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Alper Gürlek
- Department of Endocrinology and Metabolism, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mustafa Berker
- Department of Neurosurgery, Hacettepe University School of Medicine, Sihhiye, Ankara, 06230, Turkey.
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Rebollar-Vega RG, Zuarth-Vázquez JM, Hernández-Ramírez LC. Clinical Spectrum of USP8 Pathogenic Variants in Cushing's Disease. Arch Med Res 2023; 54:102899. [PMID: 37925320 DOI: 10.1016/j.arcmed.2023.102899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 11/06/2023]
Abstract
Cushing's disease (CD) is a life-threatening condition with a challenging diagnostic process and scarce treatment options. CD is caused by usually benign adrenocorticotrophic hormone (ACTH)-secreting pituitary neuroendocrine tumors (PitNETs), known as corticotropinomas. These tumors are predominantly of sporadic origin, and usually derive from the monoclonal expansion of a mutated cell. Somatic activating variants located within a hotspot of the USP8 gene are present in 11-62% of corticotropinomas, making USP8 the most frequent genetic driver of corticotroph neoplasia. In contrast, other somatic defects such as those affecting the glucocorticoid receptor gene (NR3C1), the BRAF oncogene, the deubiquitinase-encoding gene USP48, and TP53 are infrequent. Moreover, patients with familial tumor syndromes, such as multiple endocrine neoplasia, familial isolated pituitary adenoma, and DICER1 rarely develop corticotropinomas. One of the main molecular alterations in USP8-driven tumors is an overactivation of the epidermal growth factor receptor (EGFR) signaling pathway, which induces ACTH production. Hotspot USP8 variants lead to persistent EGFR overexpression, thereby perpetuating the hyper-synthesis of ACTH. More importantly, they condition a characteristic transcriptomic signature that might be useful for the clinical prognosis of patients with CD. Nevertheless, the clinical phenotype associated with USP8 variants is less well defined. Hereby we discuss the current knowledge on the molecular pathogenesis and clinical picture associated with USP8 hotspot variants. We focus on the potential significance of the USP8 mutational status for the design of tailored clinical strategies in CD.
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Affiliation(s)
- Rosa G Rebollar-Vega
- Red de Apoyo a la Investigación, Coordinación de la Investigación Científica, Universidad Nacional Autónoma de México e Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Julia M Zuarth-Vázquez
- Department of Endocrinology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Laura C Hernández-Ramírez
- Red de Apoyo a la Investigación, Coordinación de la Investigación Científica, Universidad Nacional Autónoma de México e Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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3
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Gupta N, Dutta A, Baruah MM, Bhansali A, Ahuja CK, Dhandapani S, Bhadada SK, Saikia UN, Walia R. An Integrated Clinical Score to Predict Remission in Cushing's Disease. Indian J Endocrinol Metab 2023; 27:501-505. [PMID: 38371189 PMCID: PMC10871004 DOI: 10.4103/ijem.ijem_314_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/05/2023] [Accepted: 10/25/2023] [Indexed: 02/20/2024] Open
Abstract
Objective To derive a clinical score from parameters that favor remission of Cushing's disease (CD) after pituitary surgery. Methods This is an analysis of 11 clinical, hormonal, and post-operative parameters that each favored remission in a cohort of 145 patients with CD treated by trans-sphenoidal surgery (TSS). Each parameter was designated as a categorical variable (presence/absence), and several favorable parameters present for each patient were calculated. From this, a median parameter score (clinical score) of the entire cohort was derived, which was then compared to the event of remission/persistence of CD. Results The median number of favorable parameters present in the entire cohort was 3 (0-7). The significant count of patients in remission increased with the increasing number of parameters. The receiver-operator characteristic curve showed that the presence of ≥3 parameters was associated with remission in CD with a sensitivity of 84.2% and a specificity of 80%. Patients with a clinical score ≥3 had significantly higher remission rates (88.9%) than those who had persistent disease (27.3%; P = 0.001). Conclusion A clinical score of ≥3 predicts remission in CD treated by TSS; however, it requires validation in other large cohorts. Rather than assessing individual parameters to predict remission in CD, an integrated clinical score is a better tool for follow-up and patient counseling.
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Affiliation(s)
- Nidhi Gupta
- Department of Endocrinology, PGIMER, Chandigarh, India
| | - Aditya Dutta
- Department of Endocrinology, PGIMER, Chandigarh, India
| | | | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, India
| | | | | | | | | | - Rama Walia
- Department of Endocrinology, PGIMER, Chandigarh, India
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4
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Mallick S, Chakrabarti J, Eschbacher J, Moraitis AG, Greenstein AE, Churko J, Pond KW, Livolsi A, Thorne CA, Little AS, Yuen KCJ, Zavros Y. Genetically engineered human pituitary corticotroph tumor organoids exhibit divergent responses to glucocorticoid receptor modulators. Transl Res 2023; 256:56-72. [PMID: 36640905 DOI: 10.1016/j.trsl.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
Cushing's disease (CD) is a serious endocrine disorder attributed to an adrenocorticotropic hormone (ACTH)-secreting pituitary neuroendocrine tumor (PitNET) that that subsequently leads to chronic hypercortisolemia. PitNET regression has been reported following treatment with the investigational selective glucocorticoid receptor (GR) modulator relacorilant, but the mechanisms behind that effect remain unknown. Human PitNET organoid models were generated from induced human pluripotent stem cells (iPSCs) or fresh tissue obtained from CD patient PitNETs (hPITOs). Genetically engineered iPSC derived organoids were used to model the development of corticotroph PitNETs expressing USP48 (iPSCUSP48) or USP8 (iPSCUSP8) somatic mutations. Organoids were treated with the GR antagonist mifepristone or the GR modulator relacorilant with or without somatostatin receptor (SSTR) agonists pasireotide or octreotide. In iPSCUSP48 and iPSCUSP8 cultures, mifepristone induced a predominant expression of SSTR2 with a concomitant increase in ACTH secretion and tumor cell proliferation. Relacorilant predominantly induced SSTR5 expression and tumor cell apoptosis with minimal ACTH induction. Hedgehog signaling mediated the induction of SSTR2 and SSTR5 in response to mifepristone and relacorilant. Relacorilant sensitized PitNET organoid responsiveness to pasireotide. Therefore, our study identified the potential therapeutic use of relacorilant in combination with somatostatin analogs and demonstrated the advantages of relacorilant over mifepristone, supporting its further development for use in the treatment of Cushing's disease patients.
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Affiliation(s)
- Saptarshi Mallick
- Department of Cellular and Molecular Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Jayati Chakrabarti
- Department of Cellular and Molecular Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Jennifer Eschbacher
- Department of Neuropathology, Barrow Neurological Institute, Phoenix, Arizona
| | | | | | - Jared Churko
- Department of Cellular and Molecular Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Kelvin W Pond
- Department of Cellular and Molecular Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | | | - Curtis A Thorne
- Department of Cellular and Molecular Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Kevin C J Yuen
- Department of Neuroendocrinology, Barrow Neurological Institute, Phoenix, Arizona
| | - Yana Zavros
- Department of Cellular and Molecular Medicine, University of Arizona College of Medicine, Tucson, Arizona.
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5
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Grigoriev AY, Azizyan VN, Ivashchenko OV, Starkov GY. [Diagnosis and new treatment options for pituitary adenomas]. PROBLEMY ENDOKRINOLOGII 2023; 69:4-10. [PMID: 37448265 DOI: 10.14341/probl13199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 07/15/2023]
Abstract
Currently, the treatment of pituitary adenomas is inextricably linked with transsphenoidal neurosurgical intervention. Modern technologies used in surgery for this pituitary pathology, such as endoscopy using angled optics, as well as the use of specialized instruments, sealing and hemostatic materials, increase the effectiveness of surgical treatment of pituitary adenomas and reduce the incidence of intraand postoperative complications. The development of radiation methods of diagnostics, such as MRI, makes it possible to more accurately identify the formation of the pituitary gland, assess its size, direction of growth, and the degree of invasion of surrounding tissues. The authors of the article described in detail the modern technique of transsphenoidal removal of pituitary adenoma using an endoscope. Each stage of the operation is described step by step, taking into account various anatomical features and illustrated. This article discusses the MRI characteristics of pituitary adenomas: size of the tumor, the direction of its growth, the degree of invasion of the cavernous sinuses, the compression effect on the structures of the chiasmal-sellar region. The use of treatment methods, knowledge of the features of MRI diagnostics described in this article greatly increase the effectiveness of the treatment of patients with pituitary adenomas and reduce the risk of complications after neurosurgical intervention in such patients.
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Affiliation(s)
| | | | | | - G Yu Starkov
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
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Shao C, Wang J, Wang P, Wu N. Endoscopic Transsphenoidal Surgery with a Layered Peel Strategy for Cushing's Disease Treatment: A Case Series. Brain Sci 2023; 13:brainsci13040671. [PMID: 37190636 DOI: 10.3390/brainsci13040671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
Patients with Cushing's disease (CD) who underwent endoscopic transsphenoidal surgery (ETS) with a layered peel strategy at our center were retrospectively analyzed. Records on patients' basic characteristics, preoperative and early postoperative evaluations, perioperative complications, and follow-up were collected. A total of 12 unselected, consecutive patients with CD were identified. Ten of the twelve patients were female. All tumors were confirmed by magnetic resonance imaging, with a maximum tumor diameter ranging from 5 mm to 11 mm. A lower rate of surgical complications was identified postoperatively, with no cases of carotid artery injury, epistaxis, hematoma, visual disturbance, or intracranial infection, but with one case of cerebrospinal fluid rhinorrhea. Ten patients experienced immediate remission, and two had delayed remission. No recurrence events were observed during a median follow-up of 51 months. In conclusion, our preliminary experience indicated that ETS with a layered peel strategy provided a perfect remission rate, low complication rate, and no recurrence in a case series of CD patients. Given the limited number of cases, future studies are warranted to confirm its effectiveness and safety.
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Affiliation(s)
- Chuan Shao
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
- Graduate Institute, Chongqing Medical University, Chongqing 400016, China
| | - Junwei Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
| | - Pan Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
| | - Nan Wu
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
- Graduate Institute, Chongqing Medical University, Chongqing 400016, China
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7
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Slagboom TNA, Stenvers DJ, van de Giessen E, Roosendaal SD, de Win MML, Bot JCJ, Aronica E, Post R, Hoogmoed J, Drent ML, Pereira AM. Continuing Challenges in the Definitive Diagnosis of Cushing's Disease: A Structured Review Focusing on Molecular Imaging and a Proposal for Diagnostic Work-Up. J Clin Med 2023; 12:jcm12082919. [PMID: 37109254 PMCID: PMC10144206 DOI: 10.3390/jcm12082919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
The definitive diagnosis of Cushing's disease (CD) in the presence of pituitary microadenoma remains a continuous challenge. Novel available pituitary imaging techniques are emerging. This study aimed to provide a structured analysis of the diagnostic accuracy as well as the clinical use of molecular imaging in patients with ACTH-dependent Cushing's syndrome (CS). We also discuss the role of multidisciplinary counseling in decision making. Additionally, we propose a complementary diagnostic algorithm for both de novo and recurrent or persistent CD. A structured literature search was conducted and two illustrative CD cases discussed at our Pituitary Center are presented. A total of 14 CD (n = 201) and 30 ectopic CS (n = 301) articles were included. MRI was negative or inconclusive in a quarter of CD patients. 11C-Met showed higher pituitary adenoma detection than 18F-FDG PET-CT (87% versus 49%). Up to 100% detection rates were found for 18F-FET, 68Ga-DOTA-TATE, and 68Ga-DOTA-CRH, but were based on single studies. The use of molecular imaging modalities in the detection of pituitary microadenoma in ACTH-dependent CS is of added and complementary value, serving as one of the available tools in the diagnostic work-up. In selected CD cases, it seems justified to even refrain from IPSS.
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Affiliation(s)
- Tessa N A Slagboom
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Dirk Jan Stenvers
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Elsmarieke van de Giessen
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Stefan D Roosendaal
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Maartje M L de Win
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Joseph C J Bot
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Eleonora Aronica
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of (Neuro)Pathology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - René Post
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jantien Hoogmoed
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Madeleine L Drent
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Alberto M Pereira
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Sabahi M, Ghasemi-Nesari P, Maroufi SF, Shahbazi T, Yousefi O, Shahtaheri SA, Bin-Alamer O, Dabecco R, Velasquez N, Arce KM, Adada B, Benjamin CG, Borghei-Razavi H. Recurrent Cushing Disease: An Extensive Review on Pros and Cons of Different Therapeutic Approaches. World Neurosurg 2023; 172:49-65. [PMID: 36739900 DOI: 10.1016/j.wneu.2023.01.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission. METHODS We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020. RESULTS We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60-0.70), 0.57 (95% CI 0.51-0.63), and 0.75 (95% CI 0.60-0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60-0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28). CONCLUSIONS Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range.
