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Mark IT, Welker K, Erickson D, Johnson DR, Bathla G, Messina S, Farnsworth PJ, Van Gompel J. 7T MRI for Cushing Disease: A Single-Institution Experience and Literature Review. AJNR Am J Neuroradiol 2024; 45:971-976. [PMID: 38365424 DOI: 10.3174/ajnr.a8209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/13/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND AND PURPOSE Cushing disease is typically caused by a pituitary adenoma that frequently is small and challenging to detect on conventional MR imaging. High-field-strength 7T MR imaging can leverage increased SNR and contrast-to-noise ratios compared with lower-field-strength MR imaging to help identify small pituitary lesions. We aimed to describe our institutional experience with 7T MR imaging in patients with Cushing disease and perform a review of the literature. MATERIALS AND METHODS We performed a retrospective analysis of 7T MR imaging findings in patients with pathology-proved Cushing disease from a single institution, followed by a review of the literature on 7T MR imaging for Cushing disease. RESULTS Our institutional experience identified Cushing adenomas in 10/13 (76.9%) patients on 7T; however, only 5/13 (38.5%) lesions were discrete. Overall, the imaging protocols used were heterogeneous in terms of contrast dose as well as type of postcontrast T1-weighted sequences (dynamic, 2D versus 3D, and type of 3D sequence). From our institutional data, specific postgadolinium T1-weighted sequences were helpful in identifying a surgical lesion as follows: dynamic contrast-enhanced, 2/7 (28.6%); 2D FSE, 4/8 (50%); 3D sampling perfection with application-optimized contrasts by using different flip angle evolution (SPACE), 5/6 (83.3%); and 3D MPRAGE, 8/11 (72.7%). The literature review identified Cushing adenomas in 31/33 (93.9%) patients on 7T. CONCLUSIONS 7T MR imaging for pituitary lesion localization in Cushing disease is a new technique with imaging protocols that vary widely. Further comparative research is needed to identify the optimal imaging technique as well as assess the benefit of 7T over lower-field-strength MR imaging.
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Affiliation(s)
- Ian T Mark
- From the Department of Radiology (I.T.M., K.W., D.R.J., G.B., S.M., P.J.F.), Mayo Clinic, Rochester, Minnesota
| | - Kirk Welker
- From the Department of Radiology (I.T.M., K.W., D.R.J., G.B., S.M., P.J.F.), Mayo Clinic, Rochester, Minnesota
| | - Dana Erickson
- Department of Endocrinology (D.E.), Mayo Clinic, Rochester, Minnesota
| | - Derek R Johnson
- From the Department of Radiology (I.T.M., K.W., D.R.J., G.B., S.M., P.J.F.), Mayo Clinic, Rochester, Minnesota
| | - Girish Bathla
- From the Department of Radiology (I.T.M., K.W., D.R.J., G.B., S.M., P.J.F.), Mayo Clinic, Rochester, Minnesota
| | - Steven Messina
- From the Department of Radiology (I.T.M., K.W., D.R.J., G.B., S.M., P.J.F.), Mayo Clinic, Rochester, Minnesota
| | - Paul J Farnsworth
- From the Department of Radiology (I.T.M., K.W., D.R.J., G.B., S.M., P.J.F.), Mayo Clinic, Rochester, Minnesota
| | - Jamie Van Gompel
- Department of Neurosurgery (J.V.G.), Mayo Clinic, Rochester, Minnesota
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Colao A, Scaroni C, Mezösi E, Saiegh L, Puig-Domingo M, Marques P, Deutschbein T. Diagnostic work-up of ACTH-dependent Cushing's syndrome in the context of CRH shortage: recommendation of a task force from the European Society of Endocrinology. Eur J Endocrinol 2024; 191:R32-R35. [PMID: 39005054 DOI: 10.1093/ejendo/lvae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Emese Mezösi
- Ist Department of Internal Medicine, Clinical Center, University Medical School of Pecs, Pecs, Hungary
| | - Leonard Saiegh
- Department of Endocrinology, Bnai Zion Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Manel Puig-Domingo
- Department of Endocrinology & Nutrition CIBERER Group 747 Germans Trias Research Institute and University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Pedro Marques
- Pituitary Tumor Unit, Endocrinology Department, Hospital CUF Descobertas, Lisbon, Portugal
- Faculdade de Medicina, Universidade Católica Portuguesa, Rio de Mouro, Lisbon, Portugal
- Scientific Programmes Department, European Society of Endocrinology (ESE), Bristol, United Kingdom
| | - 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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Constantinescu SM, Duprez T, Bonneville JF, Maiter D. How often should we perform magnetic resonance imaging (MRI) for the follow-up of pituitary adenoma? ANNALES D'ENDOCRINOLOGIE 2024; 85:300-307. [PMID: 38604408 DOI: 10.1016/j.ando.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/14/2024] [Accepted: 03/23/2024] [Indexed: 04/13/2024]
Abstract
Magnetic resonance imaging (MRI) is the examination of choice for diagnosing and monitoring pituitary adenoma (also known as pituitary neuroendocrine tumor or PitNET), whether treated or not. However, repeating the examination too often (and sometimes unnecessarily) is costly, and worrying data on tissue accumulation (brain, bone, etc.) of gadolinium atoms dissociated from their carrier molecule (chelator) have led European authorities to ban contrast agents based on linear chelators of gadolinium, which are particularly susceptible to rapid dissociation, in favor of chemically more stable macrocyclic chelators. It is therefore important to determine the optimal frequency for pituitary MRI monitoring in order to safely assess the natural history or therapeutic response of pituitary adenomas. The aim of this article is to summarize the most recent data on optimal follow-up intervals depending on the type, size and location of the pituitary tumor and the clinical situation in general, in order to generate monitoring algorithms to guide clinicians.
