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Khadembashiri MM, Mohseni S, Harandi H, Pejman Sani M, Khadembashiri MA, Atlasi R, SeyedAlinaghi S, Mohajeri- Tehrani M, Larijani B. Comparison of adrenalectomy with conservative treatment on mild autonomous cortisol secretion: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1374711. [PMID: 38808111 PMCID: PMC11131104 DOI: 10.3389/fendo.2024.1374711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
Objective This systematic review and meta-analysis was conducted to compare the benefits of adrenalectomy and conservative treatment for comorbidities associated with mild autonomous cortisol secretion (MACS) in patients diagnosed with MACS. Background MACS is the most common benign hormone-secreting functional adrenal incidentaloma. Overproduction of cortisol is observed in MACS patients, resulting in a variety of long-term health issues, including arterial hypertension (HTN), diabetes mellitus (DM), dyslipidemia, obesity, and osteoporosis; however, the classic clinical manifestations of Cushing's syndrome (CS) are not present. Methods A systematic search was conducted using MEDLINE, Embase, Web of Sciences, and Scopus databases on December, 2023. Two reviewers independently extracted data and assessed the quality of the included articles. A meta-analysis was performed to compare the beneficial effects of adrenalectomy versus conservative management for MACS-related comorbidities. Results Fifteen articles were included in this study, which evaluated 933 MACS patients (384 Adrenalectomy and 501 Conservative treatment, and 48 excluded due to incomplete follow-up duration). MACS diagnosis criteria were different among the included articles. All studies, however, stated that there must be no overt CS symptoms. Meta-analysis demonstrates the overall advantage of adrenalectomy over conservative treatment for MACS-related comorbidities (Cohen's d = -0.49, 95% CI [-0.64, -0.34], p = 0.00). Subgroup analysis indicated that the systolic blood pressure (pooled effect size = -0.81, 95% CI [-1.19, -0.42], p = 0.03), diastolic blood pressure (pooled effect size = -0.63, 95% CI [-1.05, -0.21], p = 0.01), and BMD (pooled effect size = -0.40, 95% CI [-0.73, -0.07], p = 0.02) were significantly in favor of adrenalectomy group rather than conservative treatment but no significant differences between the two treatment groups in other MACS-related comorbidities were reported. Conclusion Despite the limited and diverse data, this study demonstrates the advantage of adrenalectomy over conservative treatment for MACS-related comorbidities.
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Affiliation(s)
- Mohamad Mehdi Khadembashiri
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Mohseni
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Harandi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Pejman Sani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Amin Khadembashiri
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Rasha Atlasi
- Non-Communicable Diseases Research Center, Endocrine Population Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Mohajeri- Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Lou Y, Ren L, Chen H, Zhang T, Pan Q. Unveiling the hidden impact: Subclinical hypercortisolism and its subtle influence on bone health. Aging Med (Milton) 2024; 7:96-102. [PMID: 38571672 PMCID: PMC10985775 DOI: 10.1002/agm2.12286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 04/05/2024] Open
Abstract
In recent years, advancements in imaging technologies have led to an increased detection rate of adrenal incidentalomas (AI), with age demonstrating a significant correlation with their incidence. Among the various forms of functional adrenal incidentalomas, subclinical hypercortisolism (SH) stands out as a predominant subtype. Despite the absence of typical symptoms associated with Cushing's syndrome, both domestic and international research consistently establishes a robust link between SH and diverse metabolic irregularities, including hypertension, lipid metabolism disorders, glucose metabolism abnormalities, and disruptions in bone metabolism. Individuals with SH face an elevated risk of cardiovascular events and mortality, highlighting the clinical significance of addressing this condition. Prolonged exposure to elevated cortisol levels poses a significant threat to bone health, contributing to bone loss, alterations in bone microstructure, and an increased susceptibility to fractures. However, comprehensive reviews addressing bone metabolism changes and associated mechanisms in SH patients are currently lacking. Furthermore, the profound impact of concurrent SH on the overall health of the elderly cannot be overstated. A comprehensive understanding of the skeletal health status in elderly individuals with concomitant SH is imperative. This article aims to fill this gap by offering a detailed review of bone metabolism changes and associated mechanisms in SH patients arising from AI. Additionally, it provides a forward-looking perspective on research concerning skeletal health in elderly individuals with concurrent SH.
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Affiliation(s)
- Yuan Lou
- Department of Endocrinology, Beijing Hospital, National Center for Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
- Peking Union Medical College Research InstituteChinese Academy of Medical ScienceBeijingChina
| | - Luping Ren
- Department of EndocrinologyHebei General HospitalShijiazhuangChina
| | - Huan Chen
- Department of Endocrinology, Beijing Hospital, National Center for Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
- Peking Union Medical College Research InstituteChinese Academy of Medical ScienceBeijingChina
| | - Tian Zhang
- Department of EndocrinologyHebei General HospitalShijiazhuangChina
| | - Qi Pan
- Department of Endocrinology, Beijing Hospital, National Center for Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
- Peking Union Medical College Research InstituteChinese Academy of Medical ScienceBeijingChina
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Ardakani MT, Rabizadeh S, Yadegar A, Mohammadi F, Reyhan SK, Qahremani R, Ghanaati H, Esteghamati A, Nakhjavani M. Bilateral inferior petrosal sinus sampling: validity, diagnostic accuracy in lateralization of pituitary microadenoma, and treatment in eleven patients with Cushing's syndrome - a single-center retrospective cohort study. BMC Endocr Disord 2023; 23:232. [PMID: 37872539 PMCID: PMC10591461 DOI: 10.1186/s12902-023-01495-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND This single-center retrospective cohort study aimed to describe the findings and validity of Bilateral inferior petrosal sinus sampling (BIPSS) in the differential diagnosis of patients with ACTH-dependent Cushing's syndrome (CS). METHODS Eleven patients underwent BIPSS due to equivocal biochemical tests and imaging results. Blood samples were taken from the right inferior petrosal sinus (IPS), left IPS, and a peripheral vein before and after stimulation with desmopressin (DDAVP). ACTH and prolactin levels were measured. The diagnosis was based on the ACTH ratio between the IPS and the peripheral vein. Also, lateralization of pituitary adenoma in patients with Cushing's disease (CD) was predicted. No significant complications were observed with BIPSS. RESULTS Based on the pathology report, eight patients had CD, and three had ectopic ACTH syndrome (EAS). Unstimulated BIPSS resulted in a sensitivity of 87.5%, specificity of 100%, PPV of 100%, NPV of 75%, and accuracy of 91%. Stimulated BIPSS resulted in a sensitivity of 100%, specificity of 100%, PPV of 100%, NPV of 100%, and accuracy of 100%. However, pituitary magnetic resonance imaging (MRI) had a lower diagnostic accuracy (sensitivity:62.5%, specificity:33%, PPV:71%, NPV:25%, accuracy:54%). BIPSS accurately demonstrated pituitary adenoma lateralization in 75% of patients with CD. CONCLUSIONS This study suggests that BIPSS may be a reliable and low-complication technique in evaluating patients with ACTH-dependent CS who had inconclusive imaging and biochemical test results. The diagnostic accuracy is improved by DDAVP stimulation. Pituitary adenoma lateralization can be predicted with the aid of BIPSS.
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Affiliation(s)
- Mohammadali Tavakoli Ardakani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soghra Rabizadeh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Yadegar
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Mohammadi
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Karimpour Reyhan
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihane Qahremani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ghanaati
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Manouchehr Nakhjavani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Issa BG, Hanna FWF, Fryer AA, Ensah G, Ebere I, Marshall D, Keevil B. The Utility of Salivary Cortisone in the Overnight Dexamethasone Suppression Test in Adrenal Incidentalomas. J Clin Endocrinol Metab 2023; 108:e937-e943. [PMID: 37155577 DOI: 10.1210/clinem/dgad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/19/2023] [Accepted: 04/30/2023] [Indexed: 05/10/2023]
Abstract
CONTEXT Guidelines recommend the assessment of cortisol secretion in patients with adrenal incidentalomas (AI) using the overnight dexamethasone suppression test (ONDST). This requires attendance at a health care facility and venepuncture. Alternatively, the ONDST can be done by measuring salivary cortisol and cortisone, which can be collected at home. OBJECTIVE We aimed to assess the utility of these measurements in patients with AI. METHODS A retrospective analysis of data from 173 patients with AI who underwent an ONDST and salivary cortisol/cortisone diurnal studies. Serum and salivary cortisol and salivary cortisone were collected at 09:00, late night, and at 09:00 the following morning after dexamethasone. Dexamethasone levels were measured in the postdexamethasone samples. Serum and salivary samples were analyzed with liquid chromatography-tandem mass spectrometry. RESULTS We identified a strong correlation between salivary cortisone and serum cortisol after 1 mg of dexamethasone (r = 0.95). Stepwise multivariate regression showed that postdexamethasone salivary cortisone, baseline serum cortisol, salivary cortisone suppression (predexamethasone/postdexamethasone ratio), and sex were the only significant or near-significant independent variables. Performance of predictive indices using these 4 parameters (sensitivity = 88.5%, specificity = 91.2%; kappa 0.80) and postdexamethasone salivary cortisone alone (sensitivity = 85.3%, specificity = 91.7%; kappa 0.77) were comparable when used to predict an ONDST serum cortisol of ≤50 nmol/L. No correlation was observed with any of the other measured parameters. CONCLUSION In AI patients, after dexamethasone, salivary cortisone correlates very strongly with serum cortisol in the ONDST and could therefore be used as an alternative sampling method which does not require venepuncture or attendance at hospital.
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Affiliation(s)
- Basil George Issa
- Department of Endocrinology and Diabetes, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fahmy W F Hanna
- Department of Endocrinology and Diabetes, University Hospitals of North Staffordshire NHS Trust, Stoke-on-Trent, UK
| | - Anthony A Fryer
- Impact Accelerator Unit, School of Medicine, Keele University, Staffordshire, UK
| | - Grace Ensah
- Department of Endocrinology and Diabetes, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ikenna Ebere
- Department of Clinical Biochemistry, Manchester University Foundation Trust, Manchester, UK
| | - David Marshall
- Department of Clinical Biochemistry, Manchester University Foundation Trust, Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, Manchester University Foundation Trust, Manchester, UK
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Remde H, Kranz S, Morell SM, Altieri B, Kroiss M, Detomas M, Fassnacht M, Deutschbein T. Clinical course of patients with adrenal incidentalomas and cortisol autonomy: a German retrospective single center cohort study. Front Endocrinol (Lausanne) 2023; 14:1123132. [PMID: 37223045 PMCID: PMC10200872 DOI: 10.3389/fendo.2023.1123132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/01/2023] [Indexed: 05/25/2023] Open
Abstract
Background Adrenal incidentalomas with cortisol autonomy are associated with increased cardiovascular morbidity and mortality. Specific data on the clinical and biochemical course of affected patients are lacking. Methods Retrospective study from a tertiary referral centre in Germany. After exclusion of overt hormone excess, malignancy and glucocorticoid medication, patients with adrenal incidentalomas were stratified according to serum cortisol after 1 mg dexamethasone: autonomous cortisol secretion (ACS), >5.0; possible ACS (PACS), 1.9-5.0; non-functioning adenomas (NFA), ≤1.8 µg/dl. Results A total of 260 patients were enrolled (147 women (56.5%), median follow-up 8.8 (2.0-20.8) years). At initial diagnosis, median age was 59.5 (20-82) years, and median tumour size was 27 (10-116) mm. Bilateral tumours were more prevalent in ACS (30.0%) and PACS (21.9%) than in NFA (8.1%). Over time, 40/124 (32.3%) patients had a shift of their hormonal secretion pattern (NFA to PACS/ACS, n=15/53; PACS to ACS, n=6/47; ACS to PACS, n=11/24; PACS to NFA, n=8/47). However, none of the patients developed overt Cushing's syndrome. Sixty-one patients underwent adrenalectomy (NFA, 17.9%; PACS, 24.0%; ACS, 39.0%). When non-operated patients with NFA were compared to PACS and ACS at last follow-up, arterial hypertension (65.3% vs. 81.9% and 92.0%; p<0.05), diabetes (23.8% vs. 35.6% and 40.0%; p<0.01), and thromboembolic events (PACS: HR 3.43, 95%-CI 0.89-13.29; ACS: HR 5.96, 95%-CI 1.33-26.63; p<0.05) were significantly less frequent, along with a trend towards a higher rate of cardiovascular events in case of cortisol autonomy (PACS: HR 2.23, 95%-CI 0.94-5.32; ACS: HR 2.60, 95%-CI 0.87-7.79; p=0.1). Twenty-five (12.6%) of the non-operated patients died, with higher overall mortality in PACS (HR 2.6, 95%-CI 1.0-4.7; p=0.083) and ACS (HR 4.7, 95%-CI 1.6-13.3; p<0.005) compared to NFA. In operated patients, prevalence of arterial hypertension decreased significantly (77.0% at diagnosis to 61.7% at last follow-up; p<0.05). The prevalence of cardiovascular events and mortality did not differ significantly between operated and non-operated patients, whereas thromboembolic events were significantly less frequent in the surgical treatment group. Conclusion Our study confirms relevant cardiovascular morbidity in patients with adrenal incidentalomas (especially those with cortisol autonomy). These patients should therefore be monitored carefully, including adequate treatment of typical cardiovascular risk factors. Adrenalectomy was associated with a significantly decreased prevalence of hypertension. However, more than 30% of patients required reclassification according to repeated dexamethasone suppression tests. Thus, cortisol autonomy should ideally be confirmed before making any relevant treatment decision (e.g. adrenalectomy).
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Affiliation(s)
- Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Stefanie Kranz
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Dermatology and Allergology, University Hospital Augsburg, Augsburg, Germany
| | - Sarah Maria Morell
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Nephrology, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine IV, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
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Shrateh ON, Jobran AW, Zaid MA, Alshoukhi MW. Rare coexistence of primary renal cell carcinoma and primary adrenal adenoma in a cushingoid patient: A case report. Urol Case Rep 2023; 48:102411. [PMID: 37187763 PMCID: PMC10176172 DOI: 10.1016/j.eucr.2023.102411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/19/2023] [Accepted: 04/30/2023] [Indexed: 05/17/2023] Open
Abstract
Pituitary or adrenal lesions can cause Cushing syndrome, which has an incidence of 10-15 per million people. A growing variety of tumor subtypes make up the heterogeneous illness known as renal cell carcinoma (RCC). Herein, we described a case with renal clear cell carcinoma and an adrenal adenoma. As was mentioned, it is recommended that these patients routinely have their pituitary-adrenal axis evaluated. The primary etiology of these two illnesses occurring simultaneously is extremely rare.
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Affiliation(s)
- Oadi N. Shrateh
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
- Corresponding author. Ramallah, Palestine.
| | | | - Momen A. Zaid
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Monther W. Alshoukhi
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
- Department of Internal Medicine, Palestinian Medical Complex, Ramallah, Palestine
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Johnson PC, Thompson SM, Adamo D, Fleming CJ, Bancos I, McKenzie TJ, Cheville J, Young WF, Andrews JC. Adrenal venous sampling for lateralization of cortisol hypersecretion in patients with bilateral adrenal masses. Clin Endocrinol (Oxf) 2023; 98:177-189. [PMID: 36263687 DOI: 10.1111/cen.14833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the role of adrenal venous sampling (AVS) in guiding the management of patients with corticotropin (ACTH)-independent glucocorticoid secretory autonomy and bilateral adrenal masses. DESIGN AND PATIENTS A cohort with 25 patients underwent AVS and surgical management. MEASUREMENTS Cortisol was measured from the adrenal veins (AVs) and inferior vena cava (IVC). AV/IVC cortisol ratio and cortisol lateralization ratio (CLR) (dominant AV cortisol concentration divided by the nondominant AV cortisol concentration) were calculated. Posthoc receiver-operating characteristic curves were generated to determine the specificity of revised AV/IVC cortisol ratio and CLR in differentiating unilateral from bilateral disease. RESULTS Patients underwent unilateral (n = 21) or bilateral (n = 4) adrenalectomy. The mean AV/IVC cortisol ratio for unilateral adrenalectomy was 12.1 ± 9.6 (dominant) and 4.7 ± 3.8 (contralateral) with a mean CLR of 3.6 ± 3.5. The mean AV/IVC cortisol ratio for bilateral adrenalectomy was 7.5 ± 2.1, with a mean CLR of 1.1 ± 0.6. At a mean follow-up of 22 months, one patient who underwent unilateral adrenalectomy for the predicted bilateral disease developed recurrent mild autonomous cortisol secretion. Posthoc analyses demonstrated a specificity of 95%-100% for unilateral disease with AV/IVC cortisol ratio >9 for one side, <2.0 for the opposite side and a CLR > 2.3. The specificity was 80%-90% for bilateral disease with AV/IVC cortisol ratio >5.1 bilaterally and a CLR < 1.1. CONCLUSIONS Among patients with bilateral adrenal masses and ACTH-independent autonomous cortisol secretion, AVS can distinguish between unilateral and bilateral disease with high specificity and may guide surgical management.
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Affiliation(s)
- Paige C Johnson
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott M Thompson
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Adamo
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chad J Fleming
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Travis J McKenzie
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John Cheville
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - James C Andrews
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Zhang Y, Lin X, Liu F, Shou S, Jin H. Neutrophilia with subclinical Cushing's disease: A case report and literature review. Open Life Sci 2023; 18:20220540. [PMID: 36742456 PMCID: PMC9883691 DOI: 10.1515/biol-2022-0540] [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: 08/22/2022] [Revised: 10/29/2022] [Accepted: 11/23/2022] [Indexed: 01/26/2023] Open
Abstract
The increase in the level of neutrophils following subclinical Cushing's disease is an uncommon clinical phenomenon that is characterized by insignificant biochemical or clinical evidence of hypercortisolism. In this study, we reported a 37-year-old female patient who presented with palpitations and fatigue, and showed increased neutrophils that were unaffected by anti-infection therapy. The patient was suspected of having a urinary tract infection because of occasionally with urinary frequency, urgency, increased procalcitonin, leukocytosis, and an increased proportion of neutrophils. The ineffectiveness of anti-infection therapy ruled out the possibility of urinary tract infection. Further examination of the bone marrow excluded the possibility of blood disease. However, the levels of blood cortisol and adrenocorticotropic hormone (ACTH) increased, and a magnetic resonance imaging examination revealed lesions in the sphenoidal sinus and sella area of the sphenoidal bone, which confirmed the relationship between increased glucocorticoids and increased neutrophils. This was further confirmed by follow-up surgery and pathological examination, which revealed silent corticotropin adenomas, which are characterized by the lack of biochemical or clinical evidence of hypercortisolism with positive immunostaining for ACTH.
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Affiliation(s)
- Yan Zhang
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Xiaoxi Lin
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Fei Liu
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Songtao Shou
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Heng Jin
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
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Sun Q, Song J, Feng W, Wang C, Yang X, Zhang M, Cao C. Carney complex presenting as subclinical Cushing syndrome in a child due to a novel Phosphodiesterase 11A mutation. Heliyon 2022; 8:e12077. [DOI: 10.1016/j.heliyon.2022.e12077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 10/01/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
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Fallo F, Di Dalmazi G, Beuschlein F, Biermasz NR, Castinetti F, Elenkova A, Fassnacht M, Isidori AM, Kastelan D, Korbonits M, Newell-Price J, Parati G, Petersenn S, Pivonello R, Ragnarsson O, Tabarin A, Theodoropoulou M, Tsagarakis S, Valassi E, Witek P, Reincke M. Diagnosis and management of hypertension in patients with Cushing's syndrome: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension. J Hypertens 2022; 40:2085-2101. [PMID: 35950979 DOI: 10.1097/hjh.0000000000003252] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endogenous/exogenous Cushing's syndrome is characterized by a cluster of systemic manifestations of hypercortisolism, which cause increased cardiovascular risk. Its biological basis is glucocorticoid excess, acting on various pathogenic processes inducing cardiovascular damage. Hypertension is a common feature in Cushing's syndrome and may persist after normalizing hormone excess and discontinuing steroid therapy. In endogenous Cushing's syndrome, the earlier the diagnosis the sooner management can be employed to offset the deleterious effects of excess cortisol. Such management includes combined treatments directed against the underlying cause and tailored antihypertensive drugs aimed at controlling the consequences of glucocorticoid excess. Experts on endocrine hypertension and members of the Working Group on Endocrine Hypertension of the European Society of Hypertension (ESH) prepared this Consensus document, which summarizes the current knowledge in epidemiology, genetics, diagnosis, and treatment of hypertension in Cushing's syndrome.
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Affiliation(s)
- Francesco Fallo
- Clinica Medica 3, Department of Medicine, University of Padova, Padova
| | - Guido Di Dalmazi
- Unit of Endocrinology and Diabetes Prevention and Care, Department of Medical and Surgical Sciences, University of Bologna
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM
- Assistance Publique Hopitaux de Marseille
- Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Atanaska Elenkova
- Department of Endocrinology, University Specialized Hospital for Active Treatment in Endocrinology (USHATE) "Acad. Ivan Penchev", Medical University - Sofia, Sofia, Bulgaria
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb University School of Medicine, Zagreb, Croatia
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences Istituto Auxologico Italiano, IRCCS
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli
- Unesco Chair for Health Education and Sustainable Development, "Federico II" University, Naples, Italy
| | - Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital Germans Trias i Pujol, Badalona
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Bródno Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
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Adamska A, Ulychnyi V, Siewko K, Popławska-Kita A, Szelachowska M, Adamski M, Buczyńska A, Krętowski AJ. Cardiovascular risk factors in mild adrenal autonomous cortisol secretion in a Caucasian population. Endocr Connect 2022; 11:e220074. [PMID: 35900803 PMCID: PMC9422244 DOI: 10.1530/ec-22-0074] [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: 05/22/2022] [Accepted: 07/12/2022] [Indexed: 11/25/2022]
Abstract
Cardiovascular risk factors could be present in mild adrenal autonomous cortisol secretion (MACS). However, the most frequent cardiovascular risk factors in MACS have not been established. The aim of the presseent study was to analyse the difference in cardiovascular risk factors in patients with MACS in comparison to those with non-functioning adrenal tumour (NFAT). A total of 295 patients with adrenal incidentaloma were included in this retrospective study. We divided our group into those who showed suppression in 1 mg overnight dexamethasone suppression test (DST) (NFAT) (serum cortisol level ≤1.8 μg/dL) and those who did not show suppression in the DST (MACS) (serum concentration of cortisol > 1.8 μg/dL and ≤5 μg/dL). In the studied groups, we analysed the presence of cardiovascular risk factors, such as obesity, prediabetes, type 2 diabetes mellitus (T2DM), hypertension, hyperlipidaemia, chronic kidney disease and cardiovascular events. In our study, 18.9% of patients were defined as MACS. Importantly, T2DM was diagnosed in 41% of MACS vs 23% of NFAT (P < 0.01) and higher frequency of occurrence of hyperlipidaemia in NFAT (72.4%) vs MACS (53.6%) (P = 0.01) was observed. We did not observed differences in the frequency of obesity, hypertension, chronic kidney disease, prediabetes, atrial fibrillation, stroke, ST and non-ST elevation myocardial infarction and coronary angioplasty between patients with MACS and NFAT (all P > 0.05; respectively). In MACS, T2DM is more prevalent than in NFAT; hyperlipidaemia is more prevalent in NFAT. Accordingly, no differences were found in the incidence of obesity, hypertension, prediabetes, chronic kidney disease between studied groups as well as cardiovascular events.
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Affiliation(s)
- Agnieszka Adamska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Białystok, Bialystok, Poland
| | - Vitalii Ulychnyi
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Białystok, Bialystok, Poland
| | - Katarzyna Siewko
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Białystok, Bialystok, Poland
| | - Anna Popławska-Kita
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Białystok, Bialystok, Poland
| | - Małgorzata Szelachowska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Białystok, Bialystok, Poland
| | - Marcin Adamski
- Faculty of Computer Science, Bialystok University of Technology, Białystok, Poland
| | - Angelika Buczyńska
- Clinical Research Centre, Medical University of Bialystok, Bialystok, Poland
| | - Adam Jacek Krętowski
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Białystok, Bialystok, Poland
- Clinical Research Centre, Medical University of Bialystok, Bialystok, Poland
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12
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Hu L, Ji W, Guo M, Yi T, Wang J, Bao M, Gao Y, Jin H, Lu D, Ma W, Han X, Li J, Yuan Z. Case Report: Primary Aldosteronism and Subclinical Cushing Syndrome in a 49-Year-Old Woman With Hypertension Plus Hypokalaemia. Front Cardiovasc Med 2022; 9:911333. [PMID: 35707125 PMCID: PMC9189279 DOI: 10.3389/fcvm.2022.911333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/10/2022] [Indexed: 11/15/2022] Open
Abstract
Background Coexisting primary aldosteronism (PA) and subclinical Cushing's syndrome (SCS) caused by bilateral adrenocortical adenomas have occasionally been reported. Precise diagnosis and treatment of the disease pose a challenge to clinicians due to its atypical clinical manifestations and laboratory findings. Case Summary A 49-year-old woman was admitted to our hospital due to fatigue, increased nocturia and refractory hypertension. The patient had a history of severe left hydronephrosis 6 months prior. Laboratory examinations showed hypokalaemia (2.58 mmol/L) and high urine potassium (71 mmol/24 h). Adrenal computed tomography (CT) showed bilateral adrenal masses. Undetectable ACTH and unsuppressed plasma cortisol levels by dexamethasone indicated ACTH-independent Cushing's syndrome. Although the upright aldosterone-to-renin ratio (ARR) was 3.06 which did not exceed 3.7, elevated plasma aldosterone concentrations (PAC) with unsuppressed PAC after the captopril test still suggested PA. Adrenal venous sampling (AVS) without adrenocorticotropic hormone further revealed hypersecretion of aldosterone from the right side and no dominant side of cortisol secretion. A laparoscopic right adrenal tumor resection was performed. The pathological diagnosis was adrenocortical adenoma. After the operation, the supine and standing PAC were normalized; while the plasma cortisol levels postoperatively were still high and plasma renin was activated. The patient's postoperative serum potassium and 24-h urine potassium returned to normal without any pharmacological treatment. In addition, the patient's blood pressure was controlled normally with irbesartan alone. Conclusion Patients with refractory hypertension should be screened for the cause of secondary hypertension. AVS should be performed in patients in which PA is highly suspected to determine whether there is the option of surgical treatment. Moreover, patients with PA should be screened for hypercortisolism, which can contribute to a proper understanding of the AVS result.
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Affiliation(s)
- Lihua Hu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Wenjun Ji
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Meiyu Guo
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Tieci Yi
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jie Wang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Minghui Bao
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yusi Gao
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Han Jin
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Difei Lu
- Department of Endocrinology, Peking University First Hospital, Beijing, China
- *Correspondence: Difei Lu
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Xiaoning Han
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Xiaoning Han
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhenfang Yuan
- Department of Endocrinology, Peking University First Hospital, Beijing, China
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13
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Kline GA, So B, Campbell DJT, Chin A, Harvey A, Venos E, Pasieka J, Leung AA. Apparent failed and discordant adrenal vein sampling: A potential confounding role of cortisol cosecretion? Clin Endocrinol (Oxf) 2022; 96:123-131. [PMID: 34160833 DOI: 10.1111/cen.14546] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Adrenal vein sampling (AVS) and computed tomography (CT) often show confusingly discordant lateralisation results in primary aldosteronism (PA). We tested a biochemical algorithm using AVS data to detect cortisol cosecretion as a potential explanation for discordant cases. DESIGN Retrospective analysis from a large PA + AVS database. PATIENTS All patients with PA and AVS, 2005-2020. MEASUREMENTS An algorithm using biochemical data from paired AVS + CT images was devised from physiological first principles and informed by data from unilateral, AVS-CT concordant patients. The algorithm involved calculations based upon the expectation that low cortisol levels exist in adrenal vein effluent opposite an aldosterone-and-cortisol-producing adrenal mass and may reverse lateralisation due to inflated aldosterone/cortisol ratios. MAIN OUTCOMES The algorithm was applied to cases with discordant CT-AVS lateralisation to determine whether this might be a common or explanatory finding. Clinical and biochemical characteristics of identified cases were collected via chart review and compared to CT-AVS concordant cases to detect evidence of biological plausibility for cortisol cosecretion. RESULTS From a total of 588 AVS cases, 141 AVS + CT pairs were clear unilateral PA cases, used to develop the three-step algorithm for AVS interpretation. Applied to 88 AVS + CT discordant pairs, the algorithm suggested possible cortisol cosecretion in 40%. Case review showed that the proposed cortisol cosecretors, as identified by the algorithm, had low/suppressed adrenocorticotropic hormone levels, larger average nodule size and lower plasma aldosterone. CONCLUSIONS Pending external validation and outcome verification by surgery and tissue immunohistochemistry, cortisol cosecretion from aldosteronomas may be a common explanation for discordant CT-AVS results in PA.
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Affiliation(s)
- Gregory A Kline
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David J T Campbell
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alex Chin
- Department of Clinical Pathology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Calgary, Alberta, Canada
| | - Adrian Harvey
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erik Venos
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Janice Pasieka
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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14
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Voltan G, Boscaro M, Armanini D, Scaroni C, Ceccato F. A multidisciplinary approach to the management of adrenal incidentaloma. Expert Rev Endocrinol Metab 2021; 16:201-212. [PMID: 34240680 DOI: 10.1080/17446651.2021.1948327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/23/2021] [Indexed: 01/15/2023]
Abstract
An adrenal incidentaloma (AI) is an adrenal neoplasm incidentally discovered during an imaging unrelated to suspected adrenal disease. The aim of the present review is to offer practical guidance on the multidisciplinary approach of AIs.Areas covered:The prevalence of AI is high in the aging population (up to 5-8%); however, hormonally active or malignant conditions are rare. After the discovery of an AI, it is suggested to assess in parallel if the mass is potentially malignant and functionally active. The answer to the former question is mainly based on medical history (extra-adrenal malignancies, new-onset of signs or symptoms) and imaging (conventional radiology and/or nuclear medicine). The answer to the latter question is a complete endocrine evaluation of both cortical (glucocorticoids, mineralocorticoids) and medullary (catecholamines) secretion.Expert opinion:A multidisciplinary discussion is suggested for patients with adrenal disease, after the exclusion of nonfunctioning benign cortical adenoma, in order to plan a close and tailored follow-up for the suspected malignant or functioning forms. Surgery is advised for patients with malignant disease (adrenocortical cancer) or with clinically relevant secreting neoplasm (primary aldosteronism, Cushing's syndrome, and pheochromocytoma).
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Affiliation(s)
- Giacomo Voltan
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Decio Armanini
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
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15
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Hamidi O. Cardiovascular and metabolic consequences in patients with asymptomatic adrenal adenomas. Curr Opin Endocrinol Diabetes Obes 2021; 28:277-282. [PMID: 33764928 DOI: 10.1097/med.0000000000000628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The incidence of adrenal tumors has increased over the past 20 years, most of which are incidentally discovered nonfunctioning adenomas (NFA) and tumors with mild autonomous cortisol secretion (MACS). This review aimed to summarize recent progress in understanding cardiometabolic risk in patients with NFA and MACS and to provide updates on the effect of treatment on improving outcomes in this population. RECENT FINDINGS NFA and MACS are associated with adverse cardiovascular risk factors and metabolic derangements, which are likely mediated by excessive glucocorticoid secretion. Recent studies showed significantly higher prevalence of hypertension, impaired glucose metabolism, obesity, and dyslipidemia in patients with NFA and MACS. Adrenalectomy may improve comorbidities in selected patients. SUMMARY Asymptomatic adrenal adenomas are common and are associated with adverse cardiometabolic changes. In selected patients, adrenalectomy may reduce cardiometabolic risk and improve clinical outcomes.
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Affiliation(s)
- Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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16
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Okada Y, Matsushita S, Yamaguchi K. Investigation of Cushing's and subclinical Cushing's syndromes using adrenocortical scintigraphy. Nucl Med Commun 2021; 42:619-624. [PMID: 33596032 DOI: 10.1097/mnm.0000000000001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study assessed the factors related to the intake rate of adrenocortical scintigraphy in Cushing's and subclinical Cushing's syndromes, in addition to the methods for differentiating between the two. METHODS Clinical findings, blood sampling, and adrenocortical scintigraphy collected at St. Marianna University School of Medicine from 1 January 2010 to 31 December 2019 were used to diagnose initial-onset Cushing's syndrome and subclinical Cushing's syndrome, and patients who underwent 131I-NP-59 adrenocortical scintigraphy were used as study subjects. RESULTS A total of 24 (8 male and 16 female) patients were selected. Of them, 7 had Cushing's syndrome and 17 had subclinical Cushing's syndrome. A correlation coefficient of -0.474 (P = 0.026) was determined between the intake rate after 7 days and adrenocorticotropic hormone levels. Intake rates after 5 days were 0.51% and 0.31% for Cushing's and subclinical Cushing's syndromes, respectively, and were statistically significant (P = 0.03). Intake rates after 7 days were 0.47% and 0.30% for Cushing's and subclinical Cushing's syndromes, respectively, and were statistically significant (P = 0.04). Receiver operating characteristic analysis results of Cushing's and subclinical Cushing's syndromes for intake rates after 7 days were as follows: cutoff value, 0.248; area under curve, 0.769; and 95% confidence interval, 0.561-0.977. CONCLUSION There were differences in the intake rates of adrenocortical scintigraphy between the Cushing's syndrome group and subclinical Cushing's syndrome group, making it possible to differentiate between the two using the intake rate.
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Affiliation(s)
| | | | - Keiichiro Yamaguchi
- Department of Proton Therapy and Tumor Imaging, St. Marianna University School of Medicine, Kawasaki, Japan
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17
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Ishida A, Igarashi K, Ruike Y, Ishiwata K, Naito K, Kono S, Deguchi H, Fujimoto M, Shiga A, Suzuki S, Yoshida T, Tanaka T, Tatsuno I, Yokote K, Koide H. Association of urinary free cortisol with bone formation in patients with mild autonomous cortisol secretion. Clin Endocrinol (Oxf) 2021; 94:544-550. [PMID: 33296503 DOI: 10.1111/cen.14385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/10/2020] [Accepted: 11/30/2020] [Indexed: 11/27/2022]
Abstract
CONTEXT Mild autonomous cortisol secretion (ACS) is associated with an increased risk of vertebral fractures (VFx). However, the influence of this condition on bone turnover or its association with mild ACS is still controversial. OBJECTIVE This study aimed to evaluate the impact of mild ACS on bone quality among patients living with the disease. DESIGN AND SETTING A retrospective study was conducted using data from 55 mild ACS and 12 nonfunctioning adrenal tumour (NFT) patients who visited Chiba University Hospital, Japan, from 2006 to 2018. PATIENTS AND MAIN OUTCOME MEASURES We analysed clinical features and bone-related factors, including bone mineral density (BMD) and VFx, performed blood tests to assess bone metabolism markers in patients with mild ACS and NFT, and assessed the associations between bone-related markers and endocrinological parameters in patients with mild ACS. RESULTS No significant differences between mild ACS and NFT patients were observed with respect to the presence or absence of VFx and BMD. Urinary free cortisol (UFC) was higher in mild ACS patients with VFx than those without (p = .037). The T-score and young adult mean (YAM) of the BMD of the femoral neck in mild ACS patients with a body mass index <25 were positively correlated with dehydroepiandrosterone sulphate levels (ρ: 0.42, p = .017; ρ: 0.40, p = .024, respectively). Pearson's correlation analysis showed that bone-specific alkaline phosphatase was negatively correlated with UFC in the patients with mild ACS (ρ: -0.37, p = .026). CONCLUSIONS These results suggest that urinary free cortisol may be useful for predicting bone formation in mild ACS patients.
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Affiliation(s)
- Akiko Ishida
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Katsushi Igarashi
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Yutaro Ruike
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Kazuki Ishiwata
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Kumiko Naito
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Satomi Kono
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Hanna Deguchi
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Masanori Fujimoto
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Akina Shiga
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Sawako Suzuki
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Tomohiko Yoshida
- Department of Diabetes, Metabolism and Endocrinology, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Tomoaki Tanaka
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ichiro Tatsuno
- Center for Diabetes, Endocrinology, and Metabolism, Toho University Sakura Medical Center, Chiba, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Hisashi Koide
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
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18
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Neutrophil-Lymphocyte Ratio as an Initial Screening Biomarker for Differential Diagnosis of Cushing's Syndrome from Nonfunctional Adenoma in Patients with an Adrenal Mass. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6635594. [PMID: 33628798 PMCID: PMC7899776 DOI: 10.1155/2021/6635594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/25/2020] [Accepted: 02/01/2021] [Indexed: 02/07/2023]
Abstract
Objective Assessing excess adrenal hormones is important in patients with adrenal mass. Current screening tests for excess cortisol hormones are complex, so it cannot be done sometimes due to the limited medical resources. The aim of the study was to evaluate whether the neutrophil-lymphocyte ratio (NLR) can be used as an initial screening biomarker for Cushing's syndrome (CS) in patients with an adrenal mass. Methods This retrospective study included a total of 185 patients with CS and 185 patients with nonfunctional adrenal adenoma (matched 1 : 1 by sex, body mass index, and discharge date). The NLR was compared between the two groups. The association between NLR and serum and urinary cortisol concentrations was analyzed, and an NLR cut-off value for CS screening was calculated. Results NLR (3.38 (2.33, 5.45) vs. 2.13 (1.74, 3.00), P < 0.001) was significantly higher in the CS group than in the nonfunctional adenoma group. In CS patients, the NLR was positively associated with serum cortisol concentrations at 8 am, with 24-hour urine free cortisol and with serum cortisol after a 1 mg dexamethasone suppression test (P < 0.001 each). An NLR cut-off of 2.2 had a sensitivity of 80.0% and a specificity of 54.05%. The weighted Youden index for the NLR was similar to that of the 24-hour urine free cortisol and late-night serum cortisol tests, which are recommended initial tests for CS diagnosis. Conclusion The NLR may be useful for initial screening for CS among patients with an adrenal mass as an easy and convenient marker.
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19
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Bleier J, Shlomai G, Fishman B, Dotan Z, Rosenzweig B, Tirosh A. The Quantitative Relationship Between Autonomous Cortisol Secretion, Dysglycemia and the Metabolic Syndrome. Endocr Pract 2021; 26:974-982. [PMID: 33471702 DOI: 10.4158/ep-2020-0111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/29/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Autonomous cortisol secretion (ACS) is the most common endocrine abnormality in the evaluation of adrenal incidentalomas. The categorization of ACS is derived from a 1 mg dexamethasone suppression test (DST). Impaired DST is associated with several metabolic derangements. In this study we analyzed the association between post-DST cortisol level, analyzed as a continuous parameter, and indices of glycemic metabolism. METHODS We prospectively collected data of 1,976 patients evaluated for adrenal incidentalomas in a large tertiary medical center between December 1, 2017, and August 31, 2019. Seventy-three patients completed the evaluation process. Post-DST cortisol levels were analyzed for correlation with various metabolic parameters, including fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) among the general cohort and for subgroups stratified by the number of metabolic syndrome (MS) criteria. RESULTS Post-DST cortisol demonstrated a linear association with FPG and HbA1c across its entire cortisol range (R = 0.51 and 0.41, respectively; P≤.01). The association between post-DST cortisol and FPG was strengthened with an increased number of metabolic syndrome criteria. Patients with 4 MS criteria show a stronger association (R = 0.92) compared to patients with only a single criterion (R = 0.509). Furthermore, mean post-DST cortisol levels increased as the number of MS criteria accumulated. CONCLUSION Post-DST cortisol should be viewed as a continuous parameter in risk stratification algorithms for the development of MS and particularly dysglycemia.
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Affiliation(s)
- Jonathan Bleier
- Department of Internal Medicine D, Sheba Medical Center, Tel-Hashomer, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv, Israel
| | - Gadi Shlomai
- Department of Internal Medicine D, Sheba Medical Center, Tel-Hashomer, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv, Israel; The Institute of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Boris Fishman
- Department of Internal Medicine D, Sheba Medical Center, Tel-Hashomer, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv, Israel
| | - Zohar Dotan
- Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv, Israel; Department of Urology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Barak Rosenzweig
- Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv, Israel; Department of Urology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Amir Tirosh
- Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv, Israel; The Institute of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel.
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20
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Abstract
Endogenous Cushing's syndrome (CS) is a rare endocrine disorder characterised by excess cortisol secretion due to either ACTH-dependent conditions [commonly an ACTH-producing pituitary adenoma (Cushing's disease)] or ACTH-independent causes (with most common aetiology being a benign adrenal adenoma). Overall, the annual incidence of CS ranges between 1.8 and 3.2 cases per million population. Mortality in active CS is elevated compared to the general population, and a number of studies support the view that survival is also compromised even after apparent successful treatment. The main cause of death is cardiovascular disease highlighting the negative impact of cortisol excess on cardiovascular risk factors. Early diagnosis and prompt treatment of the cortisol excess, as well as vigilant monitoring and stringent control of cardiovascular risk factors are key elements for the long-term prognosis of these patients.
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Affiliation(s)
- Osamah A Hakami
- Institute of Metabolism and System Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Centre of Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
| | - Shahzada Ahmed
- Department of Ear, Nose and Throat, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
| | - Niki Karavitaki
- Institute of Metabolism and System Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Centre of Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
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21
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Zaman S, Almazrouei R, Sam AH, DiMarco AN, Todd JF, Palazzo FF, Tan T, Dhillo WS, Meeran K, Wernig F. Synacthen Stimulation Test Following Unilateral Adrenalectomy Needs to Be Interpreted With Caution. Front Endocrinol (Lausanne) 2021; 12:654600. [PMID: 34046013 PMCID: PMC8147556 DOI: 10.3389/fendo.2021.654600] [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: 01/16/2021] [Accepted: 04/28/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cortisol levels in response to stress are highly variable. Baseline and stimulated cortisol levels are commonly used to determine adrenal function following unilateral adrenalectomy. We report the results of synacthen stimulation testing following unilateral adrenalectomy in a tertiary referral center. METHODS Data were collected retrospectively for 36 patients who underwent synacthen stimulation testing one day post unilateral adrenalectomy. None of the patients had clinical signs of hypercortisolism preoperatively. No patient received pre- or intraoperative steroids. Patients with overt Cushing's syndrome were excluded. RESULTS The median age was 58 (31-79) years. Preoperatively, 16 (44%) patients had a diagnosis of pheochromocytoma, 12 (33%) patients had primary aldosteronism and 8 (22%) patients had non-functioning adenomas with indeterminate/atypical imaging characteristics necessitating surgery. Preoperative overnight dexamethasone suppression test results revealed that 6 of 29 patients failed to suppress cortisol to <50 nmol/L. Twenty (56%) patients achieved a stimulated cortisol ≥450 nmol/L at 30 minutes and 28 (78%) at 60 minutes. None of the patients developed clinical adrenal insufficiency necessitating steroid replacement. CONCLUSIONS Synacthen stimulation testing following unilateral adrenalectomy using standard stimulated cortisol cut-off values would wrongly label many patients adrenally insufficient and may lead to inappropriate prescriptions of steroids to patients who do not need them.
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Affiliation(s)
- Shamaila Zaman
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- *Correspondence: Shamaila Zaman, ; Florian Wernig,
| | - Raya Almazrouei
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Endocrine Division, Tawam Hospital, Al Ain, United Arab Emirates
| | - Amir H. Sam
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Aimee N. DiMarco
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jeannie F. Todd
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fausto F. Palazzo
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Tricia Tan
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Waljit S. Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Florian Wernig
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- *Correspondence: Shamaila Zaman, ; Florian Wernig,
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22
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Vaduva P, Bonnet F, Bertherat J. Molecular Basis of Primary Aldosteronism and Adrenal Cushing Syndrome. J Endocr Soc 2020; 4:bvaa075. [PMID: 32783015 PMCID: PMC7412855 DOI: 10.1210/jendso/bvaa075] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
This review reports the main molecular alterations leading to development of benign cortisol- and/or aldosterone-secreting adrenal tumors. Causes of adrenal Cushing syndrome can be divided in 2 groups: multiple bilateral tumors or adenomas secreting cortisol. Bilateral causes are mainly primary pigmented nodular adrenocortical disease, most of the time due to PRKAR1A germline-inactivating mutations, and primary bilateral macronodular adrenal hyperplasia that can be caused in some rare syndromic cases by germline-inactivating mutations of MEN1, APC, and FH and of ARMC5 in isolated forms. PRKACA somatic-activating mutations are the main alterations in unilateral cortisol-producing adenomas. In primary hyperaldosteronism (PA), familial forms were identified in 1% to 5% of cases: familial hyperaldosteronism type I (FH-I) due to a chimeric CYP11B1/CYP11B2 hybrid gene, FH-II due to CLCN-2 germline mutations, FH-III due to KCNJ5 germline mutations, FH-IV due to CACNA1H germline mutations and PA, and seizures and neurological abnormalities syndrome due to CACNA1D germline mutations. Several somatic mutations have been found in aldosterone-producing adenomas in KCNJ5, ATP1A1, ATP2B3, CACNA1D, and CTNNB1 genes. In addition to these genetic alterations, genome-wide approaches identified several new alterations in transcriptome, methylome, and miRnome studies, highlighting new pathways involved in steroid dysregulation.
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Affiliation(s)
- Patricia Vaduva
- Reference Center for Rare Adrenal Diseases, Department of Endocrinology, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France
| | - Fideline Bonnet
- Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France.,Hormonal Biology Laboratory, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Jérôme Bertherat
- Reference Center for Rare Adrenal Diseases, Department of Endocrinology, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France
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23
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Kelsall A, Iqbal A, Newell-Price J. Adrenal incidentaloma: cardiovascular and metabolic effects of mild cortisol excess. Gland Surg 2020; 9:94-104. [PMID: 32206602 DOI: 10.21037/gs.2019.11.19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the vast majority of cases adrenal incidentalomas (AI) are benign adrenocortical adenomas. They are present in up to 10% of the population over 70 years, with incidence increasing with age. Mild cortisol excess (MCE) in the context of AI is defined as autonomous cortisol secretion (ACS) in the absence of the classical clinical features of Cushing's syndrome. MCE has been reported in up to at least one third of patients with AI. Numerous studies have shown that MCE in AI is associated with increased cardiovascular events and mortality, likely to be consequent upon both hemodynamic changes and inflammatory pathways, and a worse metabolic phenotype characterized by: pancreatic β-cell dysfunction, insulin resistance, visceral obesity and dyslipidemia. There is currently no level 3 evidence from large intervention randomized controlled trials to guide management of MCE in AI, and there is a lack of predictive tools to allow stratification to intervention of only those patients who would benefit in terms of improved metabolic and cardiovascular end-points. Here, we describe the mal-effects of cortisol on cardiovascular and metabolic tissues and discuss management strategies based on current largely observational data.
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Affiliation(s)
- Alan Kelsall
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | - Ahmed Iqbal
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
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24
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Yasuda S, Hikima Y, Kabeya Y, Iida S, Oikawa Y, Isshiki M, Inoue I, Shimada A, Noda M. Clinical characterization of patients with primary aldosteronism plus subclinical Cushing's syndrome. BMC Endocr Disord 2020; 20:9. [PMID: 31931803 PMCID: PMC6958814 DOI: 10.1186/s12902-020-0490-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Primary aldosteronism (PA) plus subclinical Cushing's syndrome (SCS), PASCS, has occasionally been reported. We aimed to clinically characterize patients with PASCS who are poorly profiled. METHODS A population-based, retrospective, single-center, observational study was conducted in 71 patients (age, 58.2 ± 11.2 years; 24 males and 47 females) who developed PA (n = 45), SCS (n = 12), or PASCS (n = 14). The main outcome measures were the proportion of patients with diabetes mellitus (DM), serum potassium concentration, and maximum tumor diameter (MTD) on the computed tomography (CT) scans. RESULTS The proportion of DM patients was significantly greater in the PASCS group than in the PA group (50.0% vs. 13.9%, p < 0.05), without a significant difference between the PASCS and SCS groups. Serum potassium concentration was significantly lower in the PASCS group than in the SCS group (3.2 ± 0.8 mEq/L vs. 4.0 ± 0.5 mEq/L; p < 0.01), without a significant difference between the PASCS and PA groups. Among the 3 study groups of patients who had a unilateral adrenal tumor, MTD was significantly greater in the PASCS group than in the PA group (2.7 ± 0.1 cm vs. 1.4 ± 0.1 cm; p < 0.001), without a significant difference between the PASCS and SCS groups. CONCLUSIONS Any reference criteria were not obtained that surely distinguish patients with PASCS from those with PA or SCS. However, clinicians should suspect the presence of concurrent SCS in patients with PA when detecting a relatively large adrenal tumor on the CT scans.
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Affiliation(s)
- Shigemitsu Yasuda
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan.
| | - Yusuke Hikima
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Yusuke Kabeya
- Department of Home Care Medicine, Sowa Hospital, Sagamihara, Kanagawa, Japan
| | - Shinichiro Iida
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Masashi Isshiki
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Ikuo Inoue
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Mitsuhiko Noda
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
- Department of Diabetes, Metabolism and Endocrinology, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan
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25
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Araujo-Castro M, Robles Lázaro C, Parra Ramírez P, Cuesta Hernández M, Sampedro Núñez MA, Marazuela M. Cardiometabolic profile of non-functioning and autonomous cortisol-secreting adrenal incidentalomas. Is the cardiometabolic risk similar or are there differences? Endocrine 2019; 66:650-659. [PMID: 31473918 DOI: 10.1007/s12020-019-02066-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To study the differences in the cardiometabolic profile between patients with non-functioning adrenal incidentalomas (NFAI) and incidentalomas with autonomous cortisol secretion (ACS). METHODS A total of 149 patients with adrenal incidentalomas were retrospectively evaluated and followed-up for a mean time of 34.6 months at Departments of Endocrinology and Metabolic Diseases Units of four tertiary Spanish hospitals. Patients were grouped as NFAI or ACS adenomas based on two cutoffs in the dexamethasone suppression test (DST): 3.0 µg/dl (NFAIDST3 or ACSDST3) and 1.8 µg/dl (ACSDST1.8 and NFAIDST1.8). RESULTS The mean age of both groups was 62.0 (10.31) and was similar in ACS and NFAI. The prevalence of diabetes, high blood pressure, cardiovascular, and cerebrovascular disease was higher in ACS than in NFAI, but differences only reached statistical significance for cerebrovascular disease using the 3.0 µg/dl cutoff (15.8% vs 2.3%, p = 0.01) and for diabetes using the 1.8 µg/dl cutoff (38.0% vs 22.0%, p = 0.04). No differences were found in the prevalence of dyslipidemia. The prevalence of obesity was lower in patients with ACS than in NFAI 26.3% vs 39.2%, p = 0.18 (NFAIDST3 vs ACSDST3) and 32.1% vs 40.6%, p = 0.56 (ACSDST1.8 vs NFAIDST1.8), but the differences did not reach statistical significance. Maximum adenoma diameter (R-squared = 0.15, p < 0.001) and cerebrovascular disease (OR = 1.59, p = 0.04) were the only parameters that could be predicted by the DST. The DST was an inadequate predictor of clinical (systolic and diastolic blood pressure, body mass index), hormonal (DHEAS, ACTH, UFC, and basal serum cortisol), biochemical (glucose, cholesterol, LDL, HDL, and triglycerides), and other radiological (laterality, lipid content) parameters. Throughout the follow-up, patients did not develop overt Cushing's Syndrome; three NFAIDST3 developed ACSDST3, eight NFAIDST1.8 developed ACSDST1.8, and one NFAIDST1.8 progressed to ACSDST3. In both groups (NFAI and ACS) the metabolic profile remained stable. CONCLUSIONS Our data suggest higher prevalence of diabetes and cerebrovascular disease in ACS patients compared with NFAI. However, probably because of the small sample size, the differences only reached statistical significance using the cutoffs of 1.8 µg/dl for diabetes and 3.0 µg/dl for cerebrovascular disease. Patients with ACS and NFAI rarely progress to more aggressive forms of hypercortisolism, and the metabolic profile usually remains stable during the follow-up.
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Affiliation(s)
| | | | | | - Martín Cuesta Hernández
- Endocrinology Department, San Carlos Clinical University Hospital, Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | | | - Mónica Marazuela
- Endocrinology Department, Princesa University Hospital, Madrid, Spain
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26
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Jouinot A, Armignacco R, Assié G. Genomics of benign adrenocortical tumors. J Steroid Biochem Mol Biol 2019; 193:105414. [PMID: 31207362 DOI: 10.1016/j.jsbmb.2019.105414] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 04/25/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022]
Abstract
Benign adrenocortical adenomas and hyperplasia are relatively common and include a spectrum of distinct entities, which diagnosis depends on the macroscopic aspect and the secretion profile. Recent advances in genomics have proposed high-throughput molecular characterization of adrenal tumors, thereby improving our knowledge on the pathophysiology and tumorigenesis of these tumors. Genomic (exome and chromosome alteration profiles), epigenomic (micro-RNAs expression and methylation profiles) and transcriptomic (gene expression profiles) studies highlighted the major roles of intracellular calcium signaling in aldosterone-producing adenomas (APA), of protein kinase A (PKA)/cAMP pathway in cortisol-producing tumors, and of Wnt/beta-catenin pathway in non-secreting tumors. Exome sequencing revealed new major drivers in all tumor types, including KCNJ5, ATP1A1, ATP2B3, CACNA1D and CACNA1H mutations in APA, PRKACA mutations in cortisol-producing adenomas (CPA) and ARMC5 mutations in primary macronodular adrenocortical hyperplasia (PMAH). The clinical impact of these findings is just starting to evolve. The identification of genetic syndromes, such as germline ARMC5 mutations in PMAH, has allowed genetic counseling. Key molecular alterations could serve as a basis for the development of targeted medical treatments for benign adrenal tumors. The recent developments in genomics, including single-cell technologies, and in proteomics and metabolomics will probably offer new perspectives for characterizing benign adrenal tumorigenesis.
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Affiliation(s)
- Anne Jouinot
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France; Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France
| | - Roberta Armignacco
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France
| | - Guillaume Assié
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France; Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France.
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27
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Delivanis DA, Athimulam S, Bancos I. Modern Management of Mild Autonomous Cortisol Secretion. Clin Pharmacol Ther 2019; 106:1209-1221. [PMID: 31206616 DOI: 10.1002/cpt.1551] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
Incidentally discovered adrenal tumors are reported in ~ 5% of adults undergoing cross-sectional imaging. Mild autonomous cortisol secretion (MACS) from the adrenal mass is demonstrated in 5-48% of patients with adrenal tumors. The diagnosis of MACS represents a challenge due to limitations of the currently used diagnostic tests, differences in the definitions of the clinically relevant MACS, and heterogeneity in an individual's susceptibility to abnormal cortisol secretion from the adrenal mass. Patients with MACS present with increased risk of cardiovascular risk factors, cardiovascular events, metabolic bone disease, and mortality. Adrenalectomy improves or reverses MACS-associated comorbidities in selected patients. The current review will address diagnostic and management challenges in the care of patients with MACS, discuss data on emerging biomarkers, and suggest future directions in the field of MACS.
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Affiliation(s)
- Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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28
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Hsieh LB, Mackinney E, Wang TS. When to Intervene for Subclinical Cushing's Syndrome. Surg Clin North Am 2019; 99:747-758. [DOI: 10.1016/j.suc.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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29
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Acharya R, Dhir M, Bandi R, Yip L, Challinor S. Outcomes of Adrenal Venous Sampling in Patients with Bilateral Adrenal Masses and ACTH-Independent Cushing's Syndrome. World J Surg 2019; 43:527-533. [PMID: 30232569 DOI: 10.1007/s00268-018-4788-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Management of patients with bilateral adrenal masses and ACTH-independent Cushing's syndrome (AICS) is challenging, as bilateral adrenalectomy can lead to steroid dependence and lifelong risk of adrenal crisis. Adrenal venous sampling (AVS) has been previously reported to facilitate lateralization for guiding adrenalectomy. The aim of the current study was to investigate the utility of AVS using protocol from study by Young et al. in the management of patients with bilateral adrenal masses and AICS. METHODS AND DESIGN A retrospective review of all patients with bilateral adrenal masses and AICS who underwent AVS from 2008 to 2016 was performed. AVS for cortisol and epinephrine was performed with dexamethasone suppression. The adrenal vein to peripheral vein cortisol ratios and side-to-side cortisol lateralization ratios were calculated. RESULTS AVS was successful in 8 of 9 patients. All 8 patients had AVS results indicating bilateral cortisol hypersecretion. Six patients underwent adrenalectomy: 3 had unilateral adrenalectomy of the larger size mass, 2 had bilateral adrenalectomy (both sides >4 cm.) and 1 had stepwise bilateral adrenalectomy. Final pathology revealed macronodular adrenal hyperplasia in all 6 patients that underwent surgery. CONCLUSION AVS was useful in excluding a unilateral adenoma as the source of AICS in this study of patients with bilateral adrenal masses and AICS. However, adrenal mass size influenced surgical decision making more than AVS results. More data are needed before AVS can be advocated as essential for management of patients with bilateral adrenal masses and AICS.
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Affiliation(s)
- Runa Acharya
- Department of Medicine, Division of Endocrinology and Metabolism, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Mashaal Dhir
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Rupal Bandi
- Department of Radiology, Division of Interventional Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Linwah Yip
- Department of Surgery, Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sue Challinor
- Department of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA, USA.
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30
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Ren K, Wei J, Liu Q, Zhu Y, Wu N, Tang Y, Li Q, Zhang Q, Yu Y, An Z, Chen J, Li J. Hypercortisolism and primary aldosteronism caused by bilateral adrenocortical adenomas: a case report. BMC Endocr Disord 2019; 19:63. [PMID: 31208392 PMCID: PMC6580498 DOI: 10.1186/s12902-019-0395-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 06/10/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Co-existing Cushing's syndrome and primary aldosteronism caused by bilateral adrenocortical adenomas, secreting cortisol and aldosterone, respectively, have rarely been reported. Precise diagnosis and management of this disorder constitute a challenge to clinicians due to its atypical clinical manifestations and laboratory findings. CASE PRESENTATION We here report a Chinese male patient with co-existing Cushing's syndrome and primary aldosteronism caused by bilateral adrenocortical adenomas, who complained of intermittent muscle weakness for over 3 years. Computed tomography scans revealed bilateral adrenal masses. Undetectable ACTH and unsuppressed cortisol levels by dexamethasone suggested ACTH-independent Cushing's syndrome. Elevated aldosterone to renin ratio and unsuppressed plasma aldosterone concentration after saline infusion test suggested primary aldosteronism. Adrenal venous sampling adjusted by plasma epinephrine revealed hypersecretion of cortisol from the left adrenal mass and of aldosterone from the right one. A sequential bilateral laparoscopic adrenalectomy was performed. The cortisol level was normalized after partial left adrenalectomy and the aldosterone level was normalized after subsequent partial right adrenalectomy. Histopathological evaluation of the resected surgical specimens, including immunohistochemical staining for steroidogenic enzymes, revealed a left cortisol-producing adenoma and a right aldosterone-producing adenoma. The patient's symptoms and laboratory findings resolved after sequential adrenalectomy without any pharmacological treatment. CONCLUSIONS Adrenal venous sampling is essential in diagnosing bilateral functional adrenocortical adenomas prior to surgery. Proper interpretation of the laboratory findings is particularly important in these patients. Immunohistochemistry may be a valuable tool to identify aldosterone/cortisol-producing lesions and to validate the clinical diagnosis.
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Affiliation(s)
- Kaiyun Ren
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jia Wei
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qilin Liu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuchun Zhu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Nianwei Wu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ying Tang
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qianying Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yerong Yu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhenmei An
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Chen
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China.
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31
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Affiliation(s)
- Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Sarantaporou 10, 54640, Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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32
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Araujo-Castro M, Sampedro Núñez MA, Marazuela M. Autonomous cortisol secretion in adrenal incidentalomas. Endocrine 2019; 64:1-13. [PMID: 30847651 DOI: 10.1007/s12020-019-01888-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/28/2019] [Indexed: 02/06/2023]
Abstract
Adrenal incidentalomas (AI) are one of the most frequent reasons for consultation in Endocrinology, as they are present in 3-10% of the general population. Up to 20% of them may have autonomous cortisol secretion (ACS), a term that refers to AI carriers with biochemical evidence of excess cortisol, but without the "specific" clinical signs of Cushing's syndrome. As ACS is associated with an increased risk of diabetes, obesity, high blood pressure (HBP), osteoporosis, cardiovascular events, and global mortality; its correct identification is of great importance. There are different laboratory assays to detect ACS, but all of them have some limitations. The dexamethasone suppression test is the most accepted for screening. However, there is no consensus on the cutoff point that should be used. Low levels of ACTH and DHEA-S and high urinary free cortisol are also associated with ACS, but in isolation they are of little value to establish the diagnosis. Considering its clinical implications and the lack of consensus in the diagnosis and in which is the most appropriate management of these patients, this review offers a quick reference guide of ACS, presenting an exhaustive review of the topic: its definition, epidemiology, diagnosis, clinical implications, treatment, and follow-up.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Miguel Antonio Sampedro Núñez
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Mónica Marazuela
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
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Giorgi RB, Correa MV, Costa-Barbosa FA, Kater CE. Cyclic Subclinical Hypercortisolism: A Previously Unidentified Hypersecretory Form of Adrenal Incidentalomas. J Endocr Soc 2019; 3:678-686. [PMID: 30854503 PMCID: PMC6399707 DOI: 10.1210/js.2018-00385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/06/2019] [Indexed: 01/07/2023] Open
Abstract
Purpose Most adrenal incidentalomas (AIs) are nonfunctioning adenomas (NFAs), but up to 30% may secrete cortisol autonomously without clinical evidence of Cushing syndrome (CS), which nevertheless may increase cardiovascular mortality. This subclinical hypercortisolism (SCH) is confirmed by cortisol resistance to a dexamethasone suppression test (DST). Cyclic cortisol secretion occurs in classic CS but was not reported in SCH. Objective Investigate cyclic cortisol production/autonomy in AIs using sequential DSTs. Methods A total of 251 patients with AI underwent 487 DSTs over 12 years; patients with at least three DSTs were selected. DSTs were validated by measuring serum dexamethasone. Cyclic SCH was defined when at least two abnormal and two normal DSTs were documented. Results A total of 44 patients had three or more DSTs during follow-up: 9 of 44 patients (20.4%) had all negative test results (post-DST cortisol ≤1.8 μg/dL) and were classified as NFA; another nine patients had all positive results (cortisol >1.8 μg/dL) and were classified as sustained SCH. The remaining 26 (59.2%) had discordant responses: 8 of 44 (18.3%) had at least two positive and two negative tests, matching the criterion for cyclic SCH, whereas 18 of 44 (40.9%) had only one discordant test and were classified as possibly cyclic SCH. Eleven of 20 (55%) patients initially classified as NFA did not maintain their cortisol pattern. Conclusions Extended follow-up with repeated DSTs uncovered an unusual subset of AIs with cyclic SCH. Recurring production of cortisol may affect determination of AI subtypes if based on just one DST. Lack of recognition of this phenomenon makes follow-up of patients with AI misleading because even cyclic SCH may result in potential cardiovascular risk.
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Affiliation(s)
- Rafael B Giorgi
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
| | - Marcelo V Correa
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
| | - Flávia A Costa-Barbosa
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
| | - Claudio E Kater
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP) Medical School, São Paulo, SP, Brazil
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Khawandanah D, ElAsmar N, Arafah BM. Alterations in hypothalamic-pituitary-adrenal function immediately after resection of adrenal adenomas in patients with Cushing's syndrome and others with incidentalomas and subclinical hypercortisolism. Endocrine 2019; 63:140-148. [PMID: 30259310 DOI: 10.1007/s12020-018-1769-z] [Citation(s) in RCA: 5] [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: 06/27/2018] [Accepted: 09/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with cortisol secreting adrenal adenomas present with Cushing's syndrome (CS), while 5-15% of subjects with adrenal incidentalomas have subclinical hypercortisolism (SH) as they have biochemical abnormalities suggesting autonomous cortisol secretion without associated clinical features of CS. GOALS Examine HPA function immediately after resection of either of these adenomas and utilize the data to decide on initiating glucocorticoid replacement. METHODS ACTH, cortisol, and DHEA-S levels were measured frequently for 8 h after adrenalectomy in 14 patients with CS and 19 others with incidentalomas + SH. Glucocorticoids were withheld before/during surgery and administered 6-8 h postoperatively to those who had cortisol levels of <3 ug/dL (83 nmol/L). RESULTS Preoperatively, incidentalomas + SH patients had larger tumors, higher ACTH, and DHEA-S but lower dexamethasone-suppressed serum cortisol levels than those with CS. Postoperatively, ACTH levels increased in both groups: (90.1 ± 31.6; 24.1 ± 14.4 ng/L, respectively; P < 0.001). Postoperative ACTH levels correlated negatively with preoperative Dexamethasone-suppressed cortisol concentrations in both groups. Patients with CS had steeper decline in cortisol concentrations than those with incidentalomas + SH. All patients with CS had hypocortisolemia requiring glucocorticoid therapy for several months, while only 5/19 with incidentalomas + SH had cortisol levels <3 ug/dL;(83 nmol/L) 6-8 h after adrenalectomy and received hydrocortisone replacement therapy for ≤4 weeks. CONCLUSIONS Surgical stress stimulates HPA function even in patients with hypercortisolemia. Patients with incidentalomas + SH have incomplete HPA suppression that allows more robust response to surgical stress than that observed in patients with CS. HPA assessment immediately after surgical resection of adrenal incidentalomas identified those requiring glucocorticoid replacement before discharge.
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Affiliation(s)
- Dena Khawandanah
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nadine ElAsmar
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Baha M Arafah
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.
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Babinska A, Kaszubowski M, Kmieć P, Sworczak K. Adipokine and cytokine levels in patients with adrenocortical cancer, subclinical Cushing's syndrome and healthy controls. Steroids 2018; 140:39-44. [PMID: 30194955 DOI: 10.1016/j.steroids.2018.08.011] [Citation(s) in RCA: 6] [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: 06/06/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In recent years researchers have focused at hormonal activity in Cushing's syndrome (CS) in connection with metabolic disorders and the role of adipokines and cytokines secreted by the adipose tissue. The aim of the study was to investigate levels of adipokines and cytokines in patients with: subclinical CS (SCS) - in relation to hormonal parameters of hypercortisolemia, and, adrenocortical cancer (ACC). MATERIALS AND METHODS The study included 20 SCS as well as 7 ACC patients, and 18 healthy participants. Hormonal activity and serum concentrations of adiponectin, leptin, resistin, tumor necrosis factor alpha (TNFα), interleukin 6 (IL6), and monocyte chemoattractant protein 1 (MCP1), were analyzed. RESULTS In SCS patients compared to healthy volunteers a trend toward higher concentrations of all pro-inflammatory cytokines was noted, however, statistically significant differences were only found for TNFα and IL6 (p = 0.047 and p = 0.028, respectively). Adiponectin concentrations were significantly lower in the SCS group (p = 0.006). Serum adipokine and cytokine levels were independent of the presence of diabetes mellitus (DM) and hypertension (HT) in the SCS group. A significant correlation was found between subclinical glucocorticoid secretion and IL6 concentration (Pearson's r = 0.517, p = 0.02). Acquired results were independent of BMI. In ACC patients compared to controls higher IL6, TNFα and MCP1 levels were recorded. CONCLUSION It is possible that higher adipokine and pro-inflammatory cytokine concentrations as well as lower anti-inflammatory adiponectin concentrations comprise an additional risk factor of metabolic and cardiovascular diseases in SCS patients. It seems that at least among patients with SCS adipokine and cytokine secretion is independent of hormonal activity (except for IL6).
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Affiliation(s)
- Anna Babinska
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, ul. Dębinki 7, 80-288 Gdansk, Poland.
| | - Mariusz Kaszubowski
- Institute of Statistics, Department of Economic Sciences, Faculty of Management and Economics, Gdansk University of Technology, ul. Traugutta 79, 80-233 Gdańsk, Poland.
| | - Piotr Kmieć
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, ul. Dębinki 7, 80-288 Gdansk, Poland.
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, ul. Dębinki 7, 80-288 Gdansk, Poland.
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Baba R, Oki K, Kobuke K, Itcho K, Okubo H, Ohno H, Yoneda M, Hattori N. Measurement of midnight ACTH levels is useful for the evaluation of midnight cortisol levels. Steroids 2018; 140:179-184. [PMID: 30414423 DOI: 10.1016/j.steroids.2018.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Elevated midnight cortisol levels induced by non-suppressed ACTH levels may lead to false-positive results for hypercortisolism in patients with adrenal incidentaloma. We investigated whether plasma ACTH-associated high midnight serum cortisol levels are correlated with other endocrinological findings with respect to hypothalamic-pituitaryadrenal function or hypercortisolism status. METHODS Two-hundred-forty-six patients with adrenocortical adenoma were evaluated via measurements of midnight ACTH and cortisol levels, a 1-mg dexamethasone suppression test (DST), and a cosyntropin-releasing hormone (CRH) stimulation test. Patients were divided into four groups according to their midnight plasma ACTH levels. RESULTS The groups with higher midnight ACTH levels had significantly higher basal ACTH levels. A positive relationship was observed between midnight serum cortisol and serum cortisol in the 1-mg DST for all groups; stronger associations were observed in the group with lower midnight ACTH. In the CRH test, peak, delta, and sigma ACTH had significant inverse relationships with midnight cortisol levels in the lowest and second lowest midnight ACTH groups. Patients with midnight cortisol levels >3.5 μg/dL were further divided into two groups according to whether their midnight plasma ACTH levels were below or above 10.0 pg/mL. There were significantly fewer patients with hypercortisolism in the higher ACTH group; midnight serum cortisol levels were associated with hypercortisolism only in the lower ACTH group. CONCLUSION We demonstrated that midnight ACTH-associated cortisol values were not correlated with other endocrinological findings or hypercortisolism state. Measurement of midnight ACTH levels is important, and careful evaluation is needed for patients with higher midnight ACTH levels.
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Affiliation(s)
- Ryuta Baba
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kenji Oki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Kazuhiro Kobuke
- Department of Preventive Medicine for Diabetes and Lifestyle-related Disease, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kiyotaka Itcho
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hirofumi Okubo
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Haruya Ohno
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masayasu Yoneda
- Department of Preventive Medicine for Diabetes and Lifestyle-related Disease, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Ueland GÅ, Methlie P, Jøssang DE, Sagen JV, Viste K, Thordarson HB, Heie A, Grytaas M, Løvås K, Biermann M, Husebye ES. Adrenal Venous Sampling for Assessment of Autonomous Cortisol Secretion. J Clin Endocrinol Metab 2018; 103:4553-4560. [PMID: 30137397 DOI: 10.1210/jc.2018-01198] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/15/2018] [Indexed: 02/09/2023]
Abstract
CONTEXT Autonomous cortisol secretion (ACS) can be unilateral or bilateral irrespective of the presence of an adrenal tumor. A reliable method to distinguish between unilateral and bilateral ACS is lacking. OBJECTIVE Evaluate the use of adrenal venous sampling (AVS) to distinguish between unilateral and bilateral ACS. DESIGN AND METHODS This was a prospective study of AVS in patients with adrenal tumors who received a diagnosis of ACS or adrenal Cushing syndrome (CS). Unilateral secretion was defined as >2.3-fold difference in cortisol levels between the two adrenal veins. Metanephrine levels were used to ascertain correct catheter position. Results were correlated with findings on CT and iodine-131-cholesterol scintigraphy. RESULTS Thirty-nine patients underwent AVS; there were no complications. The procedure was inconclusive in six patients and repeated with success in one, giving a success rate of 85%, and leaving 34 procedures for evaluation (adrenal CS, n = 2; ACS, n = 32). Of 14 patients with bilateral tumors, 10 had bilateral and 4 had unilateral overproduction. Of 20 patients with unilateral tumors, 11 had lateralization to the side of the tumor and the remaining had bilateral secretion. Cholesterol scintigraphy findings were concordant with those of AVS in 13 of 18 cases (72%) and discordant in 5 (28%). CONCLUSION Laterality of ACS does not always correspond to findings on CT images. AVS is a safe and valuable tool for differentiation between unilateral and bilateral cortisol secretion and should be considered when operative treatment of ACS is a possibility.
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Affiliation(s)
- Grethe Å Ueland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Dag Eirik Jøssang
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Jørn V Sagen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of The Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | - Kristin Viste
- Department of The Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | | | - Anette Heie
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Surgery, Haukeland University Hospital, Bergen, Norway
| | - Marianne Grytaas
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Kristian Løvås
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Martin Biermann
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
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Koracevic G, Stojkovic M, Lovic D, Pavlovic M, Kostic T, Kutlesic M, Micic S, Koracevic M, Djordjevic M. Should Cushing's Syndrome be Considered as a Disease with High Cardiovascular Risk in Relevant Guidelines? Curr Vasc Pharmacol 2018; 18:12-24. [PMID: 30289080 DOI: 10.2174/1570161116666181005122339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/29/2018] [Accepted: 09/29/2018] [Indexed: 12/27/2022]
Abstract
A considerable amount of data supports a 1.8-7.4-fold increased mortality associated with Cushing's syndrome (CS). This is attributed to a high occurrence of several cardiovascular disease (CVD) risk factors in CS [e.g. adiposity, arterial hypertension (AHT), dyslipidaemia and type 2 diabetes mellitus (T2DM)]. Therefore, practically all patients with CS have the metabolic syndrome (MetS), which represents a high CVD risk. Characteristically, despite a relatively young average age, numerous patients with CS display a 'high' or 'very high' CVD risk (i.e. risk of a major CVD event >20% in the following 10 years). Although T2DM is listed as a condition with a high CVD risk, CS is not, despite the fact that a considerable proportion of the CS population will develop T2DM or impaired glucose tolerance. CS is also regarded as a risk factor for aortic dissection in current guidelines. This review considers the evidence supporting listing CS among high CVD risk conditions.
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | - Dragan Lovic
- Clinic for Internal Medicine Intermedica, Nis, Serbia
| | - Milan Pavlovic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | - Tomislav Kostic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | | | | | - Milan Djordjevic
- Health Centre Jagodina, Emergency Medical Service, Jagodina, Serbia
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Babinska A, Kaszubowski M, Sworczak K. Adipokine and cytokine levels in non-functioning adrenal incidentalomas (NFAI). Endocr J 2018; 65:849-858. [PMID: 29877205 DOI: 10.1507/endocrj.ej18-0066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Due to the fact that overweight or obesity is accompanied by hormonally active adrenal tumors: Cushing Syndrome-(CS) and Subclinical Cushing Syndrome (SCS), it is of high interest the correlation between different adipokines and cytokines secreted by adipose tissue, with metabolic disorders and hormonal activity in this group. Even in non-functioning adrenal incidentalomas (NFAI) elevated risk for cardiovascular disease and metabolic syndrome was demonstrated. The aim of the study was to investigate plasma adiponectin, leptin, resistin, tumor necrosis factor α (TNFα), interleukin 6 (IL6) and monocyte chemoattractant protein 1 (MCP1) levels in patients with NFAIs and healthy subjects. The study included 18 NFAI patients and 18 healthy subjects. The groups were homogeneous in terms of age, sex and body mass index (BMI). Patients with NFAI showed significantly higher circulating levels of pro-inflammatory cytokines compared to healthy controls (MCP 1: p < 0.001; TNFα p = 0.021; IL6 p = 0.012). On the other hand, adiponectin concentration was significantly lower in the NFAI group (p = 0.034). The serum leptin and resistin concentrations did not differ significantly between the two groups. Acquired results were not dependent on glucocorticoid and catecholamine secretion in NFAI patients. Also, there were no clear correlations between BMI and cytokine levels. It is possible that increased risk for cardiovascular and metabolic diseases reported in NFAI patients is at least partially dependent on adipose tissue activity.
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Affiliation(s)
- Anna Babinska
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Mariusz Kaszubowski
- Institute of Statistics, Department of Economic Sciences, Faculty of Management and Economics, Gdansk University of Technology, Gdansk, Poland
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
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Reimondo G, Puglisi S, Pia A, Terzolo M. Autonomous hypercortisolism: definition and clinical implications. MINERVA ENDOCRINOL 2018; 44:33-42. [PMID: 29963828 DOI: 10.23736/s0391-1977.18.02884-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In current practice, an adrenal adenoma usually comes as an unexpected byproduct of an imaging study performed for unrelated reasons, without any prior suspect of adrenal disease. Therefore, these tumors currently represent a public health challenge because they are increasingly recognized due to the widespread use of high-resolution cross-sectional imaging for diagnostic purposes. In radiology series, the prevalence of adrenal adenomas increases steeply with age, from around 3% below the age of 50 years up to 10% in the ageing population. These tumors may have clinical relevance because they are able to secrete cortisol autonomously, independently from the pituitary control, in up to 20-30% of patients. In most of the cases the resulting cortisol excess is insufficient to produce a typical Cushing phenotype but may have clinical consequences, such as hypertension, diabetes, obesity, dyslipidemia and osteoporosis. Despite some controversy on the most effective diagnostic algorithm to define this subtle hypercortisolism, there is mounting evidence that a simple approach by using the 1-mg overnight dexamethasone suppression test (DST) may stratify patients for their cardiovascular risk. Cross-sectional, retrospective studies showed that patients with increasingly higher cortisol following DST have an adverse cardiovascular risk profile and are at increased risk of death. Therefore, also a subtle autonomous cortisol excess is associated with increased morbidity and mortality, mainly of cardiovascular origin.
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Affiliation(s)
- Giuseppe Reimondo
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy -
| | - Soraya Puglisi
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy
| | - Anna Pia
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy
| | - Massimo Terzolo
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy
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Posterior retroperitoneoscopic adrenal surgery for clinical and subclinical Cushing’s syndrome in patients with bilateral adrenal disease. Langenbecks Arch Surg 2017; 402:775-785. [DOI: 10.1007/s00423-017-1569-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 02/13/2017] [Indexed: 12/26/2022]
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Clinical Benefits of Unilateral Adrenalectomy in Patients with Subclinical Hypercortisolism Due to Adrenal Incidentaloma: Results from a Single Center. High Blood Press Cardiovasc Prev 2017; 24:69-75. [PMID: 28138953 DOI: 10.1007/s40292-017-0182-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/19/2017] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION This study was designed to evaluate the results of unilateral laparoscopic adrenalectomy in patients with subclinical hypercortisolism (SH) due to adrenal incidentaloma (AI) concerning the main cardiometabolic disorders. METHODS We have studied between January 2000 to December 2015, 645 patients with AI (283 males and 362 females; mean age 61.9 ± 10 years) and we found 70 patients with SH (27 males and 43 females; mean age 61.9 ± 8.4 years). Twenty-six (37%) SH patients (6 males and 20 females; mean age 58.7 ± 7.1 years) underwent unilateral laparoscopic adrenalectomy, whereas 44 SH patients (21 males and 23 females; mean age 63.9 ± 9.9 years) performed a conservative treatment. All SH patients were evaluated at diagnosis and after follow-up (mean 12 months; range 9-15 months). RESULTS In only SH patients undergoing unilateral adrenalectomy we found a statistical significant reduction of the arterial hypertension and metabolic syndrome (p < 0.05, respectively). In particular we observed a reduction of 24-h systolic blood pressure and "non-dipper" pattern (p < 0.05, respectively) evaluated with ambulatory blood pressure monitoring (ABPM). CONCLUSIONS Our study confirm the high prevalence of SH in AI, and the unilateral laparoscopic adrenalectomy seemed to have a beneficial effect on some cardiometabolic disorders.
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Inder WJ. Towards a universally accepted definition of subclinical Cushing's syndrome - subclinical autonomous hypercortisolism. Clin Endocrinol (Oxf) 2017; 86:7-9. [PMID: 27662258 DOI: 10.1111/cen.13244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital and School of Medicine, the University of Queensland, Brisbane, Australia
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Chiodini I, Vainicher CE, Morelli V, Palmieri S, Cairoli E, Salcuni AS, Copetti M, Scillitani A. MECHANISMS IN ENDOCRINOLOGY: Endogenous subclinical hypercortisolism and bone: a clinical review. Eur J Endocrinol 2016; 175:R265-R282. [PMID: 27412441 DOI: 10.1530/eje-16-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/13/2016] [Indexed: 01/11/2023]
Abstract
In recent years, the condition of subclinical hypercortisolism (SH) has become a topic of growing interest. This is due to the fact that SH prevalence is not negligible (0.8-2% in the general population) and that, although asymptomatic, this subtle cortisol excess is not harmless, being associated with an increased risk of complications, in particular of osteoporosis and fragility fractures. As specific symptoms of hypercortisolism are absent in SH, the SH diagnosis relies only on biochemical tests and it is a challenge for physicians. As a consequence, even the indications for the evaluation of bone involvement in SH patients are debatable and guidelines are not available. Finally, the relative importance of bone density, bone quality and glucocorticoid sensitivity in SH is a recent field of research. On the other hand, SH prevalence seems to be increased in osteoporotic patients, in whom a vertebral fracture may be the presenting symptom of an otherwise asymptomatic cortisol excess. Therefore, the issue of who and how to screen for SH among the osteoporotic patients is widely debated. The present review will summarize the available data regarding the bone turnover, bone mineral density, bone quality and risk of fracture in patients with endogenous SH. In addition, the role of the individual glucocorticoid sensitivity in SH-related bone damage and the problem of diagnosing and managing the bone consequences of SH will be reviewed. Finally, the issue of suspecting and screening for SH patients with apparent primary osteoporosis will be addressed.
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Affiliation(s)
- I Chiodini
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Eller Vainicher
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - S Palmieri
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - E Cairoli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - A S Salcuni
- Endocrine UnitDepartment of Medical Sciences, University of Cagliari, Cagliari, Italy
| | | | - A Scillitani
- Unit of Endocrinology"Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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Bancos I, Alahdab F, Crowley RK, Chortis V, Delivanis DA, Erickson D, Natt N, Terzolo M, Arlt W, Young WF, Murad MH. THERAPY OF ENDOCRINE DISEASE: Improvement of cardiovascular risk factors after adrenalectomy in patients with adrenal tumors and subclinical Cushing's syndrome: a systematic review and meta-analysis. Eur J Endocrinol 2016; 175:R283-R295. [PMID: 27450696 DOI: 10.1530/eje-16-0465] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/14/2016] [Accepted: 07/22/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Beneficial effects of adrenalectomy on cardiovascular risk factors in patients with subclinical Cushing's syndrome (SCS) are uncertain. We sought to conduct a systematic review and meta-analysis with the following objectives: (i) determine the effect of adrenalectomy compared with conservative management on cardiovascular risk factors in patients with SCS and (ii) compare the effect of adrenalectomy on cardiovascular risk factors in patients with SCS vs those with a nonfunctioning (NF) adrenal tumor. METHODS MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trial were searched on 17 November 2015. Reviewers extracted data and assessed methodological quality in duplicate. RESULTS We included 26 studies reporting on 584 patients with SCS and 457 patients with NF adrenal tumors. Studies used different definitions of SCS. Patients with SCS undergoing adrenalectomy demonstrated an overall improvement in cardiovascular risk factors (61% for hypertension, 52% for diabetes mellitus, 45% for obesity and 24% for dyslipidemia). When compared with conservative management, patients with SCS undergoing adrenalectomy experienced improvement in hypertension (RR 11, 95% CI: 4.3-27.8) and diabetes mellitus (RR 3.9, 95% CI: 1.5-9.9), but not dyslipidemia (RR 2.6, 95% CI: 0.97-7.2) or obesity (RR 3.4, 95% CI: 0.95-12). Patients with NF adrenal tumors experienced improvement in hypertension (21/54 patients); however, insufficient data exist for comparison to patients with SCS. CONCLUSIONS Available low-to-moderate-quality evidence from heterogeneous studies suggests a beneficial effect of adrenalectomy on cardiovascular risk factors in patients with SCS overall and compared with conservative management.
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Affiliation(s)
- Irina Bancos
- Division of EndocrinologyDiabetes, Metabolism and Nutrition
| | - Fares Alahdab
- Evidence-based Practice CenterMayo Clinic, Rochester, Minnesota, USA
| | - Rachel K Crowley
- St Vincent's University Hospital and University College DublinDublin, Ireland
| | - Vasileios Chortis
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
- Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Dana Erickson
- Division of EndocrinologyDiabetes, Metabolism and Nutrition
| | - Neena Natt
- Division of EndocrinologyDiabetes, Metabolism and Nutrition
| | - Massimo Terzolo
- Internal Medicine 1Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Wiebke Arlt
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
- Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - M Hassan Murad
- Evidence-based Practice CenterMayo Clinic, Rochester, Minnesota, USA
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46
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Raffaelli M, De Crea C, D'Amato G, Gallucci P, Lombardi CP, Bellantone R. Outcome of adrenalectomy for subclinical hypercortisolism and Cushing syndrome. Surgery 2016; 161:264-271. [PMID: 27865591 DOI: 10.1016/j.surg.2016.07.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND We compared operative and metabolic outcomes in patients with subclinical Cushing syndrome and Cushing syndrome caused by unilateral adrenal lesion, aiming to clarify the role of glucocorticoid replacement treatment in patients with subclinical Cushing syndrome after adrenalectomy. METHODS The medical records of all the patients who underwent unilateral adrenalectomy for subclinical Cushing syndrome or Cushing syndrome were reviewed. Diagnostic criteria for subclinical Cushing syndrome were a pathologic dexamethasone suppression test plus 2 additional criteria. RESULTS Twenty-nine patients with subclinical Cushing syndrome and 50 with Cushing syndrome were identified. No significant difference was found between patients with subclinical Cushing syndrome and Cushing syndrome regarding lesion size, operative time, and hospital stay. Two patients out of 29 with subclinical Cushing syndrome and 3 out of 50 patients with Cushing syndrome experienced Clavien-Dindo grade II complications (P = .87). All the patients required postoperative glucocorticoid replacement that was discontinued within 6 months in 28 of the 29 patients with subclinical Cushing syndrome and in 3 out of 50 Cushing syndrome patients (P < .005). At long-term follow-up, adrenalectomy significantly improved hypertension and diabetes in affected patients, with no differences between subclinical Cushing syndrome and Cushing syndrome. Hypercortisolism was resolved in all the cases. CONCLUSION Operative and metabolic outcomes of adrenalectomy are similar in subclinical Cushing syndrome and Cushing syndrome. Postoperative glucocorticoid replacement treatment is advisable in all patients with subclinical Cushing syndrome. Prolonged adrenal insufficiency is more frequent in Cushing syndrome patients.
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Affiliation(s)
- Marco Raffaelli
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Carmela De Crea
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gerardo D'Amato
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pierpaolo Gallucci
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Celestino P Lombardi
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rocco Bellantone
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
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Ognjanović S, Macut D, Petakov M, Elezović Kovačević V, Isailović T, Bozić Antić I, Ilić D, Popović B, Bogavac T, Pekmezović T, Damjanović S. The Occurrence of Subclinical Hypercortisolism and Osteoporosis in Patients with Incidentally Discovered Unilateral and Bilateral Adrenal Tumors. J Med Biochem 2016; 35:401-409. [PMID: 28670192 PMCID: PMC5471635 DOI: 10.1515/jomb-2016-0020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/06/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Adrenal incidentalomas (AI) are clinically silent adrenal masses that are detected incidentally during imaging procedures performed for unrelated diseases. The aim of this study was to investigate the prevalence of sub-clinical hypercortisolism (SH) and associated co-morbidities in patients with unilateral AI (UAI) and bilateral AI (BAI). METHODS We evaluated 152 patients, 105 (69.1%) with UAI and 47 (30.9%) with BAI. SH was diagnosed in the presence of serum cortisol levels after 1 mg dexamethasone suppression test (DST) or after 2-day low-dose DST (LDDST) > 50 nmol/L with at least one of the following parameters: midnight serum cortisol > 208 nmol/L, 24-h urinary free cortisol > 245 nmol/24 h, or ACTH < 10 ng/L. Bone mineral density (BMD) was measured at lumbar spine (LS) and femoral neck (FN). RESULTS Age, BMI, and waist circumference were comparable, and diabetes, hypertension and dyslipidemia occurred with similar frequency in both groups. The overall prevalence of SH was 20.5% based on post-1 mg DST, and 20.0% based on post-LDDST cortisol levels, and it was more prevalent in BAI than UAI patients (31.1% vs 15.2%, respectively, p=0.026). LS BMD was lower in BAI than in UAI patients (0.96±0.14 vs 0.87±0.15, p=0.002). There were no differences in FN BMD. The prevalence of osteoporosis was higher in BAI compared to UAI patients (37.1% vs 15.9%, respectively, p=0.011). CONCLUSIONS Patients with BAI had higher prevalence of SH and osteoporosis than those with UAI. Frequency of other co-morbidities was similar. This may be due to the higher degree of autonomous cortisol secretion or different tissue-specific sensitivity to glucocorticoids.
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Affiliation(s)
- Sanja Ognjanović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Djuro Macut
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Petakov
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Tatjana Isailović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Bozić Antić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Dušan Ilić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Bojana Popović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Tamara Bogavac
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Tatjana Pekmezović
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Svetozar Damjanović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Steffensen C, Thomsen HH, Dekkers OM, Christiansen JS, Rungby J, Jørgensen JOL. Low positive predictive value of midnight salivary cortisol measurement to detect hypercortisolism in type 2 diabetes. Clin Endocrinol (Oxf) 2016; 85:202-6. [PMID: 27028214 DOI: 10.1111/cen.13071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/07/2016] [Accepted: 03/28/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypercortisolism is prevalent in type 2 diabetes (T2D), but analytical and functional uncertainties prevail. Measurement of salivary cortisol is considered an expedient screening method for hypercortisolism, but its usefulness in the context of T2D is uncertain. AIM To compare late-night salivary cortisol (LNSC) with the 1 mg overnight dexamethasone suppression test (DST), which was considered 'reference standard', in T2D. PATIENTS AND METHODS A total of 382 unselected and recently diagnosed patients with T2D underwent assessment of LNSC and DST, and the test outcome was related to age, gender, body mass index (BMI) and haemoglobin A1c levels. We used the following cut-off values: LNSC ≤ 3·6 nmol/l and DST ≤ 50 nmol/l. RESULTS The median (range) levels of LNSC and DST were 6·1 (0·3-46·2) nmol/l and 34 (11-547) nmol/l, respectively. Hypercortisolism was present in 86% based on LNSC values and 22% based on DST. LNSC, as compared to DST, had the following test characteristics: sensitivity: 85% (95% CI: 7-92%), specificity: 14% (95% CI: 10-19%), positive predictive value: 22% (95% CI: 17-27%), negative predictive value: 76% (95% CI: 63-87%), and overall accuracy: 30% (95% CI: 25-34%). LNSC and DST values were not associated with haemoglobin A1c, BMI and age in this cohort of patients with T2D. CONCLUSION The LNSC is characterized by very low specificity and poor positive predictive value as compared to the DST, resulting in an overall low accuracy. Further methodological and clinical studies are needed to substantiate the relevance of cortisol status in T2D.
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Affiliation(s)
- Charlotte Steffensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik H Thomsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Medicine, Viborg Regional Hospital, Aarhus, Denmark
| | - Olaf M Dekkers
- Department of Medicine, Section Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jens S Christiansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jørgen Rungby
- Centre for Diabetes Research, Gentofte University Hospital, Hellerup, Denmark
| | - Jens Otto L Jørgensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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Faillot S, Assie G. ENDOCRINE TUMOURS: The genomics of adrenocortical tumors. Eur J Endocrinol 2016; 174:R249-65. [PMID: 26739091 DOI: 10.1530/eje-15-1118] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/06/2016] [Indexed: 01/01/2023]
Abstract
The last decade witnessed the emergence of genomics, a set of high-throughput molecular measurements in biological samples. These pan-genomic and agnostic approaches have revolutionized the molecular biology and genetics of malignant and benign tumors. These techniques have been applied successfully to adrenocortical tumors. Exome sequencing identified new major drivers in all tumor types, including KCNJ5, ATP1A1, ATP2B3 and CACNA1D mutations in aldosterone-producing adenomas (APA), PRKACA mutations in cortisol-producing adenomas (CPA), ARMC5 mutations in primary bilateral macronodular adrenocortical hyperplasia (PBMAH) and ZNRF3 mutations in adrenocortical carcinomas (ACC). Moreover, the various genomic approaches - including exome sequencing, transcriptome, miRNome, genome and methylome - converge into a single molecular classification of adrenocortical tumors. Especially for ACC, two main molecular groups have emerged, showing major differences in outcomes. These ACC groups differ by their gene expression profiles, but also by recurrent mutations and specific DNA hypermethylation patterns in the subgroup of poor outcome. The clinical impact of these findings is just starting. The main altered signaling pathways now become therapeutic targets. The molecular groups of diseases individualize robust subtypes within diseases such as APA, CPA, PBMAH and ACC. A revised nosology of adrenocortical tumors should impact the clinical research. Obvious consequences also include genetic counseling for the new genetic diseases such as ARMC5 mutations in PBMAH, and a better prognostication of ACC based on targeted measurements of a few discriminant molecular alterations. Identifying the main molecular groups of adrenocortical tumors by extensively gathering the molecular variations is a significant step forward towards precision medicine.
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Affiliation(s)
- Simon Faillot
- Institut CochinINSERM U1016, CNRS 8104, Paris Descartes University, Paris, FranceSIRIC (Site de Recherche Intégré sur le Cancer) CARPEM (CAncer Research for PErsonalized Medicine)Assistance Publique Hôpitaux de Paris, Paris, FranceDepartment of EndocrinologyReference Center for Rare Adrenal Diseases, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014 Paris, France Institut CochinINSERM U1016, CNRS 8104, Paris Descartes University, Paris, FranceSIRIC (Site de Recherche Intégré sur le Cancer) CARPEM (CAncer Research for PErsonalized Medicine)Assistance Publique Hôpitaux de Paris, Paris, FranceDepartment of EndocrinologyReference Center for Rare Adrenal Diseases, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014 Paris, France
| | - Guillaume Assie
- Institut CochinINSERM U1016, CNRS 8104, Paris Descartes University, Paris, FranceSIRIC (Site de Recherche Intégré sur le Cancer) CARPEM (CAncer Research for PErsonalized Medicine)Assistance Publique Hôpitaux de Paris, Paris, FranceDepartment of EndocrinologyReference Center for Rare Adrenal Diseases, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014 Paris, France Institut CochinINSERM U1016, CNRS 8104, Paris Descartes University, Paris, FranceSIRIC (Site de Recherche Intégré sur le Cancer) CARPEM (CAncer Research for PErsonalized Medicine)Assistance Publique Hôpitaux de Paris, Paris, FranceDepartment of EndocrinologyReference Center for Rare Adrenal Diseases, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014 Paris, France
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50
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Stigliano A, Chiodini I, Giordano R, Faggiano A, Canu L, Della Casa S, Loli P, Luconi M, Mantero F, Terzolo M. Management of adrenocortical carcinoma: a consensus statement of the Italian Society of Endocrinology (SIE). J Endocrinol Invest 2016; 39:103-21. [PMID: 26165270 DOI: 10.1007/s40618-015-0349-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/23/2015] [Indexed: 01/10/2023]
Affiliation(s)
- A Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - I Chiodini
- Endocrinology and Metabolic Disease Unit, IRCCS Foundation Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - R Giordano
- Department of Clinical and Biological Science, University of Turin, Turin, Italy
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - A Faggiano
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - L Canu
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - S Della Casa
- Endocrinology, Department of Internal Medicine, Catholic University of Rome, Rome, Italy
| | - P Loli
- Endocrine Unit, Niguarda Cà Granda Hospital, Milan, Italy
| | - M Luconi
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - F Mantero
- Endocrinology Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - M Terzolo
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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