Ectopic Cushing' syndrome caused by a neuroendocrine carcinoma of the mesentery

ACTH-producing adrenocortical carcinoma: an exceedingly rare diagnosis

BACKGROUND

Adrenocortical carcinoma is a very rare endocrinopathy that has a poor prognosis and is frequently associated with ACTH-independent Cushing's syndrome. Despite having an adrenocortical carcinoma, our patient surprisingly had an ACTH-dependent Cushing's syndrome.

CASE REPORT

A 26-year-old female presented with Cushing's syndrome and an abdominal mass. Imaging studies revealed an adrenal mass consistent with a high-grade malignancy. Laboratory workup showed hypercortisolism, hyperandrogenism, and hypokalemia with normal levels of metanephrines. Unexpectedly, her ACTH levels were remarkably elevated. The pathological analysis of a tumor sample was conclusive for adrenocortical carcinoma with immunopositivity for ACTH.

CONCLUSIONS

Our patient suffered from an adrenocortical carcinoma that was ectopically producing ACTH. This case emphasizes that physicians should have a broad-minded approach when evaluating cases of rare endocrine malignancies.

Ectopic Cushing's syndrome from a corticotropin-releasing hormone-secreting medullary thyroid carcinoma: a rare pitfall of inferior petrosal sinus sampling

Summary

This case report describes a rare presentation of ectopic Cushing's syndrome (CS) due to ectopic corticotropin-releasing hormone (CRH) production from a medullary thyroid carcinoma (MTC). The patient, a 69-year-old man, presented with symptoms of muscle weakness, facial plethora, and easy bruising. An inferior petrosal sinus sampling test (IPSS) demonstrated pituitary adrenocorticotrophic hormone (ACTH) secretion, but a whole-body somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) revealed enhanced uptake in the right thyroid lobe which, in addition to a grossly elevated serum calcitonin level, was indicative of an MTC. A 18F-DOPA PET/CT scan supported the diagnosis, and histology confirmed the presence of MTC with perinodal growth and regional lymph node metastasis. On immunohistochemical analysis, the tumor cell stained positively for calcitonin and CRH but negatively for ACTH. Distinctly elevated plasma CRH levels were documented. The patient therefore underwent thyroidectomy and bilateral adrenalectomy. This case shows that CS caused by ectopic CRH secretion may masquerade as CS due to a false positive IPSS test. It also highlights the importance of considering rare causes of CS when diagnostic test results are ambiguous.

Learning points

Medullary thyroid carcinoma may secrete CRH and cause ectopic CS. Ectopic CRH secretion entails a rare pitfall of inferior petrosal sinus sampling yielding a false positive test. Plasma CRH measurements can be useful in selected cases.

A Case of Cushing's Syndrome from Well-Differentiated Neuroendocrine Tumors of the Small Bowel and Its Mesentery

Adrenocorticotropic (ACTH)-producing neuroendocrine tumours (NETs) are rarely found in the small bowel, and primary mesenteric NETs have only been reported in a few cases globally. We report the case of a 68-year-old female with ectopic Cushing's syndrome due to excessive ACTH secretion from small bowel primary lesions and mesenteric metastasis. Initially, only the mesenteric mass was detected on imaging and endoscopy/colonoscopy, and it was only with surgical exploration that the small bowel lesions were found. This highlights the importance of high clinical suspicion and robust investigation when locating NETs. Surgical resection of the affected small bowel and mesentery was the definitive treatment for this patient. Initial hydrocortisone replacement therapy was needed, and subsequent biochemical tests and clinical reviews demonstrated no recurrence.

Comparison of diagnostic efficacy of 18F-FDG PET/CT and 68Ga-DOTANOC PET/CT in ectopic adrenocorticotropic hormone syndrome

PURPOSE

Fluorine-18 (¹⁸F)-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and gallium-68 (⁶⁸Ga)-somatostatin analog (SSA) PET/CT imaging have been increasingly used in ectopic adrenocorticotropic hormone syndrome (EAS); however, the diagnostic efficacies of these two methods in patients with EAS remain unclear. Our study aimed to compare the diagnostic efficacies of ¹⁸F-FDG PET/CT and ⁶⁸Ga-DOTANOC PET/CT in EAS.

METHODS

The clinical and imaging data of 68 patients with EAS who underwent ¹⁸F-FDG PET/CT and ⁶⁸Ga-DOTANOC PET/CT examinations from December 2016 to April 2021 were analyzed retrospectively, and the diagnostic efficacies of these methods were compared.

