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Korbonits M, Blair JC, Boguslawska A, Ayuk J, Davies JH, Druce MR, Evanson J, Flanagan D, Glynn N, Higham CE, Jacques TS, Sinha S, Simmons I, Thorp N, Swords FM, Storr HL, Spoudeas HA. Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 2, specific diseases. Nat Rev Endocrinol 2024; 20:290-309. [PMID: 38336898 DOI: 10.1038/s41574-023-00949-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Pituitary adenomas are rare in children and young people under the age of 19 (hereafter referred to as CYP) but they pose some different diagnostic and management challenges in this age group than in adults. These rare neoplasms can disrupt maturational, visual, intellectual and developmental processes and, in CYP, they tend to have more occult presentation, aggressive behaviour and are more likely to have a genetic basis than in adults. Through standardized AGREE II methodology, literature review and Delphi consensus, a multidisciplinary expert group developed 74 pragmatic management recommendations aimed at optimizing care for CYP in the first-ever comprehensive consensus guideline to cover the care of CYP with pituitary adenoma. Part 2 of this consensus guideline details 57 recommendations for paediatric patients with prolactinomas, Cushing disease, growth hormone excess causing gigantism and acromegaly, clinically non-functioning adenomas, and the rare TSHomas. Compared with adult patients with pituitary adenomas, we highlight that, in the CYP group, there is a greater proportion of functioning tumours, including macroprolactinomas, greater likelihood of underlying genetic disease, more corticotrophinomas in boys aged under 10 years than in girls and difficulty of peri-pubertal diagnosis of growth hormone excess. Collaboration with pituitary specialists caring for adult patients, as part of commissioned and centralized multidisciplinary teams, is key for optimizing management, transition and lifelong care and facilitates the collection of health-related quality of survival outcomes of novel medical, surgical and radiotherapeutic treatments, which are currently largely missing.
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Affiliation(s)
- 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.
| | | | - Anna Boguslawska
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maralyn R Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Evanson
- Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Nigel Glynn
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Thomas S Jacques
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Saurabh Sinha
- Sheffield Children's and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Simmons
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicky Thorp
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen A Spoudeas
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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Elenius H, McGlotten R, Nieman LK. Ovine CRH Stimulation and 8 mg Dexamethasone Suppression Tests in 323 Patients With ACTH-Dependent Cushing's Syndrome. J Clin Endocrinol Metab 2023; 109:e182-e189. [PMID: 37531629 PMCID: PMC11032243 DOI: 10.1210/clinem/dgad454] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/07/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Determining the etiology of adrenocorticotropin (ACTH)-dependent Cushing's syndrome (CS) is often difficult. The gold standard test, inferior petrosal sinus sampling (IPSS), is expensive and not widely available. OBJECTIVE Evaluate the performance of the corticotropin-releasing hormone stimulation test (CRH-ST) and the 8 mg high-dose dexamethasone suppression test (HDDST) in distinguishing Cushing's disease (CD) from ectopic ACTH syndrome (EAS). METHODS Retrospective review in a tertiary referral center. A total of 323 patients with CD or EAS (n = 78) confirmed by pathology or biochemical cure (n = 15) in 96% underwent CRH-ST and HDDST performed between 1986 and 2019. We calculated test sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value, and diagnostic accuracy (DA) for the diagnosis of CD, and determined optimal response criteria for each test, alone and in combination. RESULTS The CRH-ST performed better than the HDDST (DA 91%, 95% CI 87-94% vs 75%, 95% CI 69-79%). Optimal response criteria were a ≥40% increase of ACTH and/or cortisol during the CRH test and a ≥69% suppression of cortisol during the HDDST. A ≥40% cortisol increase during the CRH test was the most specific measure, PPV 99%. Seventy-four percent of subjects had concordant positive CRH test and HDDST results, yielding Se 93%, Sp 98%, DA 95%, and PPV 99%, with a pretest likelihood of 85%. A proposed algorithm diagnosed 64% of patients with CD with near perfect accuracy (99%), obviating the need for IPSS. CONCLUSION CRH is a valuable tool to correctly diagnose the etiology of ACTH-dependent CS. Its current worldwide unavailability impedes optimal management of these patients.
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Affiliation(s)
- Henrik Elenius
- Diabetes and Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, Bethesda, MD 20892, USA
| | - Raven McGlotten
- Diabetes and Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, Bethesda, MD 20892, USA
| | - Lynnette K Nieman
- Diabetes and Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, Bethesda, MD 20892, USA
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Yami Channaiah C, Karlekar M, Sarathi V, Lila AR, Ravindra S, Badhe PV, Malhotra G, Memon SS, Patil VA, Pramesh CS, Bandgar T. Paediatric and adolescent ectopic Cushing's syndrome: systematic review. Eur J Endocrinol 2023; 189:S75-S87. [PMID: 37801647 DOI: 10.1093/ejendo/lvad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/06/2023] [Accepted: 10/04/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE The data on clinical, biochemical, radiological characteristics, and outcomes in paediatric ectopic adrenocorticotropic hormone syndrome (EAS) are limited owing to rarity of the condition. We report three new cases and perform a systematic review of paediatric EAS. DESIGN AND METHOD Case records of paediatric and adolescent EAS patient's ≤20 years presenting at our centre between 1997 and 2021 were retrospectively reviewed, and a systematic review of the literature published between January 1970 and December 2022 was performed. RESULTS A total of 161 patients including 3 new patients from our centre were identified. Bronchial neuroendocrine tumours (NET) (28.5%), thymic NET (22.9%), primitive cell-derived tumours (18.6%), and gastro-entero-pancreatic-NET (13.7%) were the common causes. Primitive cell-derived tumours were the most common in the first decade (24/45, 53.4%) and were the largest (82 [60-100] mm), whereas bronchial NETs predominated during the second decade (42/116, 36.2%) and were the smallest (15 [10-25] mm). Computed tomography localized 92.9% (118/127) of paediatric EAS patients. Immediate postoperative remission was attained in 77.9% (88/113) patients, whereas 30.4% (24/79) relapsed over a median (IQR) period of 13 (8-36) months. Over a median (IQR) follow-up of 2 (0.6-4.6) years, 31.4% of patients died. The median survival was higher in bronchial NET than in other tumour groups. Distant metastasis and tumour size were independent negative predictors of survival. CONCLUSIONS Aetiological profile of paediatric and adolescent EAS is distinct from that of adults. Bronchial NETs have the best long-term survival, whereas distant metastasis and tumour size predict poor survival.
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Affiliation(s)
- Chethan Yami Channaiah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai 400012, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai 400012, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru 560066, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai 400012, India
| | - Shruthi Ravindra
- Department of Endocrinology, Diabetes and Metabolism, Narayana Medical College, Nellore 524001, India
| | - Padma Vikram Badhe
- Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai 400012, India
| | - Gaurav Malhotra
- Radiation Medical Centre, Bhabha Atomic Research Centre, Mumbai 400012, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai 400012, India
| | | | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 400012, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai 400012, India
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Ceccato F, Di Dalmazi G. Shortage of hCRH for the diagnosis of endogenous CS: the end of an era or the beginning of a new journey? J Endocrinol Invest 2023; 46:2189-2191. [PMID: 37266826 DOI: 10.1007/s40618-023-02113-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Affiliation(s)
- F Ceccato
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padua, Padua, Italy
| | - G Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy.