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Affiliation(s)
| | - Thierry Duprez
- Department of Neuroradiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Dominique Maiter
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Mark IT, Van Gompel J, Bancos I, Nagelschneider AA, Johnson DR, Bathla G, Madhavan AA, Weber NM, Yu L. Back to the Future: Dynamic Contrast-Enhanced Photon-Counting Detector CT for the Detection of Pituitary Adenoma in Cushing Disease. AJNR Am J Neuroradiol 2024; 45:743-746. [PMID: 38290737 PMCID: PMC11288598 DOI: 10.3174/ajnr.a8171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/01/2024]
Abstract
Historically, MR imaging has been unable to detect a pituitary adenoma in up to one-half of patients with Cushing disease. This issue is problematic because the standard-of-care treatment is surgical resection, and its success is correlated with finding the tumor on imaging. Photon-counting detector CT is a recent advancement that has multiple benefits over conventional energy-integrating detector CT. We present the use of dynamic contrast-enhanced imaging using photon-counting detector CT for the detection of pituitary adenomas in patients with Cushing disease.
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Affiliation(s)
- Ian T Mark
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Jamie Van Gompel
- Department of Neurosurgery (J.V.G.), Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Department of Endocrinology (I.B.), Mayo Clinic, Rochester, Minnesota
| | - Alex A Nagelschneider
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Derek R Johnson
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Girish Bathla
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Nikkole M Weber
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Lifeng Yu
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
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Chen Y, Cai S, Li X, Zhang J, Wei L, Wang S. MRI 3D SPACE T2WI for Pituitary Adenoma Cavernous Sinus Invasion Diagnosis. World Neurosurg 2024; 185:e1257-e1267. [PMID: 38514027 DOI: 10.1016/j.wneu.2024.03.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE This study aims to assess the utility of magnetic resonance imaging (MRI) 3D SPACE T2-weighted imaging (T2WI) sequences in evaluating cavernous sinus invasion by pituitary adenomas. METHODS Data were collected from patients who underwent continuous pituitary MRIexaminations at the Medical Imaging Center of our hospital from October 2019 to February 2021. Eligible cases were evaluated for sagittal and axial T1WI sequences, coronal 3D SPACE T2WI sequences, and sagittal and coronal enhanced T1-weighted imaging (T1WI) sequences using the INFINITT PACS workstation. The Wilcoxon signed-rank test for paired samples and the Mann-Whitney U test for 2 independent samples were used to statistically analyze differences in image quality scores among various groups. In addition, the sensitivity, specificity, positive predictive value, and negative predictive value of each observation index were compared with intraoperative results. RESULTS 3D SPACE T2WI showed superior cavernous sinus imaging quality compared with contrast enhanced T1WI and T2WI plain scans (P < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 90.0%, 55.60%, and 100.0%, respectively. The accuracy for pituitary adenoma invasiveness diagnosis based on cavernous sinus medial wall integrity was 94.40%. CONCLUSIONS The imaging quality of the medial wall of the cavernous sinus on the 3D SPACE T2WI plain scan sequence surpassed that of contrast enhanced T1WI TSE-enhanced scans and T2WI TSE plain scans. The continuous observation of the medial wall of the cavernous sinus using this sequence holds great diagnostic value for assessing cavernous sinus invasion by pituitary adenomas. This strategy is more reliable than traditional MRI observation indicators.
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Affiliation(s)
- Yuyang Chen
- Neurosurgery, Fujian Medical University Fuzhou Clinical Medical College (900th Hospital), Fuzhou, China
| | - Shengyu Cai
- Neurosurgery, Fujian Medical University Fuzhou Clinical Medical College (900th Hospital), Fuzhou, China; Neurosurgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiu Li
- Neurosurgery, Fujian Medical University Fuzhou Clinical Medical College (900th Hospital), Fuzhou, China
| | - Jianhe Zhang
- Neurosurgery, Fujian Medical University Fuzhou Clinical Medical College (900th Hospital), Fuzhou, China
| | - Liangfeng Wei
- Neurosurgery, Fujian Medical University Fuzhou Clinical Medical College (900th Hospital), Fuzhou, China
| | - Shousen Wang
- Neurosurgery, Fujian Medical University Fuzhou Clinical Medical College (900th Hospital), Fuzhou, China.
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Choi US, Sung YW, Ogawa S. deepPGSegNet: MRI-based pituitary gland segmentation using deep learning. Front Endocrinol (Lausanne) 2024; 15:1338743. [PMID: 38370353 PMCID: PMC10869468 DOI: 10.3389/fendo.2024.1338743] [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: 11/15/2023] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Introduction In clinical research on pituitary disorders, pituitary gland (PG) segmentation plays a pivotal role, which impacts the diagnosis and treatment of conditions such as endocrine dysfunctions and visual impairments. Manual segmentation, which is the traditional method, is tedious and susceptible to inter-observer differences. Thus, this study introduces an automated solution, utilizing deep learning, for PG segmentation from magnetic resonance imaging (MRI). Methods A total of 153 university students were enrolled, and their MRI images were used to build a training dataset and ground truth data through manual segmentation of the PGs. A model was trained employing data augmentation and a three-dimensional U-Net architecture with a five-fold cross-validation. A predefined field of view was applied to highlight the PG region to optimize memory usage. The model's performance was tested on an independent dataset. The model's performance was tested on an independent dataset for evaluating accuracy, precision, recall, and an F1 score. Results and discussion The model achieved a training accuracy, precision, recall, and an F1 score of 92.7%, 0.87, 0.91, and 0.89, respectively. Moreover, the study explored the relationship between PG morphology and age using the model. The results indicated a significant association between PG volume and midsagittal area with age. These findings suggest that a precise volumetric PG analysis through an automated segmentation can greatly enhance diagnostic accuracy and surveillance of pituitary disorders.
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Affiliation(s)
- Uk-Su Choi
- Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Republic of Korea
| | - Yul-Wan Sung
- Kansei Fukushi Research Institute, Tohoku Fukushi University, Sendai, Japan
| | - Seiji Ogawa
- Kansei Fukushi Research Institute, Tohoku Fukushi University, Sendai, Japan
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Gadelha M, Gatto F, Wildemberg LE, Fleseriu M. Cushing's syndrome. Lancet 2023; 402:2237-2252. [PMID: 37984386 DOI: 10.1016/s0140-6736(23)01961-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
Endogenous Cushing's syndrome results from excess glucocorticoid secretion, which leads to a myriad of clinical manifestations, comorbidities, and increased mortality despite treatment. Molecular mechanisms and genetic alterations associated with different causes of Cushing's syndrome have been described in the last decade. Imaging modalities and biochemical testing have evolved; however, both the diagnosis and management of Cushing's syndrome remain challenging. Surgery is the preferred treatment for all causes, but medical therapy has markedly advanced, with new drug options becoming available. Nevertheless, several comorbidities remain even after patient remission, which can affect quality of life. Accurate and timely diagnosis and treatment are essential for mitigating chronic complications of excess glucocorticoids and improving patient quality of life. In this Seminar, we aim to update several important aspects of diagnosis, complications, and treatment of endogenous Cushing's syndrome of all causes.
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Affiliation(s)
- Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Molecular Genetics Laboratory, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
| | - Federico Gatto
- Endocrinology Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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Espinosa-Cardenas E, Garcia-Saenz M, de Los Monteros-Sanchez ALE, Sosa-Eroza E. Non-Invasive Biochemical Testing of ACTH-dependent Cushing's Disease: Do We Still Need Petrosal Sinus Sampling? Arch Med Res 2023; 54:102882. [PMID: 37749028 DOI: 10.1016/j.arcmed.2023.102882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023]
Abstract
Differentiating between a pituitary from an ectopic source of ACTH could be a real one of the major challenges of clinical endocrinology. The Bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold standard for identifying the source of ACTH; however, is not available worldwide. After the SARS-CoV-2 pandemic, algorithms that include biochemical and imaging tests have gained importance as an alternative to BIPSS. This review summarizes the drawbacks in the differential diagnosis of ACTH-dependent Cushing; the evolution of diagnostic tests, and the evidence that exists on their performance. As well as a comparison between the advantages and disadvantages of invasive and non-invasive tests.
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Affiliation(s)
- Etual Espinosa-Cardenas
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Manuel Garcia-Saenz
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Ernesto Sosa-Eroza
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Ugga L, Franca RA, Scaravilli A, Solari D, Cocozza S, Tortora F, Cavallo LM, De Caro MDB, Elefante A. Neoplasms and tumor-like lesions of the sellar region: imaging findings with correlation to pathology and 2021 WHO classification. Neuroradiology 2023; 65:675-699. [PMID: 36799985 PMCID: PMC10033642 DOI: 10.1007/s00234-023-03120-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/15/2023] [Indexed: 02/18/2023]
Abstract
The sellar region represents a complex anatomical area, composed of multiple structures of different embryological derivation, including the skull base and the pituitary gland, along with vascular, nervous, and meningeal structures. Masses arising in this region include benign and malignant lesions arising from the pituitary gland itself, but also from vestigial embryological residues or surrounding tissues, that may require different therapeutic approaches. While assessing sellar region masses, the combination of clinical presentation and imaging features is fundamental to define hypotheses about their nature. MR represents the imaging modality of choice, providing information about the site of the lesion, its imaging features, and relation with adjacent structures, while CT is useful to confirm the presence of lesion calcifications or to reveal tumor invasion of bony structures. The aim of this pictorial review is to provide an overview of the common neoplasms and tumor-like conditions of the sellar region, according to the 2021 WHO Classification of Tumors of the Central Nervous System (fifth edition), with an emphasis on the radiologic-pathologic correlation. After a brief introduction on the anatomy of this region and the imaging and pathological techniques currently used, the most relevant MRI characteristics, clinical findings, and pathological data, including histologic and molecular features, will be shown and discussed, with the aim of facilitating an appropriate differential diagnosis among these entities.
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Affiliation(s)
- Lorenzo Ugga
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Raduan Ahmed Franca
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Alessandra Scaravilli
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy.
| | - Domenico Solari
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Fabio Tortora
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Luigi Maria Cavallo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | | | - Andrea Elefante
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
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Bashari WA, Gillett D, MacFarlane J, Powlson AS, Kolias AG, Mannion R, Scoffings DJ, Mendichovszky IA, Jones J, Cheow HK, Koulouri O, Gurnell M. Modern imaging in Cushing's disease. Pituitary 2022; 25:709-712. [PMID: 35666391 PMCID: PMC9587975 DOI: 10.1007/s11102-022-01236-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 01/18/2023]
Abstract
Management of Cushing's disease is informed by dedicated imaging of the sella and parasellar regions. Although magnetic resonance imaging (MRI) remains the investigation of choice, a significant proportion (30-50%) of corticotroph tumours are so small as to render MRI indeterminate or negative when using standard clinical sequences. In this context, alternative MR protocols [e.g. 3D gradient (recalled) echo, with acquisition of volumetric data] may allow detection of tumors that have not been previously visualized. The use of hybrid molecular imaging (e.g. 11C-methionine positron emission tomography coregistered with volumetric MRI) has also been proposed as an additional modality for localizing microadenomas.
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Affiliation(s)
- W A Bashari
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D Gillett
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - J MacFarlane
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - A S Powlson
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - A G Kolias
- Department of Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - R Mannion
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D J Scoffings
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - I A Mendichovszky
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - J Jones
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - H K Cheow
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - O Koulouri
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - M Gurnell
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
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Braun LT, Vogel F, Reincke M. Long-term morbidity and mortality in patients with Cushing's syndrome. J Neuroendocrinol 2022; 34:e13113. [PMID: 35312199 DOI: 10.1111/jne.13113] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 11/28/2022]
Abstract
Increased multisystem morbidity and mortality in patients with Cushing's syndrome comprise clinical problems and challenges, both at the time of diagnosis and in remission. Relevant comorbidities and clinical problems include hypertension, diabetes, overweight, myopathy and a high risk for acute complications such as infections and venous thrombembolism. Although there are therapy recommendations for most of these comorbidities, there is a lack of large, prospective studies to confirm and optimise them. Mortality is especially high during active disease and within the first year after diagnosis, as a result of cardiovascular events, infections and suicide. All in all, interdisciplinary therapy management is important for reducing morbidity and mortality over the long-term.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
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12
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Honegger J, Nasi-Kordhishti I. Surgery and perioperative management of patients with Cushing's disease. J Neuroendocrinol 2022; 34:e13177. [PMID: 35980172 DOI: 10.1111/jne.13177] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/09/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery (TSS) is the initial treatment modality of first choice in Cushing's disease (CD). With microscopic TSS and endoscopic TSS, two operative techniques with equally favourable remission rates and operative morbidity are available. On average, remission is achieved with primary TSS in 80% of patients with microadenomas and 60% of patients with macroadenomas. The current literature indicates that remission rates in repeat TSS for microadenomas can also exceed 70%. Experience with TSS in CD plays an important role in the success rate and centralization in Pituitary Centres of Excellence has been proposed. Microadenoma stage, imaging-visible adenoma, confirmation of ACTH-positive adenoma on histopathology and noninvasiveness are positive predictors for postoperative remission. In postoperative management, a steroid-sparing protocol with early postoperative assessment of remission status is recommended. Convincing evidence suggests that prolonged postoperative prophylactic antithrombotic measures can significantly reduce the risk of postoperative thromboembolic events in CD. Prevention or successful treatment of cortisol withdrawal syndrome remains an unsolved issue that should be a focus of future research. The further development and broad availability of functional imaging hold promise for improved preoperative detection of microadenomas. Intraoperative identification of microadenomas by specific fluorescent targeting could be a promising future avenue for the treatment of patients with negative imaging.
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Affiliation(s)
- Juergen Honegger
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
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13
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Valassi E. Clinical presentation and etiology of Cushing's syndrome: Data from ERCUSYN. J Neuroendocrinol 2022; 34:e13114. [PMID: 35979717 DOI: 10.1111/jne.13114] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
This review presents the data on clinical presentation at diagnosis in 1564 patients included in the European Registry on Cushing's syndrome (ERCUSYN), of whom 1045 (67%) had pituitary-dependent Cushing's syndrome (CS) (PIT-CS), 385 (25%) had adrenal dependent CS (ADR-CS) and 89 (5%) had ectopic adrenocorticotropic hormone syndrome (ECT-CS). The most frequent symptoms in the overall series were weight gain (83%), hypertension (79%), skin alterations (76%) and myopathy (70%). Diabetes mellitus was present in 32% and depression in 35% of patients. Skin alterations, menstrual irregularities and reduced libido were more prevalent in PIT-CS patients compared to ADR-CS patients, whereas patients with ECT-CS more frequently had diabetes mellitus, myopathy, hirsutism and vertebral fractures compared to the other etiologies, consistent with a more severe clinical scenario. Reduced libido and bone fractures were more prevalent in men compared to women. Quality of life was poor at diagnosis, irrespective of the etiology of CS, and also associated with the presence of depression at baseline. A delay of 2 years between the onset of symptoms and diagnosis was also observed, with a high number of specialists consulted, who often missed the correct diagnosis. To develop strategies aimed at shortening the time elapsed to diagnosis, it is important to rapidly start treatment and reduce the burden of the disease on patient psychophysical health and longevity.
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Affiliation(s)
- Elena Valassi
- Endocrinology Department, Hospital Germans Trias i Pujol, Badalona (Barcelona), Spain
- Universitat Internacional de Catalunya (UIC), Barcelona, Spain
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14
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Hamblin R, Coulden A, Fountas A, Karavitaki N. The diagnosis and management of Cushing's syndrome in pregnancy. J Neuroendocrinol 2022; 34:e13118. [PMID: 35491087 PMCID: PMC9541401 DOI: 10.1111/jne.13118] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 11/28/2022]
Abstract
Endogenous Cushing's syndrome (CS) is rarely encountered during pregnancy. Clinical and biochemical changes in healthy pregnancy overlap with those seen in pregnancy complicated by CS; the diagnosis is therefore challenging and can be delayed. During normal gestation, adrenocorticotrophic hormone, corticotrophin-releasing hormone, cortisol, and urinary free cortisol levels rise. Dexamethasone administration fails to fully suppress cortisol in pregnant women without CS. Localisation may be hindered by non-suppressed adrenocorticotrophic hormone levels in a large proportion of those with adrenal CS; smaller corticotroph adenomas may go undetected as a result of a lack of contrast administration or the presence of pituitary hyperplasia; and inferior petrosal sinus sampling is not recommended given the risk of radiation and thrombosis. Yet, diagnosis is essential; active disease is associated with multiple insults to both maternal and foetal health, and those cured may normalise the risk of maternal-foetal complications. The published literature consists mostly of case reports or small case series affected by publication bias, heterogeneous definitions of maternal or foetal outcomes or lack of detail on severity of hypercortisolism. Consequently, conclusive recommendations, or a standardised management approach for all, cannot be made. Management is highly individualised: the decision for surgery, medical control of hypercortisolism or adoption of a conservative approach is dependent on the timing of diagnosis (respective to stage of gestation), the ability to localise the tumour, severity of CS, pre-existing maternal comorbidity, and, ultimately, patient choice. Close communication is a necessity with the patient placed at the centre of all decisions, with risks, benefits, and uncertainties around any investigation and management carefully discussed. Care should be delivered by an experienced, multidisciplinary team, with the resources and expertise available to manage such a rare and challenging condition during pregnancy.
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Affiliation(s)
- Ross Hamblin
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Amy Coulden
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
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15
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Lasolle H, Vasiljevic A, Jouanneau E, Ilie MD, Raverot G. Aggressive corticotroph tumors and carcinomas. J Neuroendocrinol 2022; 34:e13169. [PMID: 35979732 PMCID: PMC9542524 DOI: 10.1111/jne.13169] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/27/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
Pituitary tumors are generally benign, although in rare cases aggressive pituitary tumors (APTs) and carcinomas present important diagnostic and therapeutic challenges and are associated with a high mortality rate. Almost half of these APTs and carcinomas are corticotroph tumors, suggesting a specific prognosis. Clinical, pathological and molecular prognostic markers are limited and do not allow early management of these tumors. Temozolomide remains the first-line treatment once a diagnosis of aggressive pituitary tumor or carcinoma has been made. Novel alternative treatments exist, including immune checkpoint inhibitors, which can be used in the case of temozolomide treatment failure. The aim of this review is to present the clinical, pathological and molecular characteristics of aggressive corticotroph tumors and carcinomas, and to describe the results obtained with currently available treatments.
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Affiliation(s)
- Hélène Lasolle
- Inserm U1052, CNRS UMR5286Cancer Research Center of LyonLyonFrance
- Lyon 1 UniversityVilleurbanneFrance
- Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO“Groupement Hospitalier Est” Hospices Civils de LyonBronFrance
| | - Alexandre Vasiljevic
- Inserm U1052, CNRS UMR5286Cancer Research Center of LyonLyonFrance
- Lyon 1 UniversityVilleurbanneFrance
- Pathology Department, Reference Center for Rare Pituitary Diseases HYPO“Groupement Hospitalier Est” Hospices Civils de LyonBronFrance
| | - Emmanuel Jouanneau
- Inserm U1052, CNRS UMR5286Cancer Research Center of LyonLyonFrance
- Lyon 1 UniversityVilleurbanneFrance
- Neurosurgery Department, Reference Center for Rare Pituitary Diseases HYPO“Groupement Hospitalier Est” Hospices Civils de LyonBronFrance
| | - Mirela Diana Ilie
- Inserm U1052, CNRS UMR5286Cancer Research Center of LyonLyonFrance
- Lyon 1 UniversityVilleurbanneFrance
- Endocrinology Department“C.I. Parhon” National Institute of EndocrinologyBucharestRomania
| | - Gérald Raverot
- Inserm U1052, CNRS UMR5286Cancer Research Center of LyonLyonFrance
- Lyon 1 UniversityVilleurbanneFrance
- Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO“Groupement Hospitalier Est” Hospices Civils de LyonBronFrance
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16
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Losa M, Albano L, Bailo M, Barzaghi LR, Mortini P. Role of radiosurgery in the treatment of Cushing's disease. J Neuroendocrinol 2022; 34:e13134. [PMID: 35980263 DOI: 10.1111/jne.13134] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/21/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
Abstract
Radiotherapy is a useful adjuvant treatment for patients with Cushing's disease that is not cured by surgery. In particular, Gamma Knife radiosurgery (GKRS) has been increasingly used worldwide as the preferred radiation technique in patients with persistent or recurrent Cushing's disease. The most widely accepted criterion for hormonal remission after GKRS is normalization of urinary free cortisol (UFC) levels. When a clear biological target is not identified, irradiation of the whole pituitary gland can be considered. The 5-year probability of remission is 65%-75%. Normalization of hypercortisolism usually occurs within 3 years from GKRS treatment and control of tumor growth is optimal, approaching more than 90%. No clear predictor of a favorable outcome has emerged up to now, except for the experience of the treating team. In the largest series, development of partial or complete hypopituitarism occurred between 15% and 36%. Severe side effects of GKRS, such as optic neuropathy and oculomotor palsy, are uncommon but have been documented in patients previously exposed to radiation. Recurrence of disease has been reported in as high as 16%-18% of the patients who achieved normalization of UFC levels in the two largest series, whereas smaller series did not describe late failure of GKRS. The reason for this discrepancy is unclear, as is the relationship between hormonal and tumoral recurrence. Another unresolved issue is whether treatment with adrenal blocking drugs can jeopardize the results of GKRS. GKRS is an effective second-line treatment in patients with Cushing's disease not cured by surgery. Hypopituitarism is the most frequent side effect of GKRS, whereas severe neurologic complications are uncommon in radiation-naïve patients.
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Affiliation(s)
- Marco Losa
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | - Luigi Albano
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | - Michele Bailo
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | | | - Pietro Mortini
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
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17
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Balasko A, Zibar Tomsic K, Kastelan D, Dusek T. Hypothalamic-pituitary-adrenal axis recovery after treatment of Cushing's syndrome. J Neuroendocrinol 2022; 34:e13172. [PMID: 35726348 DOI: 10.1111/jne.13172] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
After successful treatment for Cushing's syndrome (CS), secondary adrenal insufficiency develops as a result of the prior suppression of the hypothalamic-pituitary-adrenal (HPA) axis by excess cortisol in the body. Until the recovery of the HPA axis, glucocorticoid replacement therapy is required to enable normal functioning of the body and prevent adrenal crisis. Significant variation in the median time of recovery of the HPA axis is found in various cohorts of CS patients ranging from several weeks to years. Despite the use of physiological glucocorticoid replacement, after cure for CS, patients often experience symptoms of glucocorticoid withdrawal syndrome (GWS). The optimal glucocorticoid regimen to reduce GWS needs to be established and requires an individualized approach aiming to avoid overtreatment at one side and minimize the risk of undertreatment and possible adrenal crisis and GWS on the other side.
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Affiliation(s)
- Annemarie Balasko
- Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Karin Zibar Tomsic
- Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Darko Kastelan
- School of Medicine University of Zagreb, Zagreb, Croatia
| | - Tina Dusek
- Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine University of Zagreb, Zagreb, Croatia
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18
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Drouin J. The corticotroph cells from early development to tumorigenesis. J Neuroendocrinol 2022; 34:e13147. [PMID: 35524583 DOI: 10.1111/jne.13147] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/06/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
Abstract
During development, highly specialized differentiated cells, such as pituitary secretory cells, acquire their identity and properties through a series of specification events exerted by transcription factors to implement a unique gene expression program and epigenomic state. The investigation of these developmental processes informs us on the unique features of a cell lineage, both to explain these features and also to outline where these processes may fail and cause disease. This review summarizes present knowledge on the developmental origin of pituitary corticotroph and melanotroph cells and on the underlying molecular mechanisms. At the onset, comparison of gene expression programs active in pituitary progenitors compared to those active in differentiated corticotrophs or melanotrophs indicated dramatic differences in the control of, for example, the cell cycle. Tpit is the transcription factor that determines terminal differentiation of pro-opiomelanocortin (POMC) lineages, both corticotrophs and melanotrophs, and its action involves this switch in cell cycle control in parallel with activation of cell-specific gene expression. There is thus far more to making a corticotroph cell than just activating transcription of the POMC gene. Indeed, Tpit also controls implementation of mechanisms for enhanced protein translation capacity and development of extensive secretory organelles. The corticotroph cell identity also includes mechanisms responsible for homotypic cell-cell interactions between corticotrophs and for privileged heterotypic cell interactions with pituitary cells of other lineages. The review also summarizes current knowledge on how a pioneer transcription factor, Pax7, remodels the epigenome such that the same determination transcription factor, Tpit, will implement the melanotroph program of gene expression. Finally, this canvas of regulatory mechanisms implementing POMC lineage identities constitutes the background to understand alterations that characterize corticotroph adenomas of Cushing's disease patients. The integration of all these data into a unified scheme will likely yield a scheme to globally understand pathogenic mechanisms in Cushing's disease.
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Affiliation(s)
- Jacques Drouin
- Institut de recherches cliniques de Montréal, Laboratoire de génétique moléculaire, Montréal, Québec, Canada
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19
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Clayton RN. Cardiovascular complications of Cushings syndrome: Impact on morbidity and mortality. J Neuroendocrinol 2022; 34:e13175. [PMID: 35764311 PMCID: PMC9541180 DOI: 10.1111/jne.13175] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Richard N. Clayton
- PlymouthUK (no current academic affiliation, formerly University of Keele, Stoke on Trent, UK)
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20
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Guignat L, Bertherat J. Long-term follow-up and predictors of recurrence of Cushing's disease. J Neuroendocrinol 2022; 34:e13186. [PMID: 35979714 DOI: 10.1111/jne.13186] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery is the first-line treatment for Cushing's disease to selectively remove the tumor. The rate of postoperative remission is estimated around 70%-80% in expert centers. However, the long-term remission rate is lower because of recurrence during follow-up that can be observed in 15% to 25% of the patients depending on the studies and duration of follow-up. There is no significant predictive factor of recurrence before surgery, but postoperative corticotroph insufficiency and its duration has been found to be a protective factor for recurrence in many studies. The persistence of a positive response to desmopressin after surgery is associated with a higher rate of recurrence. Long term monitoring for recurrence with annual clinical and hormonal investigations after the hypothalamic-pituitary-adrenal axis postoperative recovery is advised. The biological tests used for the diagnosis of Cushing's syndrome (24 h-urinary-free cortisol [UFC], late-night salivary or serum cortisol, 1 mg dexamethasone suppression test) can be used to screen for recurrence. Several studies report that increased late night cortisol and alterations of dynamic testing can be observed before the increased 24 h-UFC. For this reason it is suggested that late-night salivary cortisol would be a very sensitive tool to diagnose recurrence, pending the realization of several assays in case of borderline or discrepant result. This review will summarize the knowledge about recurrence of Cushing's disease after pituitary surgery and the current recommendations for its monitoring and diagnosis.
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Affiliation(s)
- Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
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21
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Hayes AR, Grossman AB. Distinguishing Cushing's disease from the ectopic ACTH syndrome: Needles in a haystack or hiding in plain sight? J Neuroendocrinol 2022; 34:e13137. [PMID: 35980277 PMCID: PMC9542389 DOI: 10.1111/jne.13137] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/02/2022] [Accepted: 03/25/2022] [Indexed: 11/29/2022]
Abstract
In the context of ACTH-dependent Cushing's syndrome, ectopic ACTH secretion from a neuroendocrine tumour is not uncommon, and needs to be carefully differentiated from pituitary-dependent Cushing's syndrome, Cushing's disease, in order to optimise therapy. Some cases may be quite obvious, while in others the diagnosis may be difficult to confirm and the source of ACTH problematic, as many clinical and biochemical tests may overlap with Cushing's disease. Imaging is essential, but needs to be interpreted in the light of both anatomical as well as functional imaging modalities. In this review we summarise some of the main diagnostic problems, and emphasise the multimodal and interdisciplinary nature of the diagnostic pathways.
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Affiliation(s)
- Aimee R. Hayes
- Neuroendocrine Tumour Unit, ENETS Centre of ExcellenceRoyal Free HospitalLondonUK
| | - Ashley B. Grossman
- Neuroendocrine Tumour Unit, ENETS Centre of ExcellenceRoyal Free HospitalLondonUK
- Centre for EndocrinologyBarts and the London School of MedicineLondonUK
- Green Templeton CollegeUniversity of OxfordOxfordUK
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22
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Salehidoost R, Korbonits M. Glucose and lipid metabolism abnormalities in Cushing's syndrome. J Neuroendocrinol 2022; 34:e13143. [PMID: 35980242 DOI: 10.1111/jne.13143] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022]
Abstract
Prolonged excess of glucocorticoids (GCs) has adverse systemic effects leading to significant morbidities and an increase in mortality. Metabolic alterations associated with the high level of the GCs are key risk factors for the poor outcome. These include GCs causing excess gluconeogenesis via upregulation of key enzymes in the liver, a reduction of insulin sensitivity in skeletal muscle, liver and adipose tissue by inhibiting the insulin receptor signalling pathway, and inhibition of insulin secretion in beta cells leading to dysregulated glucose metabolism. In addition, chronic GC exposure leads to an increase in visceral adipose tissue, as well as an increase in lipolysis resulting in higher circulating free fatty acid levels and in ectopic fat deposition. Remission of hypercortisolism improves these metabolic changes, but very often does not result in full resolution of the abnormalities. Therefore, long-term monitoring of metabolic variables is needed even after the resolution of the excess GC levels.
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Affiliation(s)
- Rezvan Salehidoost
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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23
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Castinetti F. Medical management of Cushing's disease: When and how? J Neuroendocrinol 2022; 34:e13120. [PMID: 35348261 DOI: 10.1111/jne.13120] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 02/20/2022] [Accepted: 03/05/2022] [Indexed: 01/07/2023]
Abstract
Transsphenoidal surgery is the first-line treatment of Cushing's disease. However, medical treatment can be given in a high proportion of patients with this rare condition. This is especially the case in severe hypercortisolism for which medical treatment will be given for a short period of time to prepare the patient for surgery, or on a long-term basis after failed transsphenoidal surgery, or when waiting for the maximal beneficial effect of radiation techniques. These different situations all require that hypercortisolism be perfectly controlled. Severe hypercortisolism is frequently treated by a block and replace approach during which a substitutive treatment is given after the induction of adrenal insufficiency. Mild hypercortisolism, the most frequent situation, is usually treated with a titration approach with a progressive dose increase. This approach requires certainty of eucortisolism because patients may be treated for a prolonged period. This review details the main situations during which medical treatment should be considered, as well as the way in which to monitor them to avoid the long-term consequences of mild hypo- or hypercortisolism.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology, Aix Marseille University, Assistance Publique-Hopitaux de Marseille, INSERM, Marseille Medical Genetics, Marmara Institute, French Reference Center for Rare Pituitary Diseases, Endo-European Reference Network and EURACAN European Expert Center on Rare Pituitary Tumors, La Conception Hospital, Marseille, France
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24
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Dekkers AJ, Amaya JM, van der Meulen M, Biermasz NR, Meijer OC, Pereira AM. Long-term effects of glucocorticoid excess on the brain. J Neuroendocrinol 2022; 34:e13142. [PMID: 35980208 PMCID: PMC9541651 DOI: 10.1111/jne.13142] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
Abstract
The metabolic and cardiovascular clinical manifestations in patients with Cushing's syndrome (CS) are generally well known. However, recent studies have broadened the perspective of the effects of hypercortisolism, showing that both endogenous and exogenous glucocorticoid excess alter brain functioning on several time scales. Consequently, cognitive deficits and neuropsychological symptoms are highly prevalent during both active CS and CS in remission, as well as during glucocorticoid treatment. In this review, we discuss the effects of endogenous hypercortisolism and exogenously induced glucocorticoid excess on the brain, as well as the prevalence of cognitive and neuropsychological deficits and their course after biochemical remission. Furthermore, we propose possible mechanisms that may underly neuronal changes, based on experimental models and in vitro studies. Finally, we offer recommendations for future studies.
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Affiliation(s)
- Alies J. Dekkers
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine, Center for Endocrine Tumours LeidenLeiden University Medical CenterLeidenThe Netherlands
| | - Jorge Miguel Amaya
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
| | - Merel van der Meulen
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine, Center for Endocrine Tumours LeidenLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke R. Biermasz
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine, Center for Endocrine Tumours LeidenLeiden University Medical CenterLeidenThe Netherlands
| | - Onno C. Meijer
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
| | - Alberto M. Pereira
- Department of Endocrinology & MetabolismAmsterdam UMC (AMC)AmsterdamThe Netherlands
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25
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Simon J, Theodoropoulou M. Genetics of Cushing's disease. J Neuroendocrinol 2022; 34:e13148. [PMID: 35596671 DOI: 10.1111/jne.13148] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Abstract
Corticotroph tumours are primarily sporadic monoclonal neoplasms and only rarely found in genetic syndromes. Recurrent mutations in the ubiquitin specific protease 8 (USP8) gene are found in around half of cases. Mutations in other genes such as USP48 and NR3C1 are less frequent, found in less than ~20% of cases. TP53 and ATXR mutations are reported in up to one out of four cases, when focusing in USP8 wild type or aggressive corticotroph tumours and carcinomas. At present, USP8 mutations are the primary driver alterations in sporadic corticotroph tumours, TP53 and ATXR mutations may indicate transition to more aggressive tumour phenotype. Next generation sequencing efforts have identified additional genomic alterations, whose role and importance in corticotroph tumorigenesis remains to be elucidated.
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Affiliation(s)
- Julia Simon
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
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26
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Affiliation(s)
- Robert P Millar
- Centre for Neuroendocrinology, Department of Immunology, University of Pretoria, Pretoria, South Africa
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Balomenaki M, Margaritopoulos D, Vassiliadi DA, Tsagarakis S. Diagnostic workup of Cushing's syndrome. J Neuroendocrinol 2022; 34:e13111. [PMID: 35979805 DOI: 10.1111/jne.13111] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Abstract
Cushing's syndrome (CS) is a rare but detrimental endocrine disorder. Early diagnosis and prompt treatment are essential since the duration of hypercortisolism has an adverse impact on the extent of comorbidities and overall survival. The diagnostic approach involves a stepwise process that includes (1) screening and confirming the diagnosis and (2) establishing the aetiology of CS. The tests currently used to confirm the diagnosis of CS include urinary free cortisol measurements, the dexamethasone suppression test and late- night salivary cortisol or midnight serum cortisol measurements. None of these tests are ideal; all have pitfalls and require careful interpretation. Following confirmation of CS, measurement of ACTH discriminates between ACTH-dependent and non-ACTH dependent causes of CS. Adrenal imaging provides clues for the aetiology of non-ACTH dependent forms. Differentiation between the ACTH-dependent forms that involve pituitary corticotroph adenomas and ectopic ACTH sources is more complex and include pituitary MRI imaging, the high dose dexamethasone suppression test, the CRH test, bilateral inferior petrosal sinus sampling and, when required imaging modalities to detect ectopic ACTH secreting lesions. This review, which is part of a special issue on "Update of Cushing's syndrome: 100 years after Minnie G" will provide an update on our current diagnostic workup for the confirmation and differential diagnosis of CS.
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Affiliation(s)
- Maria Balomenaki
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
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Dalan R, Bornstein SR, Boehm BO. Cushing's Disease Management: Glimpse Into 2051. Front Endocrinol (Lausanne) 2022; 13:943993. [PMID: 35872988 PMCID: PMC9299426 DOI: 10.3389/fendo.2022.943993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
Major advancements are expected in medicine and healthcare in the 21st century- "Digital Age", mainly due to the application of data technologies and artificial intelligence into healthcare. In this perspective article we share a short story depicting the future Cushings' Disease patient and the postulated diagnostic and management approaches. In the discussion, we explain the advances in recent times which makes this future state plausible. We postulate that endocrinology care will be completely reinvented in the Digital Age.
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Affiliation(s)
- Rinkoo Dalan
- Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- *Correspondence: Rinkoo Dalan,
| | - Stefan R. Bornstein
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany
- Division of Diabetes and Nutritional Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, University Hospital, Zürich, Switzerland
| | - Bernhard O. Boehm
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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