RESULTS

In 37 cases, imaging was performed to locate the primary tumor lesion (localization group), and in 31 to evaluate tumor load or metastasis (staging group). Primary tumors were detected in 48.65% (18/37) of the localization group patients. According to scan-based analysis, the tumor lesion detection rates and false positive rates of ¹⁸F-FDG PET/CT imaging and ⁶⁸Ga-DOTANOC PET/CT imaging were 18.92% vs. 45.95% (p < 0.05) and 21.62% vs. 2.70% (p < 0.05) respectively. For lesion-based analysis, the tumor lesion detection rates and false positive rates were 24.13% vs. 58.62% (p >0.05) and 31.04% vs. 3.45% (p < 0.05). In 90.32% (28/31) of the staging group patients, 286 of 292 lesions were confirmed as tumor lesions. Based on scan analysis, the detection rates and false positive rates of ¹⁸F-FDG PET/CT imaging and ⁶⁸Ga-DOTANOC PET/CT imaging were 83.87% vs. 67.74% (p > 0.05) and 12.90% vs. 9.68% (p > 0.05) respectively. Based on lesion analysis, the detection rate and false positive rates were 93.84% vs. 54.80% (p < 0.05) and 1.37% vs. 1.03%(p > 0.05).

CONCLUSION

⁶⁸Ga-DOTANOC PET/CT imaging may be more suitable than ¹⁸F-FDG PET/CT for identifying the primary tumor in patients with EAS, while ¹⁸F-FDG PET/CT may be more advantageous than ⁶⁸Ga-DOTANOC PET/CT for patients with suspected metastasis.

[Surgical treatment of ACTH-ectopic syndrome]

ACTH-ectopic syndrome is a severe, multiple-symptom disease characterized by secretion of adrenocorticotropic hormone (ACTH) by ectopic tumor, increased release of adrenal cortical hormones and clinical picture of hypercorticism. Diagnosis and treatment of ACTH-ectopic syndrome is still difficult problem despite the achievements of modern medicine. There are several unresolved issues including optimal diagnostic algorithm, indications for various surgical procedures and their optimal dates. This review is devoted to these questions.

Somatostatin receptor expression in non-classical locations - clinical relevance?

In-111 pentetreotide (Octreoscan) is a radiolabeled somatostatin analog with high binding affinity to somatostatin receptors (SSTR) used in somatostatin receptor scintigraphy (SRS). Pentetreotide labelled with In-111 is widely used due to its high affinity to SSTR 2 and 5. SSTR are expressed on neuroendocrine cells as well as several non-neural and non-endocrine cells with varying levels of density. We retrospectively reviewed articles and publications related to octreoscan accumulation in sites that classically do not have high concentrations of SSTR as well as in organs and tissues from diseases which are not usually diagnosed by octreoscan. The significance of a positive uptake as assessed by octreoscan in non-somatostatin receptor related diseases is not fully understood yet. Localization of octreotide in non-oncological disease states such as inflammation is due to presence of SSTR in activated immunological cells, over-expression by activated cells in the respective tissue and SSTR expression by blood vessels. In granulomatous diseases, over-expression of SSTR2 preferential binding sites were detected in epitheloid and giant cells. The purpose of the current study is to identify octreoscan localization in non-somatostatin receptor related disease sites to better understand the mechanism of this nonspecific accumulation which may help expand the clinical utilization of functional imaging utilizing somatostatin receptor scintigraphy in diagnosis and perhaps therapy.

Black swans - neuroendocrine tumors of rare locations

Neuroendocrine neoplasms (NEN) are rare and heterogeneous. Therefore, they often remain unrecognized for many years, causing significant disease burden. We here report on four unusual NEN presentations including a metastatic NEN of the kidney, hypoglycemia caused by an insulin-like growth factor-2-oma (previously called non-islet-cell tumor hypoglycemia), multifocal pheochromocytoma in von Hippel Lindau syndrome, and ileal NEN metastatic to the heart. One could say that each one of these tumors were "black swans" and learning about them will increase further awareness of the spectrum of NEN.