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de Almeida TS, Rodrigues TDC, Costenaro F, Scaffaro LA, Farenzena M, Gastaldo F, Czepielewski MA. Enhancing Cushing's disease diagnosis: exploring the impact of desmopressin on ACTH gradient during BIPSS. Front Endocrinol (Lausanne) 2023; 14:1224001. [PMID: 37600715 PMCID: PMC10436086 DOI: 10.3389/fendo.2023.1224001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction The differential diagnosis between Cushing's disease (CD) and ectopic ACTH syndrome (EAS) is complex, and bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold-standard test. However, BIPSS with corticotropin-releasing hormone (CRH) stimulation is rarely available. Objective This retrospective cohort study aimed to assess the accuracy of the inferior petrosal sinus to peripheral ACTH gradient (IPS:P) before and after desmopressin stimulation for the differential diagnosis of ACTH-dependent Cushing's syndrome (CS), applying different cutoff values. Methods A total of 50 patients (48 with CD and 2 with EAS) who underwent BIPSS were included in this study. The sensitivity and specificity of IPS:P in BIPSS before and after desmopressin stimulation were evaluated. Various cutoff values for IPS:P were examined to determine their diagnostic accuracy. Results Using the traditional IPS:P cutoff, the sensitivity was 85.1% before stimulation, 89.6% after stimulation, and a combined sensitivity of 91.7%. Applying cutoff values of IPS:P >1.4 before and >2.8 after stimulation, the sensitivity was 87.2% and 89.6%, respectively, with a combined sensitivity of 91.7%. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values of 1.2 before stimulation and 1.57 after stimulation, resulting in a sensitivity of 93.6% and 93.8%, respectively, with a combined sensitivity of 97.9%. Specificity remained at 100% throughout all analyses. Among the 43 patients who responded positively to stimulation, 42 (97.7%) did so within the first three minutes, and all 43 (100%) did so within the first five minutes. None of the assessed clinical variables predicted the ACTH response to stimulation in BIPSS with statistical significance. Discussion ACTH stimulation with desmopressin during BIPSS improves the accuracy of IPS:P, making it a valuable tool for investigating ACTH-dependent Cushing's syndrome. Considering the low risk of complications, we recommend the use of desmopressin stimulation during BIPSS for the differential diagnosis of ACTH-dependent CS.
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Affiliation(s)
- Tobias Skrebsky de Almeida
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Ticiana da Costa Rodrigues
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fabíola Costenaro
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Leandro Armani Scaffaro
- Radiology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Maurício Farenzena
- Radiology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fernando Gastaldo
- Department of Radiology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mauro Antônio Czepielewski
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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6
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Slagboom TNA, Stenvers DJ, van de Giessen E, Roosendaal SD, de Win MML, Bot JCJ, Aronica E, Post R, Hoogmoed J, Drent ML, Pereira AM. Continuing Challenges in the Definitive Diagnosis of Cushing's Disease: A Structured Review Focusing on Molecular Imaging and a Proposal for Diagnostic Work-Up. J Clin Med 2023; 12:jcm12082919. [PMID: 37109254 PMCID: PMC10144206 DOI: 10.3390/jcm12082919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
The definitive diagnosis of Cushing's disease (CD) in the presence of pituitary microadenoma remains a continuous challenge. Novel available pituitary imaging techniques are emerging. This study aimed to provide a structured analysis of the diagnostic accuracy as well as the clinical use of molecular imaging in patients with ACTH-dependent Cushing's syndrome (CS). We also discuss the role of multidisciplinary counseling in decision making. Additionally, we propose a complementary diagnostic algorithm for both de novo and recurrent or persistent CD. A structured literature search was conducted and two illustrative CD cases discussed at our Pituitary Center are presented. A total of 14 CD (n = 201) and 30 ectopic CS (n = 301) articles were included. MRI was negative or inconclusive in a quarter of CD patients. 11C-Met showed higher pituitary adenoma detection than 18F-FDG PET-CT (87% versus 49%). Up to 100% detection rates were found for 18F-FET, 68Ga-DOTA-TATE, and 68Ga-DOTA-CRH, but were based on single studies. The use of molecular imaging modalities in the detection of pituitary microadenoma in ACTH-dependent CS is of added and complementary value, serving as one of the available tools in the diagnostic work-up. In selected CD cases, it seems justified to even refrain from IPSS.
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Affiliation(s)
- Tessa N A Slagboom
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Dirk Jan Stenvers
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Elsmarieke van de Giessen
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Stefan D Roosendaal
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Maartje M L de Win
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Joseph C J Bot
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Eleonora Aronica
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of (Neuro)Pathology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - René Post
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jantien Hoogmoed
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Madeleine L Drent
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Alberto M Pereira
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Jevalikar G, Ravindra S, Reddy PK, S L SR, Sarathi V. Pediatric Ectopic Cushing Syndrome Caused by Hepatic Neoplasms: A Case Report and Systematic Review. Cureus 2023; 15:e36852. [PMID: 37123777 PMCID: PMC10143147 DOI: 10.7759/cureus.36852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
Ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS) is rare in children, and localizing the source of EAS is often challenging. Here, we report EAS in an adolescent boy who presented with Cushingoid features and had endogenous ACTH-dependent hypercortisolism on hormonal evaluation. Abdominal ultrasound and CT revealed a hepatic lesion with characteristics suggestive of hemangioma, whereas the lesion was tracer non-avid on 68Ga-DOTANOC positron emission tomography/CT. A regional sampling of ACTH was done to confirm the hepatic lesion as the source of EAS, and a definitive ACTH gradient was observed between the hepatic vein and the right internal jugular vein. Further, a preoperative biopsy of the lesion revealed a small round cell tumor with positive immunostaining for ACTH and synaptophysin, suggestive of a neuroendocrine tumor. The patient was managed with partial hepatectomy, resulting in hormonal and clinical remission of Cushing syndrome. In a systematic review of pediatric EAS due to primary hepatic tumors (n = 11), calcifying nested stromal epithelial cell tumors were the most common. EAS-associated hepatic tumors were larger (≥10 cm) except benign primary hepatic neuroendocrine tumors (PHNET). The latter were misdiagnosed as hemangioma in two cases by anatomical imaging but correctly diagnosed by somatostatin receptor scintigraphy. Hepatic tumors causing EAS in children required extensive resection, except benign PHNET. Nevertheless, all benign tumors with an uncomplicated perioperative course demonstrated disease-free survival over a median follow-up period of two years.
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Ceccato F, Barbot M, Mondin A, Boscaro M, Fleseriu M, Scaroni C. Dynamic testing for differential diagnosis of ACTH-dependent Cushing Syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab 2022; 108:e178-e188. [PMID: 36453141 DOI: 10.1210/clinem/dgac686] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Diagnostic accuracy of testing currently used for the differential diagnosis of Cushing's disease (CD) vs ectopic -ACTH secretion (EAS) is difficult to interpret. The present study aimed to identify and evaluate the diagnostic accuracy of corticotropin-releasing hormone (CRH) test, desmopressin test, and high-dose dexamethasone suppression test (HDDST) when used to establish a CD or EAS diagnosis. DESIGN This study is a systematic review of the literature and meta-analysis. METHODS MEDLINE, OVID, and Web of Science databases were searched for articles published between the years 1990-2021. Articles included described at least one test(s) (CRH, desmopressin, or HDDST) and the diagnostic reference standard(s) (histopathology, petrosal sinus sampling, surgical remission, imaging, and long-term follow-up) used to establish a CD or EAS diagnosis. RESULTS Sixty-two studies were included: 43 reported the use of HDDST, 32 CRH test, and 21 desmopressin test. CRH test was found to have the highest sensitivity in detecting CD (ACTH 86.9%, 95% confidence interval [CI] 82.1-90.6, cortisol 86.2%, 95%CI 78.3-91.5) and the highest specificity in detecting EAS (ACTH 93.9%, 95%CI 87-98.3, cortisol 89.4%, 95%CI 82.8-93.7). This resulted in a high diagnostic odds ratio (58, 95%CI 43.25-77.47), large area under the curve, and a receiver-operating characteristic (ROC) of 0.934. The diagnostic accuracy of HDDST and desmopressin test(s) was lower than that of the CRH test. CONCLUSION The meta-analysis indicates that a patient with a positive ACTH response after a CRH test is highly likely to have CD. Further studies analysing role of dynamic testing in addition to imaging are needed.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Alessandro Mondin
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Maria Fleseriu
- Oregon Health & Science University, Pituitary Center, Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition and Department of Neurological Surgery, Portland, USA
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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Ferriere A, Tabarin A. Biochemical testing to differentiate Cushing's disease from ectopic ACTH syndrome. Pituitary 2022; 25:705-708. [PMID: 35759056 DOI: 10.1007/s11102-022-01241-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
The differential diagnosis of ACTH-dependent Cushing's syndrome is often a diagnostic challenge that has been debated in numerous studies. In this short article, we will discuss the performance and main drawbacks of the biochemical tests used for this diagnosis.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, 33604, Pessac, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, 33604, Pessac, France.