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Affiliation(s)
- Mohammadmahdi Sabahi
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paniz Ghasemi-Nesari
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Taha Shahbazi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Yousefi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Alireza Shahtaheri
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Othman Bin-Alamer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nathalia Velasquez
- Department of Otolaryngology/Head and Neck Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Karla M Arce
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA.
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9
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Layard Horsfall H, Lawrence A, Venkatesh A, Loh RTS, Jayapalan R, Koulouri O, Sharma R, Santarius T, Gurnell M, Dorward N, Mannion R, Marcus HJ, Kolias AG. Reported outcomes in transsphenoidal surgery for pituitary adenomas: a systematic review. Pituitary 2023:10.1007/s11102-023-01303-w. [PMID: 36862265 DOI: 10.1007/s11102-023-01303-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Transsphenoidal surgery is an established treatment for pituitary adenomas. We examined outcomes and time points following transsphenoidal surgery for pituitary adenoma to identify reporting heterogeneity within the literature. METHODS A systematic review of studies that reported outcomes for transsphenoidal surgery for pituitary adenoma 1990-2021 were examined. The protocol was registered a priori and adhered to the PRISMA statement. Studies in English with > 10 patients (prospective) or > 500 patients (retrospective) were included. RESULTS 178 studies comprising 427,659 patients were included. 91 studies reported 2 or more adenoma pathologies within the same study; 53 studies reported a single pathology. The most common adenomas reported were growth hormone-secreting (n = 106), non-functioning (n = 101), and ACTH-secreting (n = 95); 27 studies did not state a pathology. Surgical complications were the most reported outcome (n = 116, 65%). Other domains included endocrine (n = 104, 58%), extent of resection (n = 81, 46%), ophthalmic (n = 66, 37%), recurrence (n = 49, 28%), quality of life (n = 25, 19%); and nasal (n = 18, 10%). Defined follow up time points were most reported for endocrine (n = 56, 31%), extent of resection (n = 39, 22%), and recurrence (n = 28, 17%). There was heterogeneity in the follow up reported for all outcomes at different time points: discharge (n = 9), < 30 days (n = 23), < 6 months (n = 64), < 1 year (n = 23), and > 1 year (n = 69). CONCLUSION Outcomes and follow up reported for transsphenoidal surgical resection of pituitary adenoma are heterogenous over the last 30 years. This study highlights the necessity to develop a robust, consensus-based, minimum, core outcome set. The next step is to develop a Delphi survey of essential outcomes, followed by a consensus meeting of interdisciplinary experts. Patient representatives should also be included. An agreed core outcome set will enable homogeneous reporting and meaningful research synthesis, ultimately improving patient care.
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Affiliation(s)
- Hugo Layard Horsfall
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, W1CN 3BG, UK.
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
| | | | - Ashwin Venkatesh
- Clinical School of Medicine, University of Cambridge, Cambridge, UK
| | - Ryan T S Loh
- Clinical School of Medicine, University of Cambridge, Cambridge, UK
| | - Ronie Jayapalan
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Olympia Koulouri
- Metabolic Research Laboratories, Institute of Metabolic Science and Department of Medicine, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Rishi Sharma
- Department of Otolaryngology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Thomas Santarius
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science and Department of Medicine, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Neil Dorward
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, W1CN 3BG, UK
| | - Richard Mannion
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Hani J Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, W1CN 3BG, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
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Wang B, Zheng S, Ren J, Zhong Z, Jiang H, Sun Q, Su T, Wang W, Sun Y, Bian L. Reoperation for Recurrent and Persistent Cushing's Disease without Visible MRI Findings. J Clin Med 2022; 11:jcm11226848. [PMID: 36431325 PMCID: PMC9699622 DOI: 10.3390/jcm11226848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Transsphenoidal surgery is the first-line treatment for Cushing's disease (CD), even with negative preoperative magnetic resonance imaging (MRI) results. Some patients with persistent or recurring hypercortisolism have negative MRI findings after the initial surgery. We aimed to analyze the efficacy of repeat surgery in two groups of patients and determine if there is an association between positive MRI findings and early remission. PATIENTS AND METHODS Clinical, imaging, and biochemical information of 42 patients who underwent repeat surgery by a single neurosurgeon between 2002 and 2021 was retrospectively analyzed. We compared the endocrinological, histopathological, and surgical outcomes before and after repeat surgery among 14 CD patients with negative MRI findings and 28 patients with positive MRI findings. RESULTS Immediate remission was achieved in 29 patients (69.0%) who underwent repeat surgery. Among all patients, 28 (66.7%) had MRI findings consistent with solid lesions. There was no significant difference in remission rates between the recurrence and persistence groups (77.8% vs. 57.1%, odds ratio = 2.625, 95% confidence interval = 0.651 to 10.586). Patients in remission after repeat surgery were not associated with positive MRI findings (odds ratio = 3.667, 95% confidence interval = 0.920 to 14.622). CONCLUSIONS In terms of recurrence, repeat surgery in patients with either positive or negative MRI findings showed reasonable remission rates. For persistent disease with positive MRI findings, repeat surgery is still an option; however, more solid evidence is needed to determine if negative MRI findings are predictors for failed reoperations for persistent hypercortisolism.
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Affiliation(s)
- Baofeng Wang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shuying Zheng
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jie Ren
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhihong Zhong
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hong Jiang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qingfang Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Tingwei Su
- Department of Endocrinology and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Weiqing Wang
- Department of Endocrinology and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yuhao Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Correspondence: (Y.S.); or (L.B.)
| | - Liuguan Bian
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Correspondence: (Y.S.); or (L.B.)
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11
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Guignat L, Bertherat J. Long-term follow-up and predictors of recurrence of Cushing's disease. J Neuroendocrinol 2022; 34:e13186. [PMID: 35979714 DOI: 10.1111/jne.13186] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery is the first-line treatment for Cushing's disease to selectively remove the tumor. The rate of postoperative remission is estimated around 70%-80% in expert centers. However, the long-term remission rate is lower because of recurrence during follow-up that can be observed in 15% to 25% of the patients depending on the studies and duration of follow-up. There is no significant predictive factor of recurrence before surgery, but postoperative corticotroph insufficiency and its duration has been found to be a protective factor for recurrence in many studies. The persistence of a positive response to desmopressin after surgery is associated with a higher rate of recurrence. Long term monitoring for recurrence with annual clinical and hormonal investigations after the hypothalamic-pituitary-adrenal axis postoperative recovery is advised. The biological tests used for the diagnosis of Cushing's syndrome (24 h-urinary-free cortisol [UFC], late-night salivary or serum cortisol, 1 mg dexamethasone suppression test) can be used to screen for recurrence. Several studies report that increased late night cortisol and alterations of dynamic testing can be observed before the increased 24 h-UFC. For this reason it is suggested that late-night salivary cortisol would be a very sensitive tool to diagnose recurrence, pending the realization of several assays in case of borderline or discrepant result. This review will summarize the knowledge about recurrence of Cushing's disease after pituitary surgery and the current recommendations for its monitoring and diagnosis.
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Affiliation(s)
- Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
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12
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Sabahi M, Shahbazi T, Maroufi SF, Vidal K, Recinos PF, Kshettry VR, Roser F, Adada B, Borghei-Razavi H. MRI-Negative Cushing's Disease: A Review on Therapeutic Management. World Neurosurg 2022; 162:126-137.e1. [PMID: 35338018 DOI: 10.1016/j.wneu.2022.03.076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In this systematic review and meta-analysis, we review the literature regarding patients with Cushing's disease (CD) with negative or inconclusive magnetic resonance imaging (MRI). METHODS A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), EMBASE, and Cochrane electronic bibliographic databases. RESULTS 28 articles described surgical management of inconclusive MRI or MRI-negative CD. A total of 858 patients underwent surgery for their Cushing adenoma. Different types of surgery, including endoscopic endonasal transsphenoidal surgery (EETS) (190 cases) and microscopic endonasal transsphenoidal surgery (METS) (488 cases), were performed on patients with MRI-negative CD. 7 studies, which included 164 patients, did not describe any surgery. EETS and METS are conducted to achieve selective adenomectomy (231 cases), partial adenomectomy (80 cases), total adenomectomy (13 cases), hemihypophysectomy (15 cases), or enlarged adenomectomy (48 cases). Based on available data on these studies, the remission rate, persistence rate, and recurrence rate after different types of surgeries on patients with MRI-negative CD were 72.97%, 27.03%, and 12.05%, respectively. There was no statistically significant difference between EETS and METS in the subanalysis regarding recurrence rate, remission rate, and persistence rate. However, the recurrence rate in the METS group is almost 3 times higher than in the EETS group. CONCLUSIONS Surgery has a good prognosis in patients with MRI-negative CD in terms of remission, and EETS has a lower rate of disease recurrence than METS; therefore, EETS seems to be the potential recommended treatment technique, while to confirm the therapeutic method of choice, further investigations should be done.
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Affiliation(s)
- Mohammadmahdi Sabahi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Taha Shahbazi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kevin Vidal
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Pablo F Recinos
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Florian Roser
- Department of Neurosurgery, Cleveland Clinic, Abu Dhabi, UAE
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA.
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13
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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14
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Pence A, McGrath M, Lee SL, Raines DE. Pharmacological management of severe Cushing's syndrome: the role of etomidate. Ther Adv Endocrinol Metab 2022; 13:20420188211058583. [PMID: 35186251 PMCID: PMC8848075 DOI: 10.1177/20420188211058583] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/19/2021] [Indexed: 12/31/2022] Open
Abstract
Cushing's syndrome (CS) is an endocrine disease characterized by excessive adrenocortical steroid production. One of the mainstay pharmacological treatments for CS are steroidogenesis enzyme inhibitors, including the antifungal agent ketoconazole along with metyrapone, mitotane, and aminoglutethimide. Recently, osilodrostat was added to this drug class and approved by the US Food and Drug Administration (FDA) for the treatment of Cushing's Disease. Steroidogenesis enzyme inhibitors inhibit various enzymes along the cortisol biosynthetic pathway and may be used preoperatively to lower cortisol levels and reduce surgical risk associated with tumor resection or postoperatively when surgery and/or radiation therapies are not curative. Because their selectivities for steroidogenic enzymes vary, they may even be administered in combination to achieve relatively rapid control of severe hypercortisolemia. Unfortunately, all currently available inhibitors are accompanied by serious adverse side effects that limit dosing and often result in treatment failures. Although more commonly known as a general anesthetic induction agent, etomidate is another member of the steroidogenesis enzyme inhibitor drug class. It suppresses cortisol production primarily by inhibiting 11β-hydroxylase and is the only inhibitor that may be given parenterally. However, the sedative-hypnotic actions of etomidate limit its use as an acute management option for CS. Thus, some have recommended that it be used only in intensive care settings. In this review, we discuss the initial development of etomidate as an anesthetic agent, its subsequent development as a treatment for CS, and the recent advances in dosing and drug development that dissociate sedative-hypnotic and adrenostatic drug actions to facilitate CS treatment in non-critical care settings.