Management of neuroendocrine tumors of unknown primary

Neuroendocrine neoplams (NENs) are mostly relatively indolent malignancies but a significant number have metastatic disease at diagnosis mainly to the liver. Although in the majority of such cases the primary origin of the tumor can be identified, in approximately 11-22% no primary tumor is found and such cases are designated as NENs of unknown primary origin (UPO). This has significant therapeutic implications with respect to potentially resectable hepatic disease and/or application of appropriate medical therapy, either chemotherapeutic agents or targeted treatment, as the response to various treatments varies according to the origin of the primary tumor. This lack of tumor specific orientated treatment may also account for the relatively poorer prognosis of NENs of UPO compared to metastatic NENs with a known primary site. In the majority of cases the primary tumors are located in the small bowel and the lung, but a number may still elude detection. Occasionally the presence of a functional syndrome may direct to the specific tissue of origin but in the majority of cases a number of biochemical, imaging, histopathological and molecular modalities are utilized to help identify the primary origin of the tumor and direct treatment accordingly. Several diagnostic algorithms have recently been developed to help localize an occult primary tumor; however, in a number of cases no lesion is identified even after prolonged follow-up. It is expected that the delineation of the molecular signature of the different NENs may help identify such cases and provide appropriate treatment.

Conventional and Nuclear Medicine Imaging in Ectopic Cushing's Syndrome: A Systematic Review

CONTEXT

Ectopic Cushing's Syndrome (ECS) can be a diagnostic challenge with the hormonal source difficult to find. This study analyzes the accuracy of imaging studies in ECS localization.

EVIDENCE ACQUISITION

Systematic review of medical literature for ECS case series providing individual patient data on at least one conventional imaging technique (computed tomography [CT]/magnetic resonance imaging) and one of the following: 111In-pentetreotide (OCT), 131I/123I-metaiodobenzylguanidine, 18Ffluoro-2-deoxyglucose-positron emission tomography (FDG-PET), 18F-fluorodopa-PET (F-DOPA-PET), 68Ga- DOTATATE-PET/CT or 68Ga-DOTATOC-PET/CT scan (68Gallium-SSTR-PET/CT).

EVIDENCE SUMMARY

The analysis comprised 231 patients (females, 50.2%; age, 42.617 y). Overall, 52.4%(121/231) had "overt" ECS,18.6% had "occult" ECS, and 29% had "covert" ECS. Tumors were located in the lung (55.3%), mediastinum-thymus (7.9%), pancreas (8.5%), adrenal glands (6.4%), gastrointestinal tract (5.4%), thyroid (3.7%), and other sites (12.8%), and primary tumors were mostly bronchial neuroendocrine tumors (NETs) (54.8%), pancreatic NETs (8%), mediastinum-thymus NETs (6.9%), gastrointestinal NETs (5.3%), pheochromocytoma (6.4%), neuroblastoma (3.2%), and medullary thyroid carcinoma (3.2%). Tumors were localized byCTin66.2%(137/207), magnetic resonance imaging in 51.5% (53/103), OCT in 48.9% (84/172), FDG-PET in 51.7% (46/89), F-DOPAPET in 57.1% (12/21), 131/123I-metaiodobenzylguanidine in 30.8% (4/13), and 68Gallium-SSTRPET/CT in 81.8% (18/22) of cases. Molecular imaging discovered 79.1% (53/67) of tumors unidentified by conventional radiology, with OCT the most commonly used, revealing the tumor in 64%, followed by FDG-PET in 59.4%. F-DOPA-PET was used in only seven covert cases (sensitivity, 85.7%). Notably, 68Gallium-SSTR-PET/CT had 100% sensitivity among covert cases.

CONCLUSIONS

Nuclear medicine improves the sensitivity of conventional radiology when tumor site identification is problematic. OCT offers a good availability/reliability ratio, and FDG-PET was proven useful. 68Gallium-SSTR-PET/CT use was infrequent, despite offering the highest sensitivity.

A challenging case of an ectopic cushing syndrome

Bronchopulmonary carcinoids are rare pulmonary neoplasms although they account for most cases of ectopic ACTH syndromes. When feasible, the mainstay treatment is surgical resection of the tumor. We report the case of a 52-year-old woman with signs and symptoms suggestive of hypercortisolism for 12 months, admitted to our department because of community acquired pneumonia. Blood hormone analysis showed increased levels of ACTH and urinary free cortisol and nonsuppressibility to high- and low-dose dexamethasone tests. Pituitary MRI showed no lesion and no central-to-peripheral ACTH gradient was present in bilateral inferior petrosal sinus sampling. CRH stimulation test suggested an ectopic ACTH source. Thoracic CT scan revealed a nodular region measuring 12 mm located in the inferior lingular lobule of the left superior lung with negative uptake by ¹⁸-FDG-PET scan and negative SRS. The patient was successfully treated with an atypical lung resection and histology revealed an atypical bronchial carcinoid tumor with positive ACTH immunoreactivity. This was an interesting case because the patient was admitted due to pneumonia that may have been associated with her untreated and chronic hypercortisolism and a challenging case of ectopic ACTH syndrome due to conflicting results on the diagnostic exams.

Anesthetic considerations on adrenal gland surgery

Adrenal gland surgery needs a multidisciplinary team including endocrinologist, radiologist, anesthesiologist, and surgeon. The indications for adrenal gland surgery include hormonal secreting and non-hormonal secreting tumors. Adrenal hormonal secreting tumors present to the anesthesiologist unique challenges requiring good preoperative evaluation, perioperative hemodynamic control, corrections of all electrolytes and metabolic abnormalities, a detailed and careful anesthetic strategy, overall knowledge about the specific diseases, control and maintaining of postoperative adrenal function, and finally a good collaboration with other involved colleagues. This review will focus on the endocrine issues, as well as on the above-mentioned aspects of anesthetic management during hormone secreting adrenal gland tumor resection.

Ectopic Cushing's syndrome secondary to pulmonary carcinoid tumor

Adrenocorticotropic hormone (ACTH) overproduction within the pituitary gland or ectopically leads to hypercortisolism. In this study a case of Cushing's syndrome caused by an ectopic ACTH-secreting carcinoid tumor in lung is discussed, as are the available diagnostic procedures. The patient was a 28-year-old woman with clinical features starting about 6 months previously. The results of her biochemical tests suggested ectopic Cushing's syndrome. Full-body computed tomography revealed a single nodule in the inferior lobe of the right lung. After removal of the nodule, the patient's symptoms subsided clinically, and laboratory tests confirmed remission of the hypercortisolism.

Ectopic Cushing's syndrome caused by a pulmonary ACTH-secreting tumor in a patient treated with octreotide

Ectopic ACTH syndrome is a rare disease often associated with severe hypercortisolism. When feasible, optimal management is surgical excision of the tumor. A 33-year-old male patient was admitted to the hospital in 1993 with clinical manifestations suggestive of Cushing's syndrome. He presented high plasma ACTH and markedly elevated urinary free cortisol excretion that was not suppressed with high-dose dexamethasone administration. Pituitary MRI scan was normal. No central-to-peripheral ACTH gradient was present in bilateral inferior petrosal sinus sampling. Thoracic CT scan showed a 1.7 cm nodule at the left lung. Pulmonary fine needle cytology and immunocytochemical and ultrastructural studies, together with the presence of bone metastases, led to the diagnosis of an ACTH-producing neuroendocrine carcinoma. He was initially submitted to chemotherapy and has been on treatment with octreotide LAR since 1998, having shown a favorable clinical, biochemical and imaging response. We highlight the excellent long-term response to medical therapy with octreotide LAR, without tachyphylaxis, probably due to its antiproliferative effect.

Ectopic Cushing's syndrome due to a mesenteric neuroendocrine tumour

INTRODUCTION

Neuroendocrine tumours (NETs) are tumours that commonly involve the gastrointestinal system. Common primary sites in the gastrointestinal system include the small intestine, appendix, rectum and pancreas. Mesenteric NETs are extremely rare entities and are sparsely reported in the literature.

CASE HISTORY

We report the case of a 62-year-old woman with ectopic Cushing’s syndrome due to excessive adrenocorticotropic hormone secretion by a primary mesenteric tumour in the small intestine and its liver metastases.

CONCLUSIONS

Although rare, the mesentery can be a primary site for NETs. It can cause similar symptoms and require similar treatment options. Tumour resection and debulking are acceptable ways to improve both the survival and symptoms.

Neuroendocrine carcinoma of the thyroid causing adrenocorticotrophic hormone-dependent Cushing's syndrome

BACKGROUND

Cushing's syndrome (CS) due to ectopic adrenocorticotrophic hormone (ACTH) and/or ectopic corticotropic releasing hormone (CRH) secretion accounts for <10% of all CS. Neuroendocrine carcinomas rarely cause CS. These carcinomas have been found to secrete either ACTH or rarely CRH. Herein we report a case of neuroendocrine carcinoma originating from the thyroid as the source of ACTH-dependent CS.

SUMMARY

A 30-year-old woman with features of CS presented with severe respiratory distress. Six months before that, she was diagnosed with primary hypothyroidism and started on levothyroxine (LT4) therapy. Biochemical evaluation was done, and nonsuppressed serum cortisol levels following dexamethasone with high ACTH confirmed a diagnosis of ACTH-dependent CS. Magnetic resonance imaging of the brain showed a bulky pituitary gland. Adrenal imaging showed bilateral adrenal hyperplasia. A computerized tomography scan showed a large anterior mediastinal mass arising from the neck and extending behind the transverse aortic arch. She underwent emergency thoracotomy due to rapidly progressive superior mediastinal syndrome and left vocal cord palsy. At surgery, the mass was seen originating from the thyroid and the thymus was compressed posteriorly. Near total thyroidectomy and thymectomy with removal of pericardial seedlings were done. Histopathology revealed sheets, cords, and nests of round or oval tumor cells with hyperchromatic nuclei and scant cytoplasm with local invasion and lymphovascular embolization suggestive of a neuroendocrine carcinoma arising from thyroid, staining positive for cytokeratin, synaptophysin, and chromogranin-A, and negative for calcitonin and carcinoembryonic antigen.

CONCLUSIONS

Here we report a case of a neuroendocrine tumor of the thyroid causing ACTH-dependent CS. The tumor was negative for calcitonin staining, indicating that this was not a medullary carcinoma of the thyroid. Neuroendocrine carcinomas originating from the thyroid gland are very rare. A thyroid tumor of neuroendocrine origin causing ACTH-dependent CS has not been reported previously.

Altered FDG uptake patterns in pediatric lymphoblastic lymphoma patients receiving induction chemotherapy that includes very high dose corticosteroids

BACKGROUND

Altered FDG uptake patterns were noted in certain lymphoblastic lymphoma patients during therapy.

OBJECTIVE

To describe these altered FDG uptake patterns and their relationship to chemotherapy.

MATERIALS AND METHODS

Thirty-five FDG PET or PET/CT scans obtained in 11 children with lymphoblastic lymphoma were retrospectively reviewed. FDG uptake patterns were recorded. SUV measurements were performed in liver and facial soft tissues. Results were correlated with induction chemotherapy regimens.

RESULTS

Six of the children had transiently altered FDG uptake with increased uptake in the superficial soft tissues, most notably involving the face. Altered uptake was noted approximately 1 month after initiation of chemotherapy and subsequently resolved. Hepatic uptake was transiently reduced on the 1-month scan in all six children with increased facial uptake. No significant FDG uptake in lymphoma was seen on five of six scans with altered uptake; however, two of these five affected children had FDG uptake in lymphoma on the next follow-up examination. Blood glucose levels in the affected children were in the normal range. All six children with altered FDG uptake received the same induction chemotherapy regimen, which included very high doses of corticosteroids.

CONCLUSIONS

Children with lymphoblastic lymphoma on induction chemotherapy protocols including very high doses of corticosteroids transiently demonstrated altered FDG uptake patterns, including increased superficial facial uptake and reduced hepatic uptake. The facial uptake is probably the FDG PET equivalent of Cushingoid facies. Caution in interpreting scans with this altered FDG uptake pattern is suggested, as uptake at sites of lymphomatous involvement may potentially be affected.

Cushing's surgery: Role of the anesthesiologist

Cushing's syndrome is a clinical situation, caused by excessive glucocorticoid level, resulting in several features such as central obesity, supraclavicular fat, "moon face," "buffalo hump," hyperglycemia, metabolic alkalosis, hypokalemia, poor wound healing, easy bruising, hypertension, proximal muscle weakness, thin extremities, skin thinning, menstrual irregularities, and purple striae. In the perioperative period, the anesthesiologist must deal with difficult ventilation and intubation, hemodynamic disturbances, volume overload and hypokalemia, glucose intolerance, and diabetes, maintaining the blood cortisol level and preventing the glucocorticoid deficiency. This syndrome is quite rare and its features make these patients very difficult to the anesthesiologist.

Cushing syndrome and the anesthesiologist, two case reports

Cushing's syndrome (CS) is associated with reduced life quality and increased mortality, mostly due to cardiovascular disease. The features of this syndrome are central obesity, moon facies, facial plethora, supraclavicular fat pads, buffalo hump, and purple striae. Other complications include hyperglycemia, hypertension, proximal muscle weakness, skin thinning, menstrual irregularities, amenorrhea and osteopenia. These make perioperative and anesthetic management difficult and present a challenge to the operating team, especially the anaesthesiologist. In this paper, we present two such cases of CS, which were treated with adrenalectomy. We aim to highlight the special care and precautions that need to be taken while administering anesthesia, and in the post operatory period. Anaesthesia induction in the two cases of CS was done prior to the adrenalectomy procedure and special pre and post operative care was taken. Continuous intra operative monitoring of vitals and checking for the stability of the haemodynamics was performed. With adequate care and using advanced anesthetic techniques, the patients showed uneventful post operative recovery. Though the anesthetic management of patients with CS is difficult, desired results can be achieved with continuous monitoring and special precautions.