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Lyu X, Zhang D, Pan H, Zhu H, Chen S, Lu L. A noninvasive scoring model for the differential diagnosis of ACTH-dependent Cushing's syndrome: a retrospective analysis of 311 patients based on easy-to-use parameters. Endocrine 2022; 78:114-122. [PMID: 35925471 DOI: 10.1007/s12020-022-03081-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The differential diagnosis of ACTH-dependent Cushing's disease (CS) is challenging. The gold standard approach bilateral inferior petrosal sinus sampling (BIPSS) is expensive and invasive, while other noninvasive tests, like the high-dose dexamethasone suppression test (HDDST), provide unsatisfactory diagnostic accuracy. This study aimed to find a new noninvasive practical approach with higher diagnostic accuracy to differently diagnose ACTH-dependent CS, which can be used in centers where BIPSS cannot be applied. METHODS 264 Cushing's disease (CD) patients and 47 ectopic ACTH secretion syndrome (EAS) patients were analyzed in this single-center retrospective study (2011-2021). The multivariate logistic model was used to construct the scoring model. RESULTS Female (adjusted OR 3.030, 95%CI 1.229-7.471), hypokalemia (0.209, 0.076-0.576), ACTH (0.988, 0.982-0.994), MRI pituitary lesion positive (8.671, 3.521-21.352), and HDDST positive (2.768, 1.139-6.726) have a strong association with the differential diagnosis of ACTH-dependent CS and were included in the final multivariable logistic regression model. A -14-to-14-point noninvasive scoring model was built on the model. The AUC of the noninvasive scoring model was 0.915 (95% CI 0.869-0.960), significantly higher than the AUC of HDDST (0.756, 95% CI 0.685-0.825, P = 0.004). The optimal cutoff of the model was ≥0 to diagnose CD. The sensitivity of the noninvasive scoring model was 91.3% (95% CI 87.3%-94.1%), and the specificity was 80.9% (95% CI 67.5%-89.6%). When the model's sensitivity was 100.0%, the cutoff was ≥ -10 with a specificity of 19.2%; when the model's specificity was 100.0%, the cutoff was ≥ 13 with a sensitivity of 22.7%. CONCLUSIONS We developed a noninvasive scoring model to distinguish CD and EAS in ACTH-dependent CS patients with higher diagnostic utility than HDDST in the same cohort. The noninvasive scoring model might be applied in areas where BIPSS is unavailable, the CRH is hard to obtain, or the desmopressin stimulation is not widely applied. It also provided a triage tool for selecting patients that might benefit the most from a further BIPSS test.
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Affiliation(s)
- Xiaohong Lyu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China
- Eight-year Program of Clinical Medicine, Peking Union Medical College, 100730, Beijing, China
| | - Dingyue Zhang
- Eight-year Program of Clinical Medicine, Peking Union Medical College, 100730, Beijing, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China
| | - Shi Chen
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China.
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China.
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11
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Abstract
Endogenous Cushing's syndrome (CS) is associated with morbidities (diabetes, hypertension, clotting disorders) and shortens life because of infections, pulmonary thromboembolism, and cardiovascular disease. Its clinical presentation is immensely variable, and diagnosis and treatment are often delayed. Thus, there are many opportunities for basic and clinical research leading to better tests, faster diagnosis, and optimized medical treatments. This review focuses on CS caused by excessive adrenocorticotropin (ACTH) production. It describes current concepts of the regulation of ACTH synthesis and secretion by normal corticotropes and mechanisms by which dysregulation occurs in corticotrope (termed "Cushing's disease") and noncorticotrope (so-called ectopic) ACTH-producing tumors. ACTH causes adrenal gland synthesis and pulsatile release of cortisol; the excess ACTH in these forms of CS leads to the hypercortisolism of endogenous CS. Again, the differences between healthy individuals and those with CS are highlighted. The clinical presentations and their use in the interpretation of CS screening tests are described. The tests used for screening and differential diagnosis of CS are presented, along with their relationship to cortisol dynamics, pathophysiology, and negative glucocorticoid feedback regulation in the two forms of ACTH-dependent CS. Finally, several gaps in current understanding are highlighted in the hope of stimulating additional research into this challenging disorder.
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Affiliation(s)
- Lynnette K Nieman
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
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12
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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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13
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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14
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Lam-Chung CE, Cuevas-Ramos D. The promising role of risk scoring system for Cushing syndrome: Time to reconsider current screening recommendations. Front Endocrinol (Lausanne) 2022; 13:1075785. [PMID: 36482998 PMCID: PMC9725023 DOI: 10.3389/fendo.2022.1075785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/01/2022] [Indexed: 11/24/2022] Open
Abstract
Despite the current screening approach for Cushing syndrome (CS), delayed diagnosis is common due to broad spectrum of presentation, poor discriminant symptoms featured in diabetes and obesity, and low clinical index of suspicion. Even if initial tests are recommended to screen CS, divergent results are not infrequent. As global prevalence of type 2 diabetes and obesity increases, CS may not be frequent enough to back routine screening to avoid false-positive results. This represents a greater challenge in countries with limited health resources. The development of indexes incorporates clinical features and biochemical data that are largely used to provide a tool to predict the presence of disease. In clinical endocrinology, indexes have been used in Graves' ophthalmology, hirsutism, and hypothyroidism. The use of clinical risk scoring system may assist clinicians in discriminating CS in the context of at-risk populations and, thus, may provide a potential intervention to decrease time to diagnosis. Development and validation of clinical model to estimate pre-test probability of CS in different geographic source population may help to establish regional prediction model for CS. Here, we review on the latest progress in clinical risk scoring system for CS and attempt to raise awareness for the use, validation, and/or development of clinical risk scores in CS.