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Affiliation(s)
- Andrea Pence
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Megan McGrath
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Stephanie L. Lee
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston Medical Center, Boston, MA, USA
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15
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Dutta A, Gupta N, Walia R, Bhansali A, Dutta P, Bhadada SK, Pivonello R, Ahuja CK, Dhandapani S, Hajela A, Simeoli C, Sachdeva N, Saikia UN. Remission in Cushing's disease is predicted by cortisol burden and its withdrawal following pituitary surgery. J Endocrinol Invest 2021; 44:1869-1878. [PMID: 33453019 DOI: 10.1007/s40618-020-01495-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/26/2020] [Indexed: 12/16/2022]
Abstract
AIM To ascertain the predictors of remission and relapse in patients of Cushing's disease (CD) undergoing pituitary transsphenoidal surgery (TSS). METHODS Patients with CD subjected to TSS over 35 years at a tertiary care center were included. Patients were grouped into remission and persistent disease at 1 year after surgery, and were further followed up for relapse. Demographic, clinical, biochemical, histological, radiological and post-operative follow-up parameters were analyzed. RESULTS Of the 152 patients of CD, 145 underwent TSS. Remission was achieved in 95 (65.5%) patients at 1 year. Patients in remission had shorter duration of symptoms prior to presentation (p = 0.009), more frequent presence of proximal myopathy (p = 0.038) and a tumor size of < 2.05 cm (p = 0.016) in comparison to those with persistent disease. Post-TSS, immediate post-operative 0800-h cortisol (< 159.85 nmol/L; p = 0.001), histological confirmation of tumor (p = 0.045), duration of glucocorticoid replacement (median 90 days; p = 0.001), non-visualization of tumor on MRI (p = 0.003), new-onset hypogonadism (p = 0.001), 3-month 0800-h cortisol (< 384.9 nmol/L; p = 0.001), resolution of diabetes (p = 0.001) and hypertension (p = 0.001), and recovery of hypothalamic-pituitary-adrenal axis (p = 0.018) favored remission. In logistic regression model, requirement of glucocorticoid replacement (p = 0.033), and resolution of hypertension post-TSS (p = 0.003) predicted remission. None of the parameters could predict relapse. CONCLUSION The study could ascertain the predictors of remission in CD. Apart from the tumor characteristics, surgical aspects and low post-operative 0800-h cortisol, the results suggest that baseline clinical parameters, longer glucocorticoid replacement, and resolution of metabolic complications post-TSS predict remission in CD. Long-term follow-up is essential to look for relapse.
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Affiliation(s)
- A Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - N Gupta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - R Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India.
| | - A Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - P Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - S K Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C K Ahuja
- Department of Radiology, PGIMER, Chandigarh, India
| | - S Dhandapani
- Department of Neurosurgery, PGIMER, Chandigarh, India
| | - A Hajela
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - N Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - U N Saikia
- Department of Histopathology, PGIMER, Chandigarh, India
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16
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Braun LT, Zopp S, Vogel F, Honegger J, Rubinstein G, Schilbach K, Künzel H, Beuschlein F, Reincke M. Signs, symptoms and biochemistry in recurrent Cushing disease: a prospective pilot study. Endocrine 2021; 73:762-766. [PMID: 33871792 PMCID: PMC8325659 DOI: 10.1007/s12020-021-02719-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | | | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany.
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17
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Brady Z, Garrahy A, Carthy C, O'Reilly MW, Thompson CJ, Sherlock M, Agha A, Javadpour M. Outcomes of endoscopic transsphenoidal surgery for Cushing's disease. BMC Endocr Disord 2021; 21:36. [PMID: 33658018 PMCID: PMC7931517 DOI: 10.1186/s12902-021-00679-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/02/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery (TSS) to resect an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma is the first-line treatment for Cushing's disease (CD), with increasing usage of endoscopic transsphenoidal (ETSS) technique. The aim of this study was to assess remission rates and postoperative complications following ETSS for CD. METHODS A retrospective analysis of a prospective single-surgeon database of consecutive patients with CD who underwent ETSS between January 2012-February 2020. Post-operative remission was defined, according to Endocrine Society Guidelines, as a morning serum cortisol < 138 nmol/L within 7 days of surgery, with improvement in clinical features of hypercortisolism. A strict cut-off of < 50 nmol/L at day 3 post-op was also applied, to allow early identification of remission. RESULTS A single surgeon (MJ) performed 43 ETSS in 39 patients. Pre-operative MRI localised an adenoma in 22 (56%) patients; 18 microadenoma and 4 macroadenoma (2 with cavernous sinus invasion). IPSS was carried out in 33 (85%) patients. The remission rates for initial surgery were 87% using standard criteria, 58% using the strict criteria (day 3 cortisol < 50 nmol/L). Three patients had an early repeat ETSS for persistent disease (day 3 cortisol 306-555 nmol/L). When the outcome of repeat early ETSS was included, the remission rate was 92% (36/39) overall. Remission rate was 94% (33/35) when patients with macroadenomas were excluded. There were no cases of CSF leakage, meningitis, vascular injury or visual deterioration. Transient and permanent diabetes insipidus occurred in 33 and 23% following first ETSS, respectively. There was one case of recurrence of CD during the follow-up period of 24 (4-79) months. CONCLUSION Endoscopic transsphenoidal surgery produces satisfactory remission rates for the primary treatment of CD, with higher remission rates for microadenomas. A longer follow-up period is required to assess recurrence rates. Patients should be counselled regarding risk of postoperative diabetes insipidus.
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Affiliation(s)
- Zarina Brady
- Medical University of Varna, Varna, Bulgaria
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Aoife Garrahy
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Claire Carthy
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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Zhang D, Damoiseaux R, Babayan L, Rivera-Meza EK, Yang Y, Bergsneider M, Wang MB, Yong WH, Kelly K, Heaney AP. Targeting Corticotroph HDAC and PI3-Kinase in Cushing Disease. J Clin Endocrinol Metab 2021; 106:e232-e246. [PMID: 33000123 PMCID: PMC8921634 DOI: 10.1210/clinem/dgaa699] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT Cushing disease (CD) is a life-threatening disorder. Therapeutic goals include symptom relief, biochemical control, and tumor growth inhibition. Current medical therapies for CD by and large exert no action on tumor growth. OBJECTIVE To identify drugs that inhibit corticotroph tumor adrenocorticotropic hormone (ACTH) secretion and growth. DESIGN High throughput screen employing a novel "gain of signal" ACTH AlphaLISA assay. SETTING Academic medical center. PATIENTS Corticotroph tumor tissues from patients with CD. INTERVENTIONS None. MAIN OUTCOME MEASURES Potent inhibitors of corticotroph tumor ACTH secretion and growth. RESULTS From a kinase inhibitor library, we identified the dual PI3K/HDAC inhibitor CUDC-907 as a potent inhibitor of murine and human corticotroph tumor ACTH secretion (median effective concentration 1-5 nM), and cell proliferation (median inhibitory concentration 5 nM). In an in vivo murine corticotroph tumor xenograft model, orally administered CUDC-907 (300 mg/kg) reduced corticotroph tumor volume (TV [cm3], control 0.17 ± 0.05 vs CUDC-907 0.07 ± 0.02, P < .05) by 65% and suppressed plasma ACTH (ACTH [pg/mL] control 206 ± 27 vs CUDC-907 47 ± 7, P < .05) and corticosterone (corticosterone [ng/mL] control 180 ± 87 vs CUDC-907 27 ± 5, P < .05) levels by 77% and 85% respectively compared with controls. We also demonstrated that CUDC-907 acts through HDAC1/2 inhibition at the proopiomelanocortin transcriptional level combined with its PI3K-mediated inhibition of corticotroph cell viability to reduce ACTH secretion. CONCLUSIONS Given its potent efficacy in in vitro and in vivo models of CD, combined with proven safety and tolerance in clinical trials, we propose CUDC-907 may be a promising therapy for CD.
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Affiliation(s)
- Dongyun Zhang
- Department of Medicine, University of California, David Geffen School of Medicine, Los Angeles, California
| | - Robert Damoiseaux
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Lilit Babayan
- Department of Medicine, University of California, David Geffen School of Medicine, Los Angeles, California
| | | | - Yingying Yang
- Department of Medicine, University of California, David Geffen School of Medicine, Los Angeles, California
| | - Marvin Bergsneider
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - William H Yong
- Department of Pathology and Lab Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Kathleen Kelly
- Department of Pathology and Lab Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Anthony P Heaney
- Correspondence and Reprint Requests: Anthony P. Heaney, Department of Medicine, University of California, David Geffen School of Medicine, Los Angeles, CA, USA. E-mail:
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Hinojosa-Amaya JM, Cuevas-Ramos D. The definition of remission and recurrence of Cushing's disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101485. [PMID: 33472761 DOI: 10.1016/j.beem.2021.101485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Accurate classification of postsurgical remission, and early recognition of recurrence are crucial to timely treat and prevent excess mortality in Cushing's Disease, yet the criteria used to define remission are variable and there is no consensus to define recurrence. Remission is defined as postsurgical hypocortisolemia, but delayed remission may occur. Recurrence is the return of clinical manifestations with biochemical evidence of hypercortisolism. The proper combination of tests and their timing are controversial. Reliable predicting tools may lead to earlier diagnosis upon recurrence. Many factors have been studied independently for prediction with variable performance. Novel artificial intelligence approaches seek to integrate these variables into risk calculators and machine-learning algorithms with an acceptable short-term predictive performance but lack longer-term accuracy. Prospective studies using these approaches are needed. This review summarizes the evidence behind the definitions of remission and recurrence and provide an overview of the available tools to predict and/or diagnose them.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Pituitary Clinic, Endocrinology Division and Department of Medicine, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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20
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Akirov A, Larouche V, Shimon I, Asa SL, Mete O, Sawka AM, Gentili F, Ezzat S. Significance of Crooke's Hyaline Change in Nontumorous Corticotrophs of Patients With Cushing Disease. Front Endocrinol (Lausanne) 2021; 12:620005. [PMID: 33815279 PMCID: PMC8013723 DOI: 10.3389/fendo.2021.620005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Glucocorticoid excess in Cushing disease (CD) leads to negative feedback suppression, resulting in Crooke's hyaline change (CC) of nontumorous pituitary corticotrophs. We aimed to determine the predictive value of CC of nontumorous corticotrophs in CD. METHODS The retrospective chart review study included patients with clinical, biochemical, radiologic and outcome data and evaluable histopathology specimens from pituitary surgery for CD. The main outcome was remission of CD, defined by clinical features, biochemical testing, and corticosteroid dependency. RESULTS Of 144 CD patients, 60 (50 women, mean age 43.6±14) had clinical follow-up, biochemical data and histopathology specimens that included evaluable nontumorous adenohypophysis. Specimens from 50 patients (83.3%) demonstrated CC in nontumorous corticotrophs, and 10 (16.7%) had no CC (including 3 with corticotroph hyperplasia). One patient with CC was lost to follow-up and one without CC had equivocal outcome results. During a mean (SD) follow-up period of 74.9 months (61.0), recurrent or persistent disease was documented in 18 patients (31.0%), while 40 (69.0%) were in remission. In patients with CC, the remission rate was 73.5% (95% CI, 59.7%-83.7%) (36/49), whereas it was 44.4% (95% CI, 18.9%-73.3%) (4/9) in patients with no CC. The combination of serum cortisol >138 nmol/L within a week of surgery coupled with absence of nontumorous CC greatly improved the prediction of recurrent or persistent disease. CONCLUSIONS CC of nontumorous corticotrophs was observed in 83% of patients with CD, and most patients with CC experienced remission. Absence of CC in nontumorous corticotrophs may serve as a predictor of reduced remission in patients with CD.
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Affiliation(s)
- Amit Akirov
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Amit Akirov,
| | - Vincent Larouche
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sylvia L. Asa
- Department of Pathology, University Hospitals, Cleveland, Case Western Reserve University, Cleveland, OH, United States
| | - Ozgur Mete
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shereen Ezzat
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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21
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Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
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Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
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22
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Stroud A, Dhaliwal P, Alvarado R, Winder MJ, Jonker BP, Grayson JW, Hamizan A, Harvey RJ, McCormack A. Outcomes of pituitary surgery for Cushing's disease: a systematic review and meta-analysis. Pituitary 2020; 23:595-609. [PMID: 32691356 DOI: 10.1007/s11102-020-01066-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the first-line treatment for Cushing's disease (CD). This review aimed to synthesize the remission and recurrence rates following TSS for CD and identify predictors of these outcomes. METHODS Medline (1946-) and Embase (1947-) were searched until 23rd January 2019 for original studies. A meta-analysis was performed of remission and recurrence rates. Studies were excluded if patients had prior radiosurgery/radiotherapy, mixed pathologies or interventions without separated data, follow-up not reported or population size < 20. For recurrence rate syntheses, studies with follow-up < 6 months were excluded. RESULTS The search produced 2663 studies, of which n = 68 were included, involving 5664 patients. Remission rates after primary and revision TSS were 80% [77-82] and 58% [50-66] at last follow-up. After primary TSS, predictors of remission were micro- v macroadenomas (83% v 68%, p < 0.01), imaging-visible adenomas (81% v 69%, p < 0.01), adenomas confirmed on histopathology (87% v 45%, p < 0.01), absence of cavernous sinus invasion (80% v 30%, p < 0.01), postoperative serum cortisol (MSeC) nadir < 2 μg/dL (< 55 nmol/L; 95% v 46%, p < 0.01) and lower preoperative 24-h urine free cortisol (1250 nmol v 1726 nmol, p < 0.01). For revision TSS, predictors of remission were postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L; 100% v 38%, p < 0.01) and operations for recurrence v persistence (80% v 54%, p < 0.01). Recurrence rates after primary and revision TSS were 18% [14-22] and 28% [16-42]. CONCLUSIONS TSS is most effective in primary microadenomas, visible on preoperative imaging and without CS invasion, lower preoperative 24-h urine free cortisol and postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L).