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Affiliation(s)
- CE. Lam-Chung
- Department of Endocrinology and Metabolism, Complejo Hospitalario Dr. Manuel Amador Guerrero, Colón, Panama
| | - D. Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- *Correspondence: D. Cuevas-Ramos,
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15
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Detomas M, Ritzel K, Nasi-Kordhishti I, Wolfsberger S, Quinkler M, Losa M, Tröger V, Kroiss M, Fassnacht M, Vila G, Honegger JB, Reincke M, Deutschbein T. Outcome of CRH stimulation test and overnight 8 mg dexamethasone suppression test in 469 patients with ACTH-dependent Cushing's syndrome. Front Endocrinol (Lausanne) 2022; 13:955945. [PMID: 36277711 PMCID: PMC9583401 DOI: 10.3389/fendo.2022.955945] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate diagnostic accuracy of the corticotropin-releasing hormone (CRH) stimulation test and the overnight 8 mg dexamethasone suppression test (DST) for the differentiation of Cushing's disease (CD) and ectopic Cushing's syndrome (ECS). METHODS Retrospective study in 6 European centers. Inclusion criteria: patients with a) overt adrenocorticotropin (ACTH)-dependent Cushing's syndrome at the time of dynamic testing, b) histopathological confirmed tumors and/or c) postoperative biochemical remission and/or adrenal insufficiency. Optimal cut-offs were calculated via receiver operating characteristic (ROC) analysis using CD as reference. RESULTS 469 patients were analyzed [78% females; median age 43 years (IQR 19)]. CRH test and overnight 8 mg DST were performed in 420 [CD, n=394 (94%); ECS, n=26 (6%)] and 237 patients [228 CD (96%), 9 ECS (4%)]. Both tests were performed in 205 patients (44%). The post-CRH %-increase at 30 minutes of both ACTH (cut-off ≥31%, sensitivity 83%, specificity 85%, AUC 0.81) and cortisol (cut-off ≥12%, sensitivity 82%, specificity 89%, AUC 0.86) discriminated best between CD and ECS. A test duration of >60 minutes did not improve diagnostic performance of the CRH test. The optimal cortisol cut-off for the %-suppression during the 8 mg DST was ≥55% (sensitivity 80%, specificity 78%, AUC 0.75). CONCLUSION The CRH test has equivalent sensitivity but higher specificity than the 8 mg DST and is therefore the test of first choice. The diagnostic outcome of ACTH and cortisol is well comparable, however, sampling beyond 60 minutes post-CRH does not provide diagnostic benefits.
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Affiliation(s)
- Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | | | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Marco Losa
- Department of Neurosurgery, Instituto Scientifico San Raffaele, University Vita-Salute, Milan, Italy
| | - Viola Tröger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Greisa Vila
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
- *Correspondence: Timo Deutschbein,
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16
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Chen F, Xu Q, Yue W, Yu X, Shao S. A MEN1 Patient Presenting With Multiple Parathyroid Adenomas and Transient Hypercortisolism: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2022; 13:802453. [PMID: 35370956 PMCID: PMC8965320 DOI: 10.3389/fendo.2022.802453] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Multiple endocrine neoplasia type 1 (MEN1) is a hereditary endocrine syndrome caused by mutations in MEN1 tumor suppressor gene. CASE PRESENTATION A 53-year-old Chinese female was admitted to Division of Endocrinology, Tongji Hospital, for hypercalcemic crisis. Increased level of parathyroid hormone (PTH) was confirmed by laboratory tests, and imaging examination showed multiple parathyroid adenomas. Based on gene analysis, the patient was diagnosed as MEN1 associated hyperparathyroidism (HPT) by gene analysis with c.1378C>T (p.Arg460Ter) mutation in MEN1 gene. Her condition was complicated by transient hypercortisolism, mammary mass and uterine leiomyoma. After subtotal parathyroidectomy, PTH and serum calcium levels returned to normal. CONCLUSION HPT with multiple parathyroid adenomas is an indication of MEN1 gene mutation. Serum cortisol and its circadian rhythm can be abnormal in the presence of hypercalcemia and high PTH. These parameters can return to normal after parathyroidectomy.
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Affiliation(s)
- Fuqiong Chen
- Division of Endocrinology, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Qinqin Xu
- Division of Endocrinology, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Wenzhu Yue
- Division of Endocrinology, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Xuefeng Yu
- Division of Endocrinology, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Shiying Shao
- Division of Endocrinology, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
- *Correspondence: Shiying Shao,
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17
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Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, Casanueva FF, Castinetti F, Chanson P, Findling J, Gadelha M, Geer EB, Giustina A, Grossman A, Gurnell M, Ho K, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Kelly DF, Lacroix A, McCormack A, Melmed S, Molitch M, Mortini P, Newell-Price J, Nieman L, Pereira AM, Petersenn S, Pivonello R, Raff H, Reincke M, Salvatori R, Scaroni C, Shimon I, Stratakis CA, Swearingen B, Tabarin A, Takahashi Y, Theodoropoulou M, Tsagarakis S, Valassi E, Varlamov EV, Vila G, Wass J, Webb SM, Zatelli MC, Biller BMK. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol 2021; 9:847-875. [PMID: 34687601 PMCID: PMC8743006 DOI: 10.1016/s2213-8587(21)00235-7] [Citation(s) in RCA: 298] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
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Affiliation(s)
| | | | | | | | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, Hôpital Cochin, Paris, France
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | | | | | | | - John D Carmichael
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Felipe F Casanueva
- Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM, Marseille, France; Assistance Publique Hopitaux de Marseille, Marseille, France; Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza B Geer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Ashley Grossman
- University of London, London, UK; University of Oxford, Oxford, UK
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK; NIHR Cambridge Biomedical Research Center, Cambridge, UK; Addenbrooke's Hospital, Cambridge, UK
| | - Ken Ho
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Ursula B Kaiser
- Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - 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
| | | | | | - André Lacroix
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ann McCormack
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Alberto M Pereira
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | | | - Hershel Raff
- Medical College of Wisconsin, Milwaukee, WI, USA; Advocate Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Martin Reincke
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | | | - Ilan Shimon
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | | | | | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | | | - Marily Theodoropoulou
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital General de Catalunya, Barcelona, Spain; Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- Churchill Hospital, Oxford, United Kingdom
| | - Susan M Webb
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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18
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Abstract
Cushing's disease (CD) is the most prevalent cause of endogenous hypercortisolism. CD is responsible for multiple co-morbidities and increased mortality. Accurate and prompt diagnosis and optimal treatment are essential to improve the prognosis of CD. However, the diagnosis of CD is probably one of the most difficult in endocrinology and, therefore, diagnostic workup should be performed in an experienced center. Transsphenoidal surgery performed by an expert surgeon is the only therapeutic option that can offer definitive cure and remains the first-line treatment in most patients. Second-line treatments include pharmacotherapy, pituitary radiotherapy and bilateral adrenalectomy. The second-line therapeutic strategy is complex, must be individualized and performed in a multidisciplinary expert center. Symptomatic treatments of persisting co-morbidities after remission, which are responsible for increased mortality and impaired quality of life is an important part of medical management.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France; INSERM U1215, NeuroCentre Magendie, University of Bordeaux, France.
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Yu S, Karsy M, Miller J, Beldick SR, Curtis MT, Rosen M, Evans JJ. Rapidly progressive ACTH-dependent Cushing’s disease masquerading as ectopic ACTH-producing Cushing’s syndrome: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21151. [PMID: 35854960 PMCID: PMC9272366 DOI: 10.3171/case21151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/26/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Cushing’s disease (CD) remains a challenging condition to diagnose and treat. This case study highlights the challenges of diagnosing CD when faced with discrepant clinical, biochemical, and radiological findings.
OBSERVATIONS
A 62-year-old man presented with rapid evolution of symptoms, including depression, fatigue, and extreme muscle atrophy, which resulted in the patient being a wheelchair user over the course of a few months. His rapid clinical course in conjunction with hypercortisolemia in the setting of a pituitary macroadenoma involving the cavernous sinus, two large pulmonary nodules, and urine-free cortisol levels in the thousands suggested an aggressive ectopic adrenocorticotropic hormone (ACTH) source. After extensive testing ruled out CD from an ectopic source and because of the patient’s abrupt clinical deterioration, the authors concluded that the source was likely an aggressive pituitary adenoma. Therefore, the authors performed an endonasal transsphenoidal approach for resection of the pituitary adenoma involving the cavernous sinus, and the patient was scheduled for radiosurgery to control tumor progression.