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Affiliation(s)
- Anna Stroud
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia.
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia.
| | - Pearl Dhaliwal
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Mark J Winder
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Notre Dame University, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Benjamin P Jonker
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jessica W Grayson
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | | | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Ann McCormack
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia
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23
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Guaraldi F, Zoli M, Asioli S, Corona G, Gori D, Friso F, Pasquini E, Bacci A, Sforza A, Mazzatenta D. Results and predictors of outcome of endoscopic endonasal surgery in Cushing's disease: 20-year experience of an Italian referral Pituitary Center. J Endocrinol Invest 2020; 43:1463-1471. [PMID: 32215861 DOI: 10.1007/s40618-020-01225-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess outcomes and predictors of early and long-term remission in patients with Cushing's disease (CD) due to ACTH-secreting adenomas treated via endoscopic endonasal approach (EEA). METHODS This is a retrospective study. Consecutive patients operated for CD from 1998 to 2017 in an Italian referral Pituitary Center were enrolled. Clinical, radiological, and histological data at enrollment and follow-up were collected. RESULTS 151 patients (107 F) were included; 88.7% were naïve for treatment, 11.3% had been treated surgically and 11.2% medically. At pre-operative magnetic resonance imaging (MRI), 35 had a macroadenoma and 80 a microadenoma, while tumor was undetectable in 36 patients. Mean age at surgery was 41.1 ± 16.6 years. Diagnosis was confirmed histologically in 82.4% of the cases. Patients with disease persistence underwent second surgery and/or medical and/or radiation therapy. Mean follow-up was 92.3 ± 12.0 (range 12-237.4) and median 88.2 months. Remission rate was 88.1% after the first surgery and 90.7% at last follow-up. One patient died of pituitary carcinoma. Post-surgical cortisol drop (p = 0.004), tumor detection at MRI (p = 0.03) and size < 1 cm (p = 0.045) increased the chance of disease remission; cavernous sinus invasion was a negative predictor of outcome (p = 0.002). Twenty-seven patients developed diabetes insipidus and 18 hypopituitarism. Surgery repetition increased the risk of hypopituitarism (p = 0.03), but not of other complications, which included epistaxis (N = 2), cerebrospinal fluid leakage (1), pneumonia (3), myocardial infarction (1), and pulmonary embolisms (2). CONCLUSIONS Selective adenomectomy via EEA performed by experienced surgeons, supported by a multidisciplinary dedicated team, allows long-term remission in the vast majority of CD patients with low complication rate.
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Affiliation(s)
- F Guaraldi
- IRCCS Istituto delle Science Neurologiche di Bologna, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura 3, 40139, Bologna, Italy.
| | - M Zoli
- IRCCS Istituto delle Science Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - S Asioli
- Department of Biomedical and Neuromuscular Sciences, Section of Anatomic Pathology 'M. Malpighi' at Bellaria Hospital, University of Bologna, Bologna, Italy
| | - G Corona
- Division of Endocrinology, Ospedale Maggiore, Bologna, Italy
| | - D Gori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - F Friso
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - E Pasquini
- ENT Division, Bellaria Hospital, Bologna, Italy
| | - A Bacci
- Division of Neuroradiology, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - A Sforza
- Division of Endocrinology, Ospedale Maggiore, Bologna, Italy
| | - D Mazzatenta
- IRCCS Istituto delle Science Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura 3, 40139, Bologna, Italy
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Araujo-Castro M, Pascual-Corrales E, Martínez San Millan JS, Rebolleda G, Pian H, Ruz-Caracuel I, De Los Santos Granados G, Ley Urzaiz L, Escobar-Morreale HF, Rodríguez Berrocal V. Postoperative management of patients with pituitary tumors submitted to pituitary surgery. Experience of a Spanish Pituitary Tumor Center of Excellence. Endocrine 2020; 69:5-17. [PMID: 32170587 DOI: 10.1007/s12020-020-02247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/26/2020] [Indexed: 12/13/2022]
Abstract
There is a lack of evidence on timing, frequency, and duration of postoperative endocrine, radiologic, and ophthalmologic assessments that should be performed after pituitary surgery (PS). However, it is known that careful optimization of treatment and follow-up strategies as well as a multidisciplinary approach may have a significant impact on long-term outcomes, improving surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological, and radiological reassessment throughout the follow-up. Considering that there are no specific guidelines on the postoperative management of patients with pituitary tumors (PT), we present our protocol for the postoperative management of patients with PT. It has been elaborated by the multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the management of PT thereby facilitating the postoperative management of patients submitted to PS.
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Affiliation(s)
- M Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Hospital Universitario Ramón y Cajal, M-607, km. 9, 100, 28034, Madrid, Spain.
| | - E Pascual-Corrales
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J S Martínez San Millan
- Neuroradiology Unit, Department of Diagnostic Imaging, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - G Rebolleda
- Neuro-Ophthalmology Unit, Department of Ophthalmology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
| | - H Pian
- Endocrinology Unit, Department of Pathology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - I Ruz-Caracuel
- Endocrinology Unit, Department of Pathology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - G De Los Santos Granados
- Universidad de Alcalá, Madrid, Spain
- Rinology Unit, Department of Otorhinolaryngology (ENT), Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Sanitaria Ramón y Cajal (IRYCIS), Madrid, Spain
| | - L Ley Urzaiz
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - H F Escobar-Morreale
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
- Instituto de Investigación Sanitaria Ramón y Cajal (IRYCIS), Madrid, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - V Rodríguez Berrocal
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Fleseriu M, Petersenn S, Biller BMK, Kadioglu P, De Block C, T'Sjoen G, Vantyghem M, Tauchmanova L, Wojna J, Roughton M, Lacroix A, Newell‐Price J. Long-term efficacy and safety of once-monthly pasireotide in Cushing's disease: A Phase III extension study. Clin Endocrinol (Oxf) 2019; 91:776-785. [PMID: 31465533 PMCID: PMC6899900 DOI: 10.1111/cen.14081] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Many patients with Cushing's disease (CD) require chronic pharmacotherapy to control their hypercortisolism. We evaluated the efficacy and safety of long-acting pasireotide during a long-term extension study in patients with CD. DESIGN Open-label extension to a 12-month Phase III study of long-acting pasireotide in CD (N = 150; NCT01374906). PATIENTS Patients with mean urinary free cortisol (mUFC) ≤ upper limit of normal (ULN) or receiving clinical benefit at core study end could continue long-acting pasireotide during the extension. RESULTS Eighty-one of 150 (54.0%) enrolled patients entered the extension. Median overall exposure to pasireotide at study end was 23.9 months; 39/81 (48.1%) patients completed the extension (received ≥ 12 months' treatment during the extension and could transit to a separate pasireotide safety study). mUFC was ≤ULN in 42/81 (51.9%), 13/81 (16.0%) and 43/81 (53.1%) patients at extension baseline, month (M) 36 and last assessment. Median mUFC remained within normal limits. Median late-night salivary cortisol was 2.6 × ULN at core baseline and 1.3 × ULN at M36. Clinical improvements were sustained over time. Forty-two (51.9%) patients discontinued during the extension: 25 (30.9%) before M24 and 17 (21.0%) after M24. Hyperglycaemia-related AEs occurred in 39.5% of patients. Mean fasting glucose (FPG) and glycated haemoglobin (HbA1c ) were stable during the extension, with antidiabetic medication initiated/escalated in some patients. Sixty-six (81.5%) and 71 (88.9%) patients were classified as having diabetes (HbA1c ≥ 6.5%, FPG ≥ 7.0 mmol/L, antidiabetic medication use, or history of diabetes) at extension baseline and last assessment. CONCLUSIONS Long-acting pasireotide provided sustained biochemical and clinical improvements, with no new safety signals emerging, supporting its use as an effective long-term therapy for CD.
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Affiliation(s)
- Maria Fleseriu
- Northwest Pituitary CenterOregon Health & Science UniversityPortlandORUSA
| | | | | | | | - Christophe De Block
- Department of Endocrinology, Diabetology and MetabolismAntwerp University HospitalAntwerpBelgium
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and GenderGhent University HospitalGhentBelgium
| | | | | | - Judi Wojna
- Novartis Pharmaceuticals CorporationEast HanoverNJUSA
| | | | - André Lacroix
- Centre hospitalier de l'Université de MontréalMontrealQCCanada
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Carr SB, Kleinschmidt-DeMasters BK, Kerr JM, Kiseljak-Vassiliades K, Wierman ME, Lillehei KO. Negative surgical exploration in patients with Cushing's disease: benefit of two-thirds gland resection on remission rate and a review of the literature. J Neurosurg 2019; 129:1260-1267. [PMID: 29219752 DOI: 10.3171/2017.5.jns162901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 05/15/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors report their single-institution experience with the pathological findings, rates of remission, and complications in patients with presumed Cushing's disease (CD) who underwent a two-thirds pituitary gland resection when no adenoma was identified at the time of transsphenoidal surgery (TSS). The authors also review the literature on patients with CD, negative surgical exploration, and histological findings.METHODSThis study is a retrospective analysis of cases found in neurosurgery and pathology department databases between 1989 and 2011. In all cases, patients had been operated on by the same neurosurgeon (K.O.L.). Twenty-two (13.6%) of 161 patients who underwent TSS for CD had no adenoma identified intraoperatively after systematic exploration of the entire gland; these patients all underwent a two-thirds pituitary gland resection. A chart review was performed to assess treatment data points as well as clinical and biochemical remission status.RESULTSOf the 22 patients who underwent two-thirds gland resection, 6 (27.3%) ultimately had lesions found on final pathology. All 6 patients were found to have a distinct adrenocorticotropic hormone (ACTH) cell adenoma. Sixteen (72.7%) of the patients had no tumor identified, with 3 of these patients suspected of having ACTH cell hyperplasia. The follow-up duration for the entire group was between 14 and 315 months (mean 98.9 months, median 77 months). Remission rates were 100% (6/6 patients) for the ACTH cell adenoma group and 75% (12/16) for the group without adenoma. Overall, 18 (81.8%) of the 22 patients had no evidence of hypercortisolism at last follow-up, and 4 patients (18%) had persistent hypercortisolism, defined as a postoperative cortisol level > 5 μg/dl. Of these 4 patients, 1 was suspected of harboring a cavernous sinus adenoma, 2 were found to have lung tumors secreting ACTH, and 1 remained with an undiagnosed etiology. Rates of postoperative complications were low.CONCLUSIONSThe diagnosis and treatment of CD can be challenging for neurosurgeons, endocrinologists, and pathologists alike. Failure to find a discrete adenoma at the time of surgery occurs in at least 10%-15% of cases, even in experienced centers. The current literature provides little guidance regarding rational intraoperative approaches in such cases. The authors' experience with 161 patients with CD, when no intraoperative tumor was localized, demonstrates the utility of a two-thirds pituitary gland resection with a novel and effective surgical strategy, as suggested by a high initial remission rate and a low operative morbidity.
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Affiliation(s)
| | | | - Janice M Kerr
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Katja Kiseljak-Vassiliades
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Margaret E Wierman
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
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Abellán-Galiana P, Fajardo-Montañana C, Riesgo-Suárez P, Pérez-Bermejo M, Ríos-Pérez C, Gómez-Vela J. Prognostic usefulness of ACTH in the postoperative period of Cushing's disease. Endocr Connect 2019; 8:1262-1272. [PMID: 31394502 PMCID: PMC6733365 DOI: 10.1530/ec-19-0297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To analyze the usefulness of plasma ACTH in predicting CD remission after surgery and to evaluate the prognostic usefulness of ACTH measurement after the cortisol and ACTH nadir (48 h prior to discharge). DESIGN A prospective study was made of 65 patients with CD operated upon between 2005 and 2016. METHODS Postsurgery plasma ACTH and cortisol were measured every 6 h, in the absence of corticosteroid coverage. Hydrocortisone was started in the presence of adrenal insufficiency or cortisol <55.2 nmol/L. Plasma ACTH was again determined before discharge. MAIN OUTCOME MEASURE Usefulness of plasma ACTH in predicting CD remission. RESULTS Remission at 3 months of CD was achieved in 56 of 65 cases, with late recurrence in 18 of 58 cases. Following resection, the ACTH nadir was significantly lower referred to late remission (2.8 vs 6.5 pmol/L; P = 0.031) and higher for recurrence (2.1 vs 4.8 pmol/L; P < 0.001), and identical results were obtained for the ACTH values before discharge. In the analysis of the ROC curves, nadir and before discharge ACTH values <1.9 pmol/L and <2.6 pmol/L were respectively indicative of early remission (AUC 0.827; P < 0.001); <6.2 pmol/L of remission at 3 months (AUC 0.847; P = 0.001) and >3.2 pmol/L of recurrence (AUC 0.810; P < 0.001) in both ACTH values. A time to ACTH nadir <46 h was indicative of early remission (AUC 0.751; P = 0.001), while a time >39 h was indicative of recurrence (AUC 0.773; P = 0.001). CONCLUSIONS We propose an ACTH value <3.3 pmol/L as a good long-term prognostic marker in the postoperative period of CD. Reaching the ACTH nadir in less time is associated to a lesser recurrence rate.
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Affiliation(s)
- Pablo Abellán-Galiana
- Department of Endocrinology, Hospital General Universitari de Castelló, Castellón, Spain
- Department of Medicine, Universidad Cardenal Herrera-CEU, Castellón, Spain
| | - Carmen Fajardo-Montañana
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
- Correspondence should be addressed to C Fajardo-Montañana:
| | - Pedro Riesgo-Suárez
- Department of Neurosurgery, Hospital Universitario de la Ribera, Alzira, Spain
| | | | - Celia Ríos-Pérez
- Centro de Salud Tavernes de la Valldigna, Hospital Comarcal Francesc de Borja, Gandía, Spain
| | - José Gómez-Vela
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
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McGrath M, Hofmann A, Raines DE. Behavioral and steroidogenic pharmacology of phenyl ring substituted etomidate analogs in rats. BMC Pharmacol Toxicol 2019; 20:48. [PMID: 31383012 PMCID: PMC6683373 DOI: 10.1186/s40360-019-0328-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/29/2019] [Indexed: 12/14/2022] Open
Abstract
Background Cushing’s syndrome is an endocrine disorder characterized by the overproduction of adrenocortical steroids. Steroidogenesis enzyme inhibitors are the mainstays of pharmacological treatment. Unfortunately, they produce significant side effects. Among the most potent inhibitors is the general anesthetic etomidate whose GABAA receptor-mediated sedative-hypnotic actions restrict use. In this study, we defined the sedative-hypnotic and steroidogenesis inhibiting actions of etomidate and four phenyl-ring substituted etomidate analogs (dimethoxy-etomidate, isopropoxy-etomidate, naphthalene-etomidate, and naphthalene (2)-etomidate) that possess negligible GABAA receptor modulatory activities. Methods In the first set of experiments, male Sprague-Dawley rats were assessed for loss of righting reflexes (LoRR) after receiving intravenous boluses of either etomidate (1 mg/kg) or an etomidate analog (40 mg/kg). In the second set of experiments, rats were assessed for LoRR and their abilities to produce adrenocortical and androgenic steroids after receiving 2-h infusions (0.5 mg kg− 1 min− 1) of either etomidate or an etomidate analog. Results All rats that received etomidate boluses or infusions had LoRR that persisted for minutes or hours, respectively. In contrast, no rat that received an etomidate analog had LoRR. Compared to rats in the vehicle control group, rats that received etomidate analog infusions had plasma corticosterone and aldosterone concentrations that were reduced by 80–84% and 68–94%, respectively. Rats that received etomidate infusions had plasma corticosterone and aldosterone concentrations that were also significantly reduced (by 92 and 96%, respectively). Rats that received etomidate or isopropoxy-etomidate had significant reductions (90 and 57%, respectively) in plasma testosterone concentrations whereas those that received naphthalene-etomidate had significant increases (1400%) in plasma dehydroepiandrosterone concentrations. Neither etomidate nor any etomidate analog significantly affected plasma androstenedione and dihydrotestosterone concentrations. Conclusions Our studies demonstrate that the four phenyl-ring substituted etomidate analogs form a novel class of compounds that are devoid of sedative-hypnotic activities and suppress plasma concentrations of adrenocortical steroids but vary in their effects on plasma concentrations of androgenic steroids.
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Affiliation(s)
- Megan McGrath
- Department of Anesthesia Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB444, Boston, MA, 02114, USA
| | - Alissa Hofmann
- Department of Anesthesia Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB444, Boston, MA, 02114, USA
| | - Douglas E Raines
- Department of Anesthesia Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB444, Boston, MA, 02114, USA.
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Pivonello R, Arnaldi G, Scaroni C, Giordano C, Cannavò S, Iacuaniello D, Trementino L, Zilio M, Guarnotta V, Albani A, Cozzolino A, Michetti G, Boscaro M, Colao A. The medical treatment with pasireotide in Cushing's disease: an Italian multicentre experience based on "real-world evidence". Endocrine 2019; 64:657-672. [PMID: 30968338 PMCID: PMC6551343 DOI: 10.1007/s12020-018-1818-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022]
Abstract
A phase III study has demonstrated that 6-month pasireotide treatment induced disease control with good safety in 15-26% of patients with Cushing's disease (CD). The aim of the current study was to evaluate the 6-month efficacy and safety of pasireotide treatment according to the real-world evidence. Thirty-two CD patients started pasireotide at the dose of 600 µg twice a day (bid) and with the chance of up-titration to 900 µg bid, or down-titration to 450 or 300 µg bid, on the basis of urinary cortisol (UC) levels or safety. Hormonal, clinical and metabolic parameters were measured at baseline and at 3-month and 6-month follow-up, whereas tumour size was evaluated at baseline and at 6-month follow-up. At baseline, 31 patients had very mild to moderate disease and 1 patient had very severe disease. Five (15.6%) patients discontinued treatment for adverse events; the remaining 27 patients (26 with very mild to moderate disease and 1 with very severe disease), reached 6-month follow-up. Considering the group of patients with very mild to moderate disease, responsiveness, defined by the normalization (<1 the upper limit of normal range, ULN) or near normalization (>1 and ≤1.1 ULN) of UC levels, was registered in 21 patients (full control in 19 and near control in 2), corresponding to 67.7% and 80.8% according to an "intention-to-treat" or "per-protocol" methodological approach, respectively. Weight, body mass index, waist circumference, as well as total and LDL-cholesterol significantly decreased, whereas fasting plasma glucose and glycated haemoglobin significantly increased. Hyperglycaemia was documented in 81.2%, whereas gastrointestinal disturbances in 40.6% of patients. In conclusion, in the real-life clinical practice, pasireotide treatment normalizes or nearly normalizes UC in at least 68% of patients with very mild to moderate disease, with consequent improvement in weight, visceral adiposity and lipid profile, despite the occurrence or deterioration of diabetes in the majority of cases, confirming the usefulness of this treatment in patients with milder disease and without uncontrolled diabetes.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Carla Scaroni
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Carla Giordano
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Salvo Cannavò
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Laura Trementino
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marialuisa Zilio
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Valentina Guarnotta
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Adriana Albani
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Sperimentale, Università "La Sapienza", Roma, Italy
| | - Grazia Michetti
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marco Boscaro
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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Varlamov EV, McCartney S, Fleseriu M. Functioning Pituitary Adenomas - Current Treatment Options and Emerging Medical Therapies. EUROPEAN ENDOCRINOLOGY 2019; 15:30-40. [PMID: 31244908 PMCID: PMC6587904 DOI: 10.17925/ee.2019.15.1.30] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/11/2019] [Indexed: 12/12/2022]
Abstract
Pituitary adenomas are benign tumours comprising approximately 16% of all primary cranial neoplasms. Functioning pituitary adenomas (prolactinomas, somatotroph, corticotroph, thyrotroph and rarely gonadotroph adenomas) cause complex clinical syndromes and require prompt treatment to reduce associated morbidity and mortality. Treatment approaches include transsphenoidal surgery, medical therapy and radiation. Medical therapy is the primary therapy for prolactinomas, and surgery by a skilled neurosurgeon is the first-line approach for other functioning pituitary adenomas. A multimodal treatment is frequently necessary to achieve biochemical and clinical control, especially, when surgery is not curative or when medical therapy fails. Several emerging, novel, medical treatments for acromegaly, Cushing's disease and prolactinomas are in phase II and III clinical trials and may become effective additions to the current drug armamentarium. The availability of various management options will allow an individualised treatment approach based on the unique tumour type, clinical situation and patient preference.
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Saini S, Kanwar J, Gupta S, Behari S, Bhatia E, Yadav S. Long-term outcome of trans-sphenoidal surgery for Cushing's disease in Indian patients. Acta Neurochir (Wien) 2019; 161:119-127. [PMID: 30465277 DOI: 10.1007/s00701-018-3736-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The results of trans-sphenoidal surgery (TSS) in Cushing's disease (CD) vary widely depending upon patient characteristics as well as surgical experience. Patients in India are often referred late to referral centers. We studied the rates of remission and endocrine deficiencies after TSS in patients with CD presenting to a referral hospital in India. METHODS Sixty consecutive patients (45 females, median age 24.5 years) who underwent TSS between 2000 and 2015 were studied. The median (range) duration of follow-up was 40 (3-138) months. Initial and long-term remission and relapse rates and pituitary hypofunction post-TSS were evaluated. RESULTS Eighteen (30%) patients harbored macroadenomas. Twenty-eight (47%) patients achieved remission in the immediate post-operative period (8 AM serum cortisol < 140 nmol/l), while a higher remission rate was noted at 6 months (39/54 patients, 72%). At 1 year 70% patients and at final follow-up [median duration 40 (range 3-138) months], 58% of patients were in remission. No pre- or post-surgical variables were consistently associated with remission, except for the 8-AM serum cortisol level on the fifth day after surgery. Seven (18%) patients relapsed on follow-up, including five patients who had fifth post-operative day 8 AM serum cortisol < 140 nmol/l. Twelve (25%) patients newly developed hypothyroidism and one (1.6%) patient developed amenorrhoea after TSS. CONCLUSION Remission rate at 6 months was higher than immediately after TSS. A significant proportion of patients relapsed, thus necessitating life-long follow-up. New-onset hypothyroidism was frequent after TSS.
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Affiliation(s)
- S Saini
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - J Kanwar
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - S Gupta
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - S Behari
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - E Bhatia
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Subhash Yadav
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Liu Y, Liu X, Hong X, Liu P, Bao X, Yao Y, Xing B, Li Y, Huang Y, Zhu H, Lu L, Wang R, Feng M. Prediction of Recurrence after Transsphenoidal Surgery for Cushing's Disease: The Use of Machine Learning Algorithms. Neuroendocrinology 2019; 108:201-210. [PMID: 30630181 DOI: 10.1159/000496753] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are no reliable predictive models for recurrence after transsphenoidal surgery (TSS) for Cushing's disease (CD). OBJECTIVES This study aimed to develop machine learning (ML)-based predictive models for CD recurrence after initial TSS and to evaluate their performance. METHOD A total of 354 CD patients were included in this retrospective, supervised learning, data mining study. Predictive models for recurrence were developed according to 17 variables using 7 algorithms. Models were evaluated based on the area under the receiver operating characteristic curve (AUC). RESULTS All patients were followed up for over 12 months (mean ± SD 43.80 ± 35.61). The recurrence rate was 13.0%. Age (p < 0.001), postoperative morning serum cortisol nadir (p = 0.002), and postoperative (p < 0.001) and preoperative (p = 0.04) morning adrenocorticotropin (ACTH) level were significantly related to recurrence. AUCs of the 7 models ranged from 0.608 to 0.781. The best performance (AUC = 0.781, 95% CI 0.706, 0.856) appeared when 8 variables were introduced to the random forest (RF) algorithm, which was much better than that of logistic regression (AUC = 0.684, p = 0.008) and that of using only postoperative morning serum cortisol (AUC = 0.635, p < 0.001). According to the feature selection algorithms, the top 3 predictors were age, postoperative serum cortisol, and postoperative ACTH. CONCLUSIONS Using ML-based models for prediction of the recurrence after initial TSS for CD is feasible, and RF performs best. The performance of most of ML-based models was significantly better than that of some conventional models.
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Affiliation(s)
- Yifan Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xinyu Hong
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Penghao Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | | | - Yi Huang
- DHC Software Co. Ltd, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China,
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Uvelius E, Höglund P, Valdemarsson S, Siesjö P. An early post-operative ACTH suppression test can safely predict short- and long-term remission after surgery of Cushing's disease. Pituitary 2018; 21:490-498. [PMID: 30039432 PMCID: PMC6132983 DOI: 10.1007/s11102-018-0902-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The present study evaluates the usefulness of an ACTH suppression test shortly after surgery, and to determine optimal cut-off values of included laboratory analyses, in predicting short- and long-term remission after surgery of Cushing's disease. METHODS A 48 h suppression test with betamethasone 2 mg/day applied after 45 transphenoidal adenomectomies in 28 patients was evaluated. Receiver operating characteristic (ROC)-curves were created for the included assays: plasma cortisol, plasma adrenocorticotropic hormone (ACTH) and urinary free cortisol (UFC). Plasma levels of cortisol and ACTH were measured both at 24 and 48 h. Youden's index was used to determine cut-off with the highest sensitivity and specificity in predicting short- (3 months) and long-term (5 years or longer) remission. The area under curve (AUC) illustrated the clinical accuracy of the different assays. RESULTS Plasma cortisol after 24 h with betamethasone was most accurate in predicting both short- and long-term remission. 3 months remission with cut-off 107 nmol/L: sensitivity 0.85, specificity 0.94, positive predictive value (PPV) 0.96 and AUC 0.92 (95% CI 0.85-1). 5 years remission with cut-off 49 nmol/L: sensitivity: 0.94, specificity 0.93, PPV 0.88, AUC 0.98 (95% CI 0.95-1). Analyses of ACTH or UFC did not improve diagnostic accuracy. CONCLUSIONS A 48 h, 2 mg/day betamethasone suppression test after transphenoidal surgery of Cushing's disease could predict short- and long-term remission with a high accuracy. Suppression of plasma cortisol after 24 h with betamethasone to values excluding Cushings disease in the diagnostic setting yielded the highest accuracy in predicting long-term remission.
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Affiliation(s)
- Erik Uvelius
- Neurosurgery, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, EA-Blocket Plan 3, 221 85, Lund, Sweden.
| | - Peter Höglund
- Laboratory Medicine, Department of Clinical Chemistry & Pharmacology, Lund University, Lund, Sweden
| | - Stig Valdemarsson
- Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Peter Siesjö
- Neurosurgery, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, EA-Blocket Plan 3, 221 85, Lund, Sweden
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Abstract
PURPOSE Surgical experience is considered paramount for excellent outcome of transsphenoidal surgery (TSS). However, objective data demonstrating the surgical success in relation to the experience of pituitary surgery units or individual experience of pituitary surgeons is sparse. METHODS Based on literature data, we have investigated the influence of experience with TSS for pituitary adenomas on endocrinological remission rates and on operative complications. The surgical experience was assessed by calculating the number of transsphenoidal operations per year. RESULTS For TSS of microprolactinomas, mean remission rates were 77% in centers with < 2 operations per year for microprolactinomas, 82% with 2-4 operations, 84% with 4-6 operations, and 91% with > 6 operations. A yearly experience with more than 10 initial operations for Cushing's disease (CD) warrants a remission rate exceeding 70%. Remission rates in CD exceeding 86% have only been reported for single surgeon series. Extraordinarily high complication rates were found in some series with < 25 yearly total operations for pituitary adenomas. Major vascular complications were less than 2% and revision rates for rhinorrhea usually < 2.5% in centers performing > 25 transsphenoidal operations per year. CONCLUSIONS We conclude that a center with experience of > 25 transsphenoidal operations for pituitary adenomas per year provides a high likelihood of safe TSS. Surgery for CD requires a particularly high level of practice to guarantee excellent remission rates. The endocrinologist has the unique opportunity to audit the surgical success by hormone measurement and to refer patients to neurosurgeons with proven excellence.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Florian Grimm
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Valassi E, Feelders R, Maiter D, Chanson P, Yaneva M, Reincke M, Krsek M, Tóth M, Webb SM, Santos A, Paiva I, Komerdus I, Droste M, Tabarin A, Strasburger CJ, Franz H, Trainer PJ, Newell-Price J, Wass JA, Papakokkinou E, Ragnarsson O. Worse Health-Related Quality of Life at long-term follow-up in patients with Cushing's disease than patients with cortisol producing adenoma. Data from the ERCUSYN. Clin Endocrinol (Oxf) 2018; 88:787-798. [PMID: 29574994 DOI: 10.1111/cen.13600] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/05/2018] [Accepted: 03/16/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hypercortisolism in Cushing's syndrome (CS) is associated with impaired health-related quality of life (HRQoL), which may persist despite remission. We used the data entered into the European Registry on Cushing's syndrome (ERCUSYN) to evaluate if patients with CS of pituitary origin (PIT-CS) have worse HRQoL, both before and after treatment than patients with adrenal causes (ADR-CS). METHODS Data from 595 patients (492 women; 83%) who completed the CushingQoL and/or EQ-5D questionnaires at baseline and/or following treatment were analysed. RESULTS At baseline, HRQoL did not differ between PIT-CS (n = 293) and ADR-CS (n = 120) on both EuroQoL and CushingQoL. Total CushingQoL score in PIT-CS and ADR-CS was 41 ± 18 and 44 ± 20, respectively (P = .7). At long-time follow-up (>1 year after treatment) total CushingQoL score was however lower in PIT-CS than ADR-CS (56 ± 20 vs 62 ± 23; P = .045). In a regression analysis, after adjustment for baseline age, gender, remission status, duration of active CS, glucocorticoid dependency and follow-up time, no association was observed between aetiology and HRQoL. Remission was associated with better total CushingQoL score (P < .001), and older age at diagnosis with worse total score (P = .01). Depression at diagnosis was associated with worse total CushingQoL score at the last follow-up (P < .001). CONCLUSION PIT-CS patients had poorer HRQoL than ADR-CS at long-term follow-up, despite similar baseline scoring. After adjusting for remission status, no interaetiology differences in HRQoL scoring were found. Age and presence of depression at diagnosis of CS may be potential predictors of worse HRQoL regardless of CS aetiology.
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Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | | | - Philippe Chanson
- Univ Paris-Sud, Université Paris-Saclay UMR-S1185, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service de Endocrinologie et des Maladies de la Reproduction, Paris, France
- Institut National de la Santé et de la Recherche Médicale U1185, Paris, France
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Michal Krsek
- 2nd Department of Medicine, 3rd Faculty of Medicine, Charle University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Miklós Tóth
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Isabel Paiva
- Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - Irina Komerdus
- Moscow Regional Research Clinical Institute n.a. Vladimirsky, Moscow, Russia
| | | | - Antoine Tabarin
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Christian J Strasburger
- Division of Clinical Endocrinology, Department of Medicine CCM, Charité- Universitätsmedizin, Berlin, Germany
| | - Holger Franz
- Lohmann & Birkner Health Care Consulting GmbH, Berlin, Germany
| | - Peter J Trainer
- Department of Endocrinology, Christie Hospital, Manchester, UK
| | - John Newell-Price
- Academic Unit of Diabetes, Endocrinology and Reproduction, Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - John Ah Wass
- Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
| | - Eleni Papakokkinou
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and the Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and the Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ioachimescu AG. Prognostic Factors of Long-Term Remission After Surgical Treatment of Cushing's Disease. Endocrinol Metab Clin North Am 2018; 47:335-347. [PMID: 29754635 DOI: 10.1016/j.ecl.2018.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Transsphenoidal surgery is the main treatment of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. Although biochemical remission occurs in most patients undergoing operations at specialized centers, the recurrence risk is significant. Visualization of microadenomas on preoperative imaging and confirmation of ACTH-positive adenomas have been associated with higher remission rates. Low cortisol levels in the first 2 weeks postoperatively have been associated with durable remission; however, recurrence cannot be excluded by any cortisol threshold. The decision to perform a pituitary reoperation is based on this parameter; the protocols are institution specific. Patients with Cushing's disease warrant lifelong endocrinologic surveillance.
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Affiliation(s)
- Adriana G Ioachimescu
- Department of Medicine (Endocrinology) and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road Northeast, B6209, Atlanta, GA 30322, USA.
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Valassi E, Franz H, Brue T, Feelders RA, Netea-Maier R, Tsagarakis S, Webb SM, Yaneva M, Reincke M, Droste M, Komerdus I, Maiter D, Kastelan D, Chanson P, Pfeifer M, Strasburger CJ, Tóth M, Chabre O, Krsek M, Fajardo C, Bolanowski M, Santos A, Trainer PJ, Wass JAH, Tabarin A. Preoperative medical treatment in Cushing's syndrome: frequency of use and its impact on postoperative assessment: data from ERCUSYN. Eur J Endocrinol 2018; 178:399-409. [PMID: 29440375 DOI: 10.1530/eje-17-0997] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/12/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Surgery is the definitive treatment of Cushing's syndrome (CS) but medications may also be used as a first-line therapy. Whether preoperative medical treatment (PMT) affects postoperative outcome remains controversial. OBJECTIVE (1) Evaluate how frequently PMT is given to CS patients across Europe; (2) examine differences in preoperative characteristics of patients who receive PMT and those who undergo primary surgery and (3) determine if PMT influences postoperative outcome in pituitary-dependent CS (PIT-CS). PATIENTS AND METHODS 1143 CS patients entered into the ERCUSYN database from 57 centers in 26 countries. Sixty-nine percent had PIT-CS, 25% adrenal-dependent CS (ADR-CS), 5% CS from an ectopic source (ECT-CS) and 1% were classified as having CS from other causes (OTH-CS). RESULTS Twenty per cent of patients took PMT. ECT-CS and PIT-CS were more likely to receive PMT compared to ADR-CS (P < 0.001). Most commonly used drugs were ketoconazole (62%), metyrapone (16%) and a combination of both (12%). Median (interquartile range) duration of PMT was 109 (98) days. PIT-CS patients treated with PMT had more severe clinical features at diagnosis and poorer quality of life compared to those undergoing primary surgery (SX) (P < 0.05). Within 7 days of surgery, PIT-CS patients treated with PMT were more likely to have normal cortisol (P < 0.01) and a lower remission rate (P < 0.01). Within 6 months of surgery, no differences in morbidity or remission rates were observed between SX and PMT groups. CONCLUSIONS PMT may confound the interpretation of immediate postoperative outcome. Follow-up is recommended to definitely evaluate surgical results.
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Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Holger Franz
- Lohmann & Birkner Health Care Consulting GmbHBerlin, Germany
| | - Thierry Brue
- Aix-Marseille UniversitéCNRS, CRN2M UMR 7286, Marseille, France
- APHMHôpital Conception, Marseille, France
| | | | | | | | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IVCampus Innestadt, Klinikum der Universität München, München, Germany
| | | | - Irina Komerdus
- Moscow Regional Research Clinical Institute n.a. VladimirskyMoscow, Russia
| | | | - Darko Kastelan
- Department of EndocrinologyUniversity Hospital Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Philippe Chanson
- Univ Paris-SudUniversité Paris-Saclay UMR-S1185, Paris, France
- Assistance Publique-Hôpitaux de ParisHôpital de Bicêtre, Service de Endocrinologie et des Maladies de la Reproduction, Paris, France
- Institut National de la Santé et de la Recherche Médicale U1185Paris, France
| | - Marija Pfeifer
- Department of EndocrinologyUniversity Medical Centre Ljubljana, Ljubljana Slovenia
| | - Christian J Strasburger
- Division of Clinical EndocrinologyDepartment of Medicine CCM, Charité-Universitätsmedizin, Berlin, Germany
| | - Miklós Tóth
- 2nd Department of MedicineSemmelweis University, Budapest, Hungary
| | - Olivier Chabre
- Service d'Endocrinologie-Diabétologie-NutritionGrenoble Cedex, France
| | - Michal Krsek
- 2nd Department of Medicine3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Carmen Fajardo
- Department of EndocrinologyHospital Universitario de la Ribera, Alzira, Spain
| | - Marek Bolanowski
- Department of EndocrinologyDiabetology and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Peter J Trainer
- Department of EndocrinologyChristie Hospital, Manchester, UK
| | - John A H Wass
- Oxford University Hospital Foundation TrustOxford, UK
| | - Antoine Tabarin
- Centre Hospitalier Universitaire de BordeauxBordeaux, France
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Ironside N, Chatain G, Asuzu D, Benzo S, Lodish M, Sharma S, Nieman L, Stratakis CA, Lonser RR, Chittiboina P. Earlier post-operative hypocortisolemia may predict durable remission from Cushing's disease. Eur J Endocrinol 2018; 178:255-263. [PMID: 29330227 PMCID: PMC5812811 DOI: 10.1530/eje-17-0873] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/08/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT Achievement of hypocortisolemia following transsphenoidal surgery (TSS) for Cushing's disease (CD) is associated with successful adenoma resection. However, up to one-third of these patients recur. OBJECTIVE We assessed whether delay in reaching post-operative cortisol nadir may delineate patients at risk of recurrence for CD following TSS. METHODS A retrospective review of 257 patients who received 291 TSS procedures for CD at NIH, between 2003 and 2016. Early biochemical remission (serum cortisol nadir <5 μg/dL) was confirmed with endocrinological and clinical follow-up. Recurrence was detected by laboratory testing, clinical stigmata or medication dependence during a median follow-up of 11 months. RESULTS Of the 268 unique admissions, remission was recorded in 241 instances. Recurrence was observed in 9% of these cases with cortisol nadir ≤5 μg/dL and 6% of cases with cortisol nadir ≤2 μg/dL. The timing of hypocortisolemia was critical in detecting late recurrences. Morning POD-1 cortisol <3.3 μg/dL was 100% sensitive in predicting durable remission and morning POD-3 cortisol ≥18.5 μg/dL was 98.6% specific in predicting remote recurrence. AUROC analysis revealed that hypocortisolemia ≤5 µg/dL before 15 h (post-operative) had 95% sensitivity and an NPV of 0.98 for durable remission. Serum cortisol level ≤2 µg/dL, when achieved before 21 h, improved sensitivity to 100%. CONCLUSIONS In our cohort, early, profound hypocortisolemia could be used as a clinical prediction tool for durable remission. Achievement of hypocortisolemia ≤2 µg/dL before 21 post-operative hours appeared to accurately predict durable remission in the intermediate term.
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Affiliation(s)
- Natasha Ironside
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Department of NeurosurgeryAuckland City Hospital, Auckland, New Zealand
| | - Gregoire Chatain
- Neurosurgery Unit for Pituitary and Inheritable DiseasesNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
| | - David Asuzu
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Yale School of MedicineNew Haven, Connecticut, USA
| | - Sarah Benzo
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
| | - Maya Lodish
- Section on Endocrinology and GeneticsEunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Susmeeta Sharma
- Pituitary Endocrinology SectionMedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Lynnette Nieman
- National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of Health, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section on Endocrinology and GeneticsEunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Russell R Lonser
- Department of Neurological SurgeryWexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Prashant Chittiboina
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Neurosurgery Unit for Pituitary and Inheritable DiseasesNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
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Sandouk Z, Johnston P, Bunch D, Wang S, Bena J, Hamrahian A, Kennedy L. Variability of Late-Night Salivary Cortisol in Cushing Disease: A Prospective Study. J Clin Endocrinol Metab 2018; 103:983-990. [PMID: 29329418 DOI: 10.1210/jc.2017-02020] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/04/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND The frequency of variable hormonogenesis in patients with Cushing disease (CD) but without cyclical symptoms is unclear. AIM To assess the frequency of variable hormonogenesis in patients presenting with CD. METHODS Over a 6-month period, patients with confirmed or suspected CD provided late-night salivary samples for up to 42 consecutive nights. RESULTS Of 19 patients confirmed to have CD, 16 provided at least 7 consecutive salivary samples, and 13 provided at least 21; these 16 patients are the subjects of this report. Twelve patients had at least three peak and two trough levels of late-night salivary cortisol (LNSC) but in only two patients were strict criteria for cyclical hormonogenesis fulfilled; variation was assessed as random in the others. Eight patients had de novo CD, and eight had recurrent/persistent disease. All patients with recurrent/persistent CD had two or more normal results, and in four of these patients, >50% of LNSC were normal. In six patients with de novo disease with at least one normal LNSC level, the maximum levels ranged from 1.55 to 15.5 times the upper limit of normal. CONCLUSIONS Extreme fluctuations of cortisol production, measured by sequential LNSC, are common in CD. In newly diagnosed disease, this may only occasionally impair diagnostic ability, whereas in most patients with recurrent/persistent disease after pituitary surgery, LNSC is frequently within the reference range, with potential to cause diagnostic problems.
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Affiliation(s)
- Zahrae Sandouk
- Division of Metabolism, Endocrinology, and Diabetes, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Philip Johnston
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Dustin Bunch
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Sihe Wang
- Department of Clinical Pathology, Cleveland Clinic, Cleveland, Ohio
| | - James Bena
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amir Hamrahian
- Department of Endocrinology, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, Ohio
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Yurekli BS, Karaca B, Kisim A, Bozkurt E, Atmaca H, Cetinkalp S, Ozgen G, Yilmaz C, Uzunoglu S, Uslu R, Saygili F. AT-101 acts as anti-proliferative and hormone suppressive agent in mouse pituitary corticotroph tumor cells. J Endocrinol Invest 2018; 41:233-240. [PMID: 28730425 DOI: 10.1007/s40618-017-0733-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 07/12/2017] [Indexed: 01/19/2023]
Abstract
PURPOSE Gossypol, a naturally occurring compound in cottonseeds, has anticancer effects against several tumor cell lines. It has been extensively studied in clinical trials and is well tolerated with a favorable safety profile. AT-101, a derivative of R (-)-gossypol, binds to Bcl-2 family proteins and induces apoptosis in vitro. Although transsphenoidal surgical excision of the pituitary corticotroph adenoma is the gold standard of care, it is not successful all the time. Medical therapy for Cushing's disease still remains a challenge for the clinicians. We aimed to investigate the cytotoxic and apoptotic effects of AT-101 in mouse pituitary corticotroph tumor AtT20 cells. METHODS Cytotoxic effect of AT-101 was assessed by XTT cell viability assay. Apoptosis was shown by measuring DNA fragmentation and Caspase-3/7 activity. Changes in mRNA expressions of apoptosis-related genes were investigated by qPCR array after treatment with AT-101. ACTH was measured by ACTH-EIA Kit. RESULTS AT-101 induced cytotoxicity and apoptosis in AtT20 cells. mRNA levels of pro-apoptotic genes such as TNFR-SF-10B, Bid, PYCARD, Caspase-8, Caspase-3, and Caspase-7 were induced by 2.0-, 1.5-, 1.7-, 1.5-, 1.6-, and 2-fold, respectively, in AtT20 cells by AT-101 treatment. Moreover, some of the anti-apoptotic genes such as BCL2L10, NAIP1, and PAK-7 were reduced by 2.1-, 2.3-, 4.0-fold, respectively, in AtT20 cells. AT-101 also decreased ACTH secretion significantly. CONCLUSION AT-101 induces apoptosis in mouse pituitary corticotroph tumor cells.
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Affiliation(s)
- B S Yurekli
- Division of Endocrinology and Metabolism, Ege University School of Medicine, 35100, Izmir, Turkey.
| | - B Karaca
- Division Medical Oncology, Tulay Aktas Oncology Hospital, Ege University School of Medicine, 35100, Izmir, Turkey
| | - A Kisim
- Section of Molecular Biology, Department of Biology, Faculty of Science and Letters, Celal Bayar University, 45140, Muradiye/Manisa, Turkey
| | - E Bozkurt
- Section of Molecular Biology, Department of Biology, Faculty of Science and Letters, Celal Bayar University, 45140, Muradiye/Manisa, Turkey
| | - H Atmaca
- Section of Molecular Biology, Department of Biology, Faculty of Science and Letters, Celal Bayar University, 45140, Muradiye/Manisa, Turkey
| | - S Cetinkalp
- Division of Endocrinology and Metabolism, Ege University School of Medicine, 35100, Izmir, Turkey
| | - G Ozgen
- Division of Endocrinology and Metabolism, Ege University School of Medicine, 35100, Izmir, Turkey
| | - C Yilmaz
- Division of Endocrinology and Metabolism, Ege University School of Medicine, 35100, Izmir, Turkey
| | - S Uzunoglu
- Section of Molecular Biology, Department of Biology, Faculty of Science and Letters, Celal Bayar University, 45140, Muradiye/Manisa, Turkey
| | - R Uslu
- Division Medical Oncology, Tulay Aktas Oncology Hospital, Ege University School of Medicine, 35100, Izmir, Turkey
| | - F Saygili
- Division of Endocrinology and Metabolism, Ege University School of Medicine, 35100, Izmir, Turkey
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Perry A, Graffeo CS, Marcellino C, Pollock BE, Wetjen NM, Meyer FB. Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm. J Neurol Surg B Skull Base 2018; 79:91-114. [PMID: 29404245 DOI: 10.1055/s-0038-1625984] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3-581), nine remained with recurrent/persistent disease (23%). Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0-240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.
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Affiliation(s)
- Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
| | | | | | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
| | - Nicholas M Wetjen
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
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Yuen KC, Mercado JU, Moloney K, Broyles F. Effective Medical Therapy for Cushing Disease Can Increase the Susceptibility to Relative Hypocortisolism. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171745.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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McGrath M, Ma C, Raines DE. Dimethoxy-etomidate: A Nonhypnotic Etomidate Analog that Potently Inhibits Steroidogenesis. J Pharmacol Exp Ther 2017; 364:229-237. [PMID: 29203576 DOI: 10.1124/jpet.117.245332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/01/2017] [Indexed: 01/02/2023] Open
Abstract
Cushing's syndrome is characterized by the overproduction of adrenocortical steroids. Steroidogenesis inhibitors are mainstays of medical therapy for Cushing's syndrome; unfortunately, adverse side effects and treatment failures are common with currently available drugs. The general anesthetic induction agent etomidate is among the most potent inhibitors of adrenocortical steroidogenesis. However, its use as a treatment of Cushing's syndrome is complicated by its sedative-hypnotic activity and ability to produce myoclonus, central nervous system actions thought to be mediated by the GABAA receptor. Here, we describe the pharmacology of the novel etomidate analog (R)-ethyl 1-(1-(3,5-dimethoxyphenyl)ethyl)-1H-imidazole-5-carboxylate (dimethoxy-etomidate). In contrast to etomidate, dimethoxy-etomidate minimally enhanced GABA-evoked GABAA receptor-mediated currents even at a near-saturating aqueous concentration. In Sprague-Dawley rats, dimethoxy-etomidate's potency for producing loss of righting reflexes-an animal model of sedation/hypnosis-was 2 orders of magnitude lower than that of etomidate, and it did not produce myoclonus. However, similar to etomidate, dimethoxy-etomidate potently suppressed adrenocortical steroid synthesis primarily by inhibiting 11β-hydroxylase. [3H]etomidate binding to rat adrenocortical membranes was inhibited by dimethoxy-etomidate in a biphasic manner with IC50 values of 8.2 and 3970 nM, whereas that by etomidate was monophasic with an IC50 of 22 nM. Our results demonstrate that, similar to etomidate, dimethoxy-etomidate potently and dose-dependently suppresses adrenocortical steroid synthesis by inhibiting 11β-hydroxylase. However, it is essentially devoid of etomidate's GABAA receptor positive modulatory and sedative-hypnotic activities and produces no myoclonus, providing proof of concept for the design of etomidate analogs without important central nervous system actions for the pharmacologic treatment of Cushing's syndrome.
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Affiliation(s)
- Megan McGrath
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Celena Ma
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas E Raines
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Ambrogio AG, Andrioli M, De Martin M, Cavagnini F, Pecori Giraldi F. Usefulness of desmopressin testing to predict relapse during long-term follow-up in patients in remission from Cushing's disease. Endocr Connect 2017; 6:791-799. [PMID: 29018154 PMCID: PMC5682421 DOI: 10.1530/ec-17-0292] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/08/2022]
Abstract
Recurrence of Cushing's disease after successful transsphenoidal surgery occurs in some 30% of the patients and the response to desmopressin shortly after surgery has been proposed as a marker for disease recurrence. The aim of the present study was to evaluate the response to desmopressin over time after surgery. We tested 56 patients with Cushing's disease in remission after transsphenoidal surgery with desmopressin for up to 20 years after surgery. The ACTH and cortisol response to desmopressin over time was evaluated in patients on long-term remission or undergoing relapse; an increase by at least 27 pg/mL in ACTH levels identified responders. The vast majority of patients who underwent successful adenomectomy failed to respond to desmopressin after surgery and this response pattern was maintained over time in patients on long-term remission. Conversely, a response to desmopressin reappeared in patients who subsequently developed a recurrence of Cushing's disease, even years prior to frank hypercortisolism. It appears therefore that a change in the response pattern to desmopressin proves predictive of recurrence of Cushing's disease and may indicate which patients require close monitoring.
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Affiliation(s)
| | - Massimiliano Andrioli
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Martina De Martin
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesco Cavagnini
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesca Pecori Giraldi
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
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Erfe JM, Perry A, McClaskey J, Inzucchi SE, James WS, Eid T, Bronen RA, Mahajan A, Huttner A, Santos F, Spencer D. Long-term outcomes of tissue-based ACTH-antibody assay-guided transsphenoidal resection of pituitary adenomas in Cushing disease. J Neurosurg 2017; 129:629-641. [PMID: 29027854 DOI: 10.3171/2017.3.jns162245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cushing disease is caused by a pituitary micro- or macroadenoma that hypersecretes adrenocorticotropic hormone (ACTH), resulting in hypercortisolemia. For decades, transsphenoidal resection (TSR) has been an efficacious treatment but with certain limitations, namely precise tumor localization and complete excision. The authors evaluated the novel use of a double-antibody sandwich assay for the real-time quantitation of ACTH in resected pituitary specimens with the goals of augmenting pathological diagnosis and ultimately improving long-term patient outcome. METHODS This study involved a retrospective review of records and an analysis of assay values, pathology slides, and MRI studies of patients with Cushing disease who had undergone TSR in the period from 2009 to 2014 and had at least 1 year of follow-up in coordination with an endocrinologist. In the operating room, biopsy specimens from the patients had been analyzed for tissue ACTH concentration. Additional samples were simultaneously sent for frozen-section pathological analysis. The ACTH assay performance was compared against pathology assessments of surgical tumor samples using receiver operating characteristic (ROC) analysis and against pre- and postoperative MRI studies. RESULTS Fourteen patients underwent TSR with guidance by ACTH-antibody assay and pathological assessment of 127 biopsy samples and were followed up for an average of 3 years. The ACTH threshold for discriminating adenomatous from normal tissue was 290,000 pg/mg of tissue, based on jointly maximized sensitivity (95.0%) and specificity (71.3%). Lateralization discordance between preoperative MRI studies and surgical visualization was noted in 3 patients, confirming the impression that MRI alone may not achieve optimal localization. A majority of the patients (85.7%) attained long-term disease remission based on urinary free cortisol levels, plasma cortisol levels, and long-term corticosteroid therapy. Comparisons of patient-months of remission and treatment failure showed that the remission rate in the study sample statistically exceeds the rate in historical controls (71.9%; p = 0.0007, Fisher's exact test). Long-term unexpected hormonal deficiencies were statistically similar between study patients (29%) and those in a meta-analysis (25%; p = 0.7596, Fisher's exact test). CONCLUSIONS These preliminary findings reflect the promising potential of tissue-based ACTH-antibody-guided assay for improving the cure rates of Cushing disease patients undergoing TSR. Further studies with larger sample sizes, further refinements of assay interpretation, and longer-term follow-ups are needed.
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Affiliation(s)
- J Mark Erfe
- 1Yale School of Medicine, New Haven, Connecticut
| | - Avital Perry
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - John McClaskey
- 3Department of Pathology, Mount Sinai Hospital, New York, New York; and
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Johnston PC, Kennedy L, Hamrahian AH, Sandouk Z, Bena J, Hatipoglu B, Weil RJ. Surgical outcomes in patients with Cushing's disease: the Cleveland clinic experience. Pituitary 2017; 20:430-440. [PMID: 28265841 DOI: 10.1007/s11102-017-0802-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Transsphenoidal surgery (TSS) to resect a pituitary adenoma is considered first-line treatment for patients with Cushing's disease (CD). Early, post-operative remission rates >80% are expected for patients with a microadenoma (≤ 10 mm) visible on magnetic resonance (MR) imaging. OBJECTIVE To report surgical outcomes and predictors of remission in a specialist center for patients with CD. PATIENTS AND METHODS Clinical data was obtained from a prospective CD database in addition to review of all electronic medical, laboratory and surgical patient records. Patients who underwent their first TSS by one neurosurgeon between 2004 and 2013, and had a minimum 1 year follow up, were evaluated. RESULTS One hundred and one consecutive patients with CD (73F, 28M) underwent TSS. Median (range) age and follow-up were 47 (15-87) and 4.33 (1-9.8) years, respectively. At surgery, 74 (73.2%) patients had a microadenoma, 27 a macroadenoma; six of the latter patients had a planned, subtotal resection to control neurological signs due to mass effect. Initial remission rates were: microadenoma, 89% (66/74); macroadenoma, 63% (17/27); and 81% (17/21) in those macroadenomas where complete surgical removal was anticipated. Initial non-remission occurred in 18 patients, ten macro- and eight microadenoma; six of 18 had residual disease on most recent follow up. Six (2 macro, 4 micro) of the 83 patients with initial remission have had late (>12 months) recurrence of hypercortisolism that required either repeat TSS or adjunctive therapy, three of whom have persistent hypercortisolism. Macroadenoma (p = 0.003) and tumor invasion beyond the pituitary and sella (p < 0.001) were associated with failure to obtain remission with the initial TSS and greater likelihood of late recurrence. Patients in whom no lesion was seen on neuroimaging had rates of initial remission (21/25 or 84%) and a similar late recurrence rate of 4% (1/25) in comparison with those with MR-visible microadenomas (3/49, or 6%). CONCLUSIONS A team-based approach, in a specialized pituitary center, can lead to initial and durable, long-term remission in patients with CD. The presence of a macroadenoma and tumor extension beyond the pituitary and sella were predictive of initial non-remission as well as risk of late recurrence.
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Affiliation(s)
- Philip C Johnston
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA.
- Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Grosvenor Road, Belfast, UK.
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA
| | - Amir H Hamrahian
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA
- Department of Endocrinology, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Zahrae Sandouk
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA
| | - James Bena
- Department of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Betul Hatipoglu
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA
| | - Robert J Weil
- Department of Neurosurgery, the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- National Clinical Enterprise, Catholic Health Initiatives, Englewood, CO, USA
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Cold inducible RNA binding protein upregulation in pituitary corticotroph adenoma induces corticotroph cell proliferation via Erk signaling pathway. Oncotarget 2016; 7:9175-87. [PMID: 26824322 PMCID: PMC4891034 DOI: 10.18632/oncotarget.7037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 01/19/2016] [Indexed: 11/25/2022] Open
Abstract
Cushing's disease is caused by pituitary corticotroph adenoma, and the pathogenesis of it has remained obscure. Here, we showed that cold inducible RNA binding protein (CIRP) was markedly elevated in corticotroph tumors. Forced overexpression of CIRP in murine AtT20 pituitary corticotroph cell line increased corticotroph precursor hormone proopiomelanocortin (POMC) transcription, ACTH secretion and cellular proliferation. In vivo, CIRP overexpression promotes murine corticotroph tumor growth and enhances ACTH production. Mechanistically, we show that CIRP could promote AtT20 cells proliferation by inducing cyclinD1 and decreasing p27 expression via Erk1/2 signaling pathway. Clinically, CIRP overexpression is significantly correlated with Cushing's disease recurrence. CIRP appears to play a critical tumorigenesis function in Cushing's disease and its expression might be a useful biomarker for tumor recurrence.
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Adrenocorticotropic hormone levels before treatment predict recurrence of Cushing's disease. J Formos Med Assoc 2016; 116:441-447. [PMID: 28029519 DOI: 10.1016/j.jfma.2016.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/30/2016] [Accepted: 08/19/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND/PURPOSE Cushing's disease (CD) is the most common cause of endogenous Cushing's syndrome. Transsphenoidal surgery (TSS) is the first choice of treatment. Predicting prognosis after treatment can benefit further strategies of management, but currently there is no convenient predictor. This study aims to investigate characteristic changes after treatment and to identify potential prognostic predictors. METHODS We retrospectively studied the records of CD patients presenting to the National Taiwan University Hospital, Taipei, Taiwan between 1992 and 2011. They were categorized according to treatment response. Clinical features and examination findings were compared between groups. RESULTS Forty-one patients with CD were included. The follow-up time was 0.26-19.3 years. The time interval between the onset of symptoms and diagnosis was 2.1-120.0 months. The initial remission rate of CD after the first treatment was 82.9%. Mean body mass index (BMI) was 27.4 kg/m2 before treatment and 26.0 kg/m2 3 months after treatment. The patients in remission had a greater decrease in BMI after treatment and lower dehydroepiandrosterone sulfate (DHEAS) levels before treatment, compared with the recurrent group (both p < 0.05). Adrenocorticotropic hormone (ACTH) levels before treatment showed a significant positive correlation with recurrent diseases (p < 0.05). CONCLUSION A larger decrease in BMI after treatment and lower DHEAS levels before treatment were noted for the patients who stayed in CD remission. Higher ACTH levels before treatment predicted a recurrence of CD. These are potentially simple and practical predictors of prognosis.
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Abstract
AbstractBackground: Our study evaluated the perioperative quality of life (QoL) in Cushing’s disease (CD) patients, along with correlations between patient variables and cure rate. Methods: The 36-item Short-Form Health Survey (SF)-36 questionnaire was used to assess perioperative QoL. Patients completed one survey preoperatively and two surveys postoperatively. Retrospective chart review was conducted to collect SF-36 data as well as examine variables including: age, hospital stay, size of tumour, pathological diagnosis, timing of cure, and complication rates. Statistical analysis was conducted on the scores reported by the SF-36, and were compared with the normal Canadian population values, and to a sample of QoL from nonfunctioning pituitary tumour patients. This project was approved by University of British Columbia Research Ethics Board #H15-01572. Results: In general, CD patients have relatively poor QoL that does improve as expected when cured, but not quite to normal levels. Factors associated with cure included presence of macroadenoma, confirmatory pathology, and patient age. Postoperative timing of cure appears to affect the durability of cure, with an immediate cure having a higher durability rate than delayed cure. Most recurrences occurred within 10 months postoperatively. Conclusions: This review of the perioperative QoL in CD helps to illustrate how QoL changes throughout the treatment process, how QoL compares to normal Canadian population levels, and how QoL compares to patients with nonfunctioning pituitary adenomas. As treatment outcome has such a high impact on QoL, the variables identified in this study will help to better inform patients about the treatment course.
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Chandler WF, Barkan AL, Hollon T, Sakharova A, Sack J, Brahma B, Schteingart DE. Outcome of Transsphenoidal Surgery for Cushing Disease: A Single-Center Experience Over 32 Years. Neurosurgery 2016; 78:216-23. [PMID: 26348007 DOI: 10.1227/neu.0000000000001011] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery is the standard approach for treating Cushing disease. Evidence is needed to document effectiveness. OBJECTIVE To analyze results of transsphenoidal surgery in 276 consecutive patients, including 19 children. METHODS Medical records were reviewed for patients treated initially with surgery for Cushing disease from 1980 to 2012. Radiographic features, pathology, remissions, recurrences, and complications were recorded. Patients were categorized for statistical analysis based on tumor size (microadenomas, macroadenomas, and negative imaging) and remission type (type 1 = morning cortisol ≤3 μg/dL; type 2 = morning cortisol normal). RESULTS Females comprised 78% of patients and were older than men. Imaging showed 50% microadenomas, 13% macroadenomas, and 37% negative for tumor. Remission rates for microadenomas, macroadenomas, and negative imaging were 89%, 66%, and 71%, respectively. Patients with microadenomas were more likely to have type 1 remission. Pathology showed adrenocorticotropic hormone-secreting adenomas in 82% of microadenomas, in 100% of macroadenomas, and in 43% of negative imaging. The incidence of hyperplasia was 8%. The finding of hyperplasia or no tumor on pathology predicted treatment failure. The recurrence rate was 17%, with an average time to recurrence of 4.0 years. Patients with type 1 remission had a lower rate of recurrence (13% type 1 vs 50% type 2) and a longer time to recurrence. Children had similar imaging findings, remission rates, and pathology. There were no operative deaths. CONCLUSION Transsphenoidal surgery provides a safe and effective treatment for Cushing disease. For both adults and children, the best outcomes occurred in patients with microadenomas and/or those with type 1 remission.
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Affiliation(s)
- William F Chandler
- *Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; ‡Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan; §Michigan Endocrine Consultants, Berkley, Michigan; ¶Department of Neurosurgery, University of San Diego Health System, San Diego, California; ‖Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta, Atlanta, Georgia
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