LESSONS
Although extremely high levels of cortisol and ACTH are associated with ectopic Cushing’s syndrome, they may also indicate an aggressive form of CD. Suspicion should be maintained for hypercortisolemia from a pituitary source even when faced with discrepant information that may suggest an ectopic source.
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Affiliation(s)
| | | | | | | | | | - Marc Rosen
- Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - James J. Evans
- Departments of Neurological Surgery
- Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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20
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Qiang W, Song S, Chen T, Wang Z, Feng J, Zhang J, Guo H. A rare case of ectopic ACTH syndrome with rhabdomyolysis. BMC Endocr Disord 2021; 21:98. [PMID: 33971870 PMCID: PMC8111963 DOI: 10.1186/s12902-021-00755-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 04/19/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Manifestations of hypokalaemia in ectopic adrenocorticotropic hormonesyndrome(EAS) vary from mild muscle weakness to life-threatening arrhythmia. Herein, we present a rare case of EAS with concomitant rhabdomyolysis(RM) as a result of intractable hypokalaemia. CASE PRESENTATION A 64-year-old man was admitted for limb weakness and facial hyperpigmentation for 2 weeks. Lab tests revealed intractable hypokalaemia (lowest at 1.8 mmol/L) and metabolic alkalosis. The diagnosis of RM was based on a creatine kinase(CK)level of 5 times the upper limit. The elevated CK and myohemoglobin (Mb) levels returned to within the normal range after the alleviation of hypokalaemia. The patient was diagnosed with ACTH-dependent Cushing's syndrome (CS) based on unsuppressed serum cortisol after a low-dose dexamethasone suppression test(LDDST) and remarkably elevated ACTH levels. The diagnosis of EAS was made based on the results of a high-dose dexamethasone suppression test(HDDST) and bilateral inferior petrosal sinus sampling(BIPSS). Multiple lymph nodes in the left supraclavicular fossa, right root of neck, mediastinum and bilateral hili of the lung were found with abnormal uptake of 68Ga-DOTA-NOC. Mediastinoscopic lymph node biopsy was performed. The pathological diagnosis was small-cell and large-cell neuroendocrine carcinoma with positive ACTH staining. The patient was prescribed mifepristone and received one cycle of chemotherapy. The patient could not tolerate subsequent chemotherapy and died of dyscrasia. CONCLUSIONS RM is a rare complication of EAS with insidious onset and atypical clinical manifestations. Serum potassium levels should be vigilantly monitored to avoid RM in EAS.
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Affiliation(s)
- Wei Qiang
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
| | - Sucai Song
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
- Department of Endocrinology, The First Affiliated Hospital of Zhengzhou University, 450052 Zhengzhou, People’s Republic of China
| | - Tianjun Chen
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Zhe Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jun Feng
- Department of Vascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jiaojiao Zhang
- Department of Pathology, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Hui Guo
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
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21
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Chen K, Chen S, Lu L, Zhu H, Zhang X, Tong A, Pan H, Wang R, Lu Z. An Optimized Pathway for the Differential Diagnosis of ACTH-Dependent Cushing's Syndrome Based on Low-Dose Dexamethasone Suppression Test. Front Endocrinol (Lausanne) 2021; 12:720823. [PMID: 34539574 PMCID: PMC8445331 DOI: 10.3389/fendo.2021.720823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Traditionally, low-dose dexamethasone suppression test (LDDST) was used to confirm the diagnosis of Cushing's syndrome (CS), and high-dose dexamethasone suppression test (HDDST) was used to differentiate Cushing's disease (CD) and ectopic adrenocorticotropin (ACTH) syndrome (EAS), but some studies suggested that HDDST might be replaced by LDDST. For the differential diagnosis of CS, dexamethasone suppression test was usually combined with other tests such as bilateral petrosal sinus sampling (BIPSS) and pituitary magnetic resonance imaging, but the optimal pathway to incorporate these tests is still controversial. OBJECTIVES To develop an optimized pathway for the differential diagnosis of CD and EAS based on LDDST. DESIGN AND SETTING Single-center retrospective study (2011-2019). PATIENTS Two hundred sixty-nine CD and 29 EAS patients with pathological diagnosis who underwent consecutive low- and high-dose DST. RESULTS For the differential diagnosis of CD and EAS, the area under curve (AUC) of LDDST using urine free cortisol (0.881) was higher than that using serum cortisol (0.685) (p < 0.001) in head-to-head comparison among a subgroup of 108 CD and 10 EAS. The AUC of LDDST (0.883) was higher than that of HDDST (0.834) among all the included patients. With the cutoff of <26%, the sensitivity and specificity of LDDST were 39.4% and 100%. We designed a new pathway in which BIPSS was only reserved for those patients with unsuppressed LDDST and adenoma <6mm, yielding an overall sensitivity of 97.7% and specificity of 86.7%. CONCLUSION LDDST had similar value to HDDST in differentiating CD and EAS using the specific cutoff point. The pathway that combined LDDST and BIPSS could differentiate CD and EAS accurately.
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Affiliation(s)
- Kang Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shi Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Shi Chen, ; Lin Lu,
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Shi Chen, ; Lin Lu,
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaobo Zhang
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Anli Tong
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Pan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhaolin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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22
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Frete C, Corcuff JB, Kuhn E, Salenave S, Gaye D, Young J, Chanson P, Tabarin A. Non-invasive Diagnostic Strategy in ACTH-dependent Cushing's Syndrome. J Clin Endocrinol Metab 2020; 105:5864157. [PMID: 32594169 DOI: 10.1210/clinem/dgaa409] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 06/22/2020] [Indexed: 01/29/2023]
Abstract
CONTEXT Inferior petrosal sinus sampling (IPSS) is used to diagnose Cushing's disease (CD) when dexamethasone-suppression and CRH tests, and pituitary magnetic resonance imaging (MRI), are negative or give discordant results. However, IPSS is an invasive procedure and its availability is limited. OBJECTIVE To test a noninvasive diagnostic strategy associated with 100% positive predictive value (PPV) for CD. DESIGN Retrospective study. SETTING Two university hospitals. PATIENTS A total of 167 patients with CD and 27 patients with ectopic ACTH-syndrome investigated between 2001 and 2016. MAIN OUTCOME MEASURE(S) Performance of a strategy involving the CRH and desmopressin tests with pituitary MRI followed by thin-slice whole-body computed tomography (CT) scan in patients with inconclusive results. RESULTS Using thresholds of a cortisol increase > 17% with an ACTH increase > 37% during the CRH test and a cortisol increase > 18% with an ACTH increase > 33% during the desmopressin test, the combination of both tests gave 73% sensitivity and 98% PPV of CD. The sensitivity and PPV for pituitary MRI were 71% and 99%, respectively. CT scan identified 67% EAS at presentation with no false-positives. The PPV for CD was 100% in patients with positive responses to both tests, with negative pituitary MRI and CT scan. The Negative Predictive Value was 100% in patients with negative responses to both tests, with negative pituitary MRI and positive CT scan. Using this strategy, IPPS could have been avoided in 47% of patients in whom it is currently recommended. CONCLUSIONS In conjunction with expert radiologic interpretation, the non-invasive algorithm studied significantly reduces the need for IPSS in the investigation of ACTH-dependent Cushing's syndrome.
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Affiliation(s)
- Caroline Frete
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Pessac, France
| | - Jean-Benoît Corcuff
- Department of Nuclear Medicine, University Hospital of Bordeaux, Pessac, France
- Nutrition et Neurobiologie Intégrée, UMR 1286, University of Bordeaux, Bordeaux, France
| | - Emmanuelle Kuhn
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Sylvie Salenave
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Delphine Gaye
- Department of Radiology, University Hospital of Bordeaux, Pessac, France
| | - Jacques Young
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
- Université Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
- Université Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Le Kremlin-Bicêtre, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Pessac, France
- Physiopathologie de la Plasticité Neuronale, INSERM U1215, Neurocentre Magendie, Bordeaux, France
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23
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Barbot M, Zilio M, Scaroni C. Cushing's syndrome: Overview of clinical presentation, diagnostic tools and complications. Best Pract Res Clin Endocrinol Metab 2020; 34:101380. [PMID: 32165101 DOI: 10.1016/j.beem.2020.101380] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cushing's syndrome (CS) is a severe condition that results from chronic exposure to elevated circulating cortisol levels; it is a rare but potentially life-threating condition, especially when not timely diagnosed and treated. Even though the diagnosis can be straightforward in florid cases due to their typical phenotype, milder forms can be missed. Despite the availability of different screening tests, the diagnosis remains challenging as none of the available tools proved to be fully accurate. Due to the ubiquitous effect of cortisol, it is easy understandable that its excess leads to a variety of systemic complications including hypertension, metabolic syndrome, bone damages and neurocognitive impairment. This article discusses clinical presentation of CS with an eye on the most frequent cortisol-related comorbidities and discuss the main pitfalls of first- and second-line tests in endogenous hypercortisolism diagnostic workup.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy.
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy
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24
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Nees F, Löffler M, Usai K, Flor H. Hypothalamic-pituitary-adrenal axis feedback sensitivity in different states of back pain. Psychoneuroendocrinology 2019; 101:60-66. [PMID: 30414593 DOI: 10.1016/j.psyneuen.2018.10.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/23/2018] [Accepted: 10/25/2018] [Indexed: 12/14/2022]
Abstract
Pain normally signals a threat to bodily integrity and causes emotional distress. Acute pain serves a protective function, yet, when pain turns chronic, the protective function is lost. A chain of psychophysiological alterations including changes in the stress regulation system, apparent in dysfunctional activity and responsivity of the hypothalamic-pituitary-adrenal (HPA) axis, might be an important factor in this context. Moreover, maladaptive responses may be complicated by affective comorbid symptoms such as anxiety and depression, and alter nociceptive processing. However, the relationship among pain chronicity, stress regulation, and contributing components of comorbid symptomatology as well as somatosensory profiles has rarely been examined. In the present study, we obtained diurnal cortisol profiles at baseline and feedback regulation (following a dexamethasone suppression test (DST)) in subacute (SABP) and chronic (CBP) back pain patients and healthy control individuals (HC). We also assessed anxiety, depression and chronic stress levels and used quantitative sensory testing (QST) to detect sensory abnormalities. We found a hyper-suppression of cortisol following DST and thus enhanced negative stress feedback sensitivity in SABP compared to both CBP and HC. In SABP, DST-related cortisol levels were negatively associated with pain intensity, mediated by cold pain thresholds and anxiety. These data support a stress model of pain chronicity and suggest that stress responses might be indicators of individual vulnerability in the transition period of subacute pain.
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Affiliation(s)
- Frauke Nees
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Martin Löffler
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Katrin Usai
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Herta Flor
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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25
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Abstract
BACKGROUND Two types of ectopic Cushing syndrome (ECS) are described: ECS associated with aggressive neoplasms, and ECS with indolent and occult tumors, however, there is a lack of studies that thoroughly review their characteristics. METHODS A systematic review was carried out on PUBMED of all the papers about the ECS, in order to better define the types of this subcategory of Cushing's syndrome, highlighting the differential aspects between these subgroups. RESULTS It was found that in 50% of cases the prototypic "aggressive" ECS is caused by small cell lung carcinomas (SCLC). In these cases, the clinical presentation may be atypical, predominating the signs and symptoms derived from the protein catabolism. Cortisol and ACTH levels are extremely high, the clinical presentation is abrupt (< 3-6 months) and the tumor is usually advanced, being impossible a curative treatment. On the other hand, "indolent" ECS is mainly represented by carcinoid tumors (CT). In these cases the clinical presentation overlaps enormously with that of Cushing's disease (CD). Cortisol and ACTH levels are slightly elevated, the clinical presentation is progressive (> 6 months) and the prognosis is usually good, and a curative treatment is possible in about 75% of the cases. CONCLUSION Although there is no absolute differentiation between the two extremes of ECS, a classification could be established in two groups, guided by its clinical and biochemical characteristics, and mainly by the type and stage of the ACTH-secreting tumor. However, a small percentage of tumors do not fit in this simple grouping, and may present both phenotypes or an intermediate one.
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Affiliation(s)
- Marta Araujo Castro
- Department Endocrinology, Hospital Universitario de la Princesa, Madrid, Spain.
- Department Endocrinology, Hospital Universitario Rey Juan Carlos, Madrid, Spain.
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26
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Hayes AR, Grossman AB. The Ectopic Adrenocorticotropic Hormone Syndrome: Rarely Easy, Always Challenging. Endocrinol Metab Clin North Am 2018; 47:409-425. [PMID: 29754641 DOI: 10.1016/j.ecl.2018.01.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Despite modern imaging techniques, differentiating ectopic adrenocorticotropic hormone (ACTH) syndrome from pituitary-dependent Cushing's syndrome, Cushing's disease, is especially difficult when well-differentiated carcinoids are the source of ACTH secretion, particularly pulmonary carcinoid tumors. ACTH-secreting pulmonary carcinoids, like the corticotroph adenomas causing Cushing's disease, are often small and difficult to detect, and patients present with a gradual onset of the classical signs and symptoms of Cushing's syndrome, indistinguishable from the presentation of Cushing's disease. Hence, the differential diagnosis relies on a combination of clinical assessment, dynamic biochemical tests, inferior petrosal sinus sampling, and multimodal imaging, each with its own caveats and pitfalls.
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Affiliation(s)
- Aimee R Hayes
- Neuroendocrine Tumour Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - Ashley B Grossman
- Neuroendocrine Tumour Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK.
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27
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Jarial KDS, Bhansali A, Mukherjee KK, Pal R, Sharma A, Vashishtha RK, Sukumar SP, Sachdeva N, Walia R. UTILITY OF A SINGLE LATE-NIGHT PLASMA CORTISOL AND ACTH FOR THE DIAGNOSIS OF CUSHING SYNDROME. Endocr Pract 2017; 24:156-162. [PMID: 29144801 DOI: 10.4158/ep171803.or] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the diagnostic efficacy of various screening tests for the diagnosis of Cushing syndrome (CS). METHODS Thirty-five patients with CS and 16 patients of pseudo-CS were enrolled. Assessment of 24-h urinary free cortisol (UFC), late-night salivary cortisol (LNSC), overnight dexamethasone suppression test (ONDST), late-night plasma cortisol (LNPC), and adrenocorticotropic hormone (ACTH) on outpatient basis, and during sleep as well as in awake state after 48 hours of hospital admission. RESULTS We found that 24-h UFC performed the best among the screening tests with sensitivity, specificity and areas under the curve (AUCs) of 96.0%, 99%, and 0.988, respectively, at a cut-off of 144.6 μg/24 h. A cut-off of 10.5 nmol/L for LNSC had sensitivity 85.7%, specificity 88.2%, and an AUC of 0.897. A cut-off of 412.4 nmol/L for LNPC on outpatient basis had sensitivity 88.2%, specificity 91.2%, and an AUC of 0.957. Cut-offs of 215 and 243.3 nmol/L for LNPC during sleep and awake states after acclimatization had sensitivity, specificity, and an AUC of 94.1%, 88.2%, and 0.958, respectively. An ONDST cut-off of 94.6 nmol/L provided sensitivity, specificity, and an AUC of 96.0%, 99.03% and 0.995, respectively. A cut-off of 30.3 pg/mL for late-night ACTH on outpatient basis had sensitivity 67.6%, specificity 99.9%, and an AUC 0.796.A cut-off of 22.6 pg/mL for ACTH during sleep state after acclimatization had sensitivity, specificity, and an AUC of 73.5%, 99.2%, and 0.827, respectively. CONCLUSION UFC is the best screening test for CS. Furthermore, single measurements of LNPC and ACTH help to establish the diagnosis and ACTH dependency of CS in the majority of patients with CS. ABBREVIATIONS ACTH = adrenocorticotropic hormone AUC = area under the curve CRH = corticotropin-releasing hormone CS = Cushing syndrome ECLIA = electrochemiluminescence immuno-assay LDDST = low-dose dexamethasone suppression test LNPC = late-night plasma cortisol LNSC = late-night salivary cortisol ONDST = overnight dexamethasone suppression test RIA = radio-immuno assay UFC = urinary free cortisol.
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28
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Cushing Syndrome: Diagnostic Workup and Imaging Features, With Clinical and Pathologic Correlation. AJR Am J Roentgenol 2017. [PMID: 28639924 DOI: 10.2214/ajr.16.17290] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Cushing syndrome (CS) is a constellation of clinical signs and symptoms resulting from chronic exposure to excess cortisol, either exogenous or endogenous. Exogenous CS is most commonly caused by administration of glucocorticoids. Endogenous CS is subdivided into two types: adrenocorticotropic hormone (ACTH) dependent and ACTH independent. CONCLUSION Cushing disease, which is caused by a pituitary adenoma, is the most common cause of ACTH-dependent CS for which pituitary MRI can be diagnostic, with bilateral inferior petrosal sinus sampling useful in equivocal cases. In ectopic ACTH production, which is usually caused by a tumor in the thorax (e.g., small cell lung carcinoma, bronchial and thymic carcinoids, or medullary thyroid carcinoma) or abdomen (e.g., gastroenteropancreatic neuroendocrine tumors or pheochromocytoma), CT, MRI, and nuclear medicine tests are used for localizing the source of ACTH. In ACTH-independent CS, which is caused by various adrenal abnormalities, adrenal protocol CT or MRI is usually diagnostic.
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Barbot M, Trementino L, Zilio M, Ceccato F, Albiger N, Daniele A, Frigo AC, Mardari R, Rolma G, Boscaro M, Arnaldi G, Scaroni C. Second-line tests in the differential diagnosis of ACTH-dependent Cushing's syndrome. Pituitary 2016; 19:488-95. [PMID: 27236452 DOI: 10.1007/s11102-016-0729-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Diagnosing Cushing's syndrome (CS) can be a challenge, especially in ACTH-dependent CS, when it comes to detecting the origin of ACTH secretion. MATERIALS AND METHODS Retrospective data were collected on 170 patients with ACTH-dependent CS (149 CD, 21 EAS) referring to two endocrinology units, focusing on three non-invasive tests: dexamethasone 8 mg overnight challenge (HDDST); corticotrophin-releasing hormone (CRH) assay and the desmopressin (DDAVP) test. RESULTS Patients with EAS were slightly older and had higher ACTH, serum and urinary cortisol levels than patients with CD (p < 0.01). CD patients had a stronger ACTH and cortisol response after CRH injection (p < 0.0001), and a more pronounced reduction in cortisol levels after HDDST (p < 0.0001). A threshold percentage ACTH increase after CRH stimulation of 72.4 % was able to identify CD with a sensitivity (SE) of 76 % (95 % CI 68-83) and a specificity (SP) of 100 % (95 % CI 83-100). As for HDDST, a cortisol suppression >52.7 % below the basal level suggested a pituitary origin with a SE of 88 % (95 % CI 81-93) and a SP of 90 % (95 % CI 68-99). There were no cases of EAS with positive responses to both these tests. Increases in ACTH and cortisol levels after the DDAVP test were also higher in CD than in EAS (p < 0.01), though the SE and SP were lower. CONCLUSIONS Patients with CD showed a stronger response to HDDST and CRH, and the adopted cut-offs showed a good SE and SP in discriminating them from patients with EAS. Concordant tests indicated CD when positive, whereas no response to either test was highly suggestive of EAS. The DDAVP test was of limited utility in the diagnostic phase. In conclusion, the choice of tests may play an important part in the differential diagnosis of ACTH-dependent CS.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
| | - Laura Trementino
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Nora Albiger
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Andrea Daniele
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital, Padua, Italy
| | | | | | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Giorgio Arnaldi
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
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Carroll TB, Javorsky BR, Findling JW. POSTSURGICAL RECURRENT CUSHING DISEASE: CLINICAL BENEFIT OF EARLY INTERVENTION IN PATIENTS WITH NORMAL URINARY FREE CORTISOL. Endocr Pract 2016; 22:1216-1223. [PMID: 27409817 DOI: 10.4158/ep161380.or] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the performance of biochemical markers in the detection of recurrent Cushing disease (CD), as well as the potential benefit of early intervention in recurrent CD patients with elevated late-night salivary cortisol (LNSC) and normal urinary free cortisol (UFC). METHODS The design was a single-center, retrospective chart review. Patients treated by the authors from 2008-2013 were included. Recurrence was defined by postsurgical remission of CD with subsequent abnormal LNSC, UFC, or dexamethasone suppression test (DST). RESULTS We identified 15 patients with postsurgical recurrent CD after initial remission; all but one underwent testing with LNSC, DST, and UFC. Although 12 of 15 patients had normal UFC at time of recurrence, DST was abnormal in 11 of 15, and all 14 patients with LNSC results had ≥1 elevated measurement. Nine patients (7 with normal UFC) showed radiologic evidence of a pituitary tumor at time of recurrence. Among the 14 patients with available follow-up data, 12 have demonstrated significant improvement since receiving treatment. Five patients underwent repeat pituitary surgery and 4 achieved clinical and biochemical remission. Eight patients received mifepristone or cabergoline, and 6 showed clinical and/or biochemical improvement. Three patients (2 with prior mifepristone) underwent bilateral adrenalectomy and 2 demonstrated significant clinical improvements. CONCLUSION LNSC is more sensitive than UFC or DST for detection of CD recurrence. Prompt intervention when LNSC is elevated, despite normal UFC, may yield significant clinical benefit for many patients with CD. Early treatment for patients with recurrent CD should be prospectively evaluated, utilizing LNSC elevation as an early biochemical marker. ABBREVIATIONS ACTH = adrenocorticotropic hormone CD = Cushing disease CS = Cushing syndrome CV = coefficient of variation DST = dexamethasone suppression test IPSS = inferior petrosal sinus sampling LNSC = late-night salivary cortisol QoL = quality of life TSS = transsphenoidal adenoma resection UFC = urinary free cortisol.
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Chen YY, Li SQ, Liu HS, Qin YZ, Li L, Huang C, Bi YL, Meng YX, He J, Zhou XY, Ma DJ. Ectopic adrenocorticotropic hormone syndrome caused by neuroendocrine tumors of the thymus: 30-year experience with 16 patients at a single institute in the People's Republic of China. Onco Targets Ther 2016; 9:2193-201. [PMID: 27217765 PMCID: PMC4853161 DOI: 10.2147/ott.s100585] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and purpose Thymic neuroendocrine carcinomas (TNECs) are extremely uncommon. Certain cases of TNECs can produce the adrenocorticotropic hormone (ACTH) and cause ectopic ACTH syndrome (EAS). The current literature on this topic consists mainly of case reports, and therapeutic guidelines are lacking. The aim of this study was to discuss the diagnosis, surgical management, and prognosis of EAS caused by TNECs to improve clinical experience with this rare disease. Methods From June 1984 to June 2014, at the Peking Union Medical College Hospital, the surgical interventions and follow-up outcomes of 16 consecutive patients (eight men and eight women) with EAS caused by TNECs were retrospectively analyzed. Results The median age was 32.5 years (range: 13–47 years), and the median disease duration was 8.5 months (range: 1–150 months). All patients presented with clinical and biochemical evidence indicating a diagnosis of Cushing’s syndrome. Contrast-enhanced thoracic computed tomography scans were critical to locating the ACTH-producing tumor and evaluating the feasibility of resection. All patients underwent surgery. One patient died of septicemia in the intensive care unit 2 weeks after surgery. No other morbidity or mortality occurred during the perioperative period. The median overall survival (OS) was 41 months (95% CI: 30.3–51.7 months), and the progression-free survival was 28 months (95% CI: 21.6–34.3 months). Both overall survival (P=0.002) and progression-free survival (P=0.030) improved significantly after complete resection. Conclusion TNEC is an extremely aggressive disease that should be considered when treating patients with Cushing’s syndrome due to ectopic ACTH secretion. In particular, all suspected patients should undergo contrast-enhanced thoracic computed tomography scans to facilitate early diagnosis. The current first-line treatment is surgical resection, and complete resection is a favorable prognostic factor. However, additional patients and a longer follow-up will be needed to determine the variables that are predictive of survival and to improve patient prognosis.
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Affiliation(s)
- Ye-Ye Chen
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Shan-Qing Li
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China; Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Hong-Sheng Liu
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China; Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Ying-Zhi Qin
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Li Li
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Cheng Huang
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Ya-Lan Bi
- Department of Pathology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Yun-Xiao Meng
- Department of Pathology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Jia He
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Xiao-Yun Zhou
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Dong-Jie Ma
- Department of Thoracic Surgery, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
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Aktas G, Soyluoglu Demir S, Sarikaya A. Bilateral symmetrical adrenal hypermetabolism on FDG PET/CT due to Cushing syndrome in well differentiated neuroendocrine carcinoma. Rev Esp Med Nucl Imagen Mol 2016. [DOI: 10.1016/j.remnie.2016.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Dobreva EA, Krylov VV, Kuznetsov NS, Parshin VV, Ippolitov LI. [ACTH-producing tumors of the chest: features of clinical course, diagnosis and surgical treatment]. Khirurgiia (Mosk) 2016:45-51. [PMID: 26753201 DOI: 10.17116/hirurgia20158245-51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- E A Dobreva
- Surgical Endocrinology Research Center of Russian Ministry of Health
| | - V V Krylov
- Chair of Faculty Surgery, Medical Faculty of I.M. Sechenov First Moscow State Medical University, Russian Ministry of Health, Moscow, Russia
| | - N S Kuznetsov
- Surgical Endocrinology Research Center of Russian Ministry of Health
| | - V V Parshin
- Department of Thoracic Surgery of I.M. Sechenov First Moscow State Medical University, Russian Ministry of Health, Moscow, Russia
| | - L I Ippolitov
- Surgical Department of the University's Clinical Hospital #1 of I.M. Sechenov First Moscow State Medical University, Russian Ministry of Health, Moscow, Russia
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Aktas GE, Soyluoglu Demir S, Sarikaya A. Bilateral symmetrical adrenal hypermetabolism on FDG PET/CT due to Cushing syndrome in well differentiated neuroendocrine carcinoma. Rev Esp Med Nucl Imagen Mol 2015; 35:118-20. [PMID: 26522002 DOI: 10.1016/j.remn.2015.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 07/11/2015] [Accepted: 08/20/2015] [Indexed: 11/15/2022]
Abstract
The (18)F-FDG PET/CT scan has been suggested for whole-body imaging to identify ectopic adrenocorticotrophic hormone secreting tumours, but there are some challenges involved. The case of a patient is presented, who was admitted with the pre-diagnosis of ectopic ACTH syndrome. On the CT, a nodular lesion was detected in the medial segment of the right lung. The FDG uptake of the lesion seemed to be increased visually, but was not pathological quantitatively (SUVmax: 1.8) on the PET/CT. There was also diffuse increased uptake (SUVmax: 14.2) in the enlarged adrenal glands. The lesion was reported as a possible malignant lesion with low FDG affinity, such as a low grade neuroendocrine tumour, while the diffuse enlarged adrenal glands with high uptake were interpreted as diffusely hyperplasic, due to Cushing's syndrome. The patient was treated with a surgical wedge resection. The histopathological diagnosis confirmed that the tumour was a grade 1 well-differentiated neuroendocrine carcinoma.
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Affiliation(s)
- G E Aktas
- Trakya University Medical Faculty Hospital, Department of Nuclear Medicine, Turkey.
| | - S Soyluoglu Demir
- Trakya University Medical Faculty Hospital, Department of Nuclear Medicine, Turkey
| | - A Sarikaya
- Trakya University Medical Faculty Hospital, Department of Nuclear Medicine, Turkey
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Isidori AM, Sbardella E, Zatelli MC, Boschetti M, Vitale G, Colao A, Pivonello R. Conventional and Nuclear Medicine Imaging in Ectopic Cushing's Syndrome: A Systematic Review. J Clin Endocrinol Metab 2015; 100:3231-44. [PMID: 26158607 PMCID: PMC4570166 DOI: 10.1210/jc.2015-1589] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Shusterman M, Bloomgarden NA, Sotardi ST, Shastri A. Tumor Lysis Syndrome in an Unusual Metastatic Pancreatic Neuroendocrine Tumor with Ectopic ACTH Secretion. J Gastrointest Cancer 2015; 47:423-428. [PMID: 26271662 DOI: 10.1007/s12029-015-9755-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Michael Shusterman
- Department of Medicine, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Noah A Bloomgarden
- Department of Medicine, Division of Endocrinology, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Susan T Sotardi
- Department of Radiology, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Aditi Shastri
- Department of Oncology, Montefiore Medical Center, 111 East 210th Street, Hofheimer Main, Room 111, Bronx, NY, 10467, USA.
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Ritzel K, Beuschlein F, Berr C, Osswald A, Reisch N, Bidlingmaier M, Schneider H, Honegger J, Geyer LL, Schopohl J, Reincke M. ACTH after 15 min distinguishes between Cushing's disease and ectopic Cushing's syndrome: a proposal for a short and simple CRH test. Eur J Endocrinol 2015; 173:197-204. [PMID: 25953828 DOI: 10.1530/eje-14-0912] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 05/06/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of the present study was to validate criteria of corticotropin-releasing hormone (CRH) stimulation and 8 mg dexamethasone suppression (high-dose dexamethasone suppression, HDDS) to distinguish the etiology of ACTH-dependent Cushing's syndrome. SUBJECTS AND METHODS We retrospectively analyzed cortisol and ACTH after the injection of 100 μg human CRH in confirmed Cushing's disease (CD, n=78) and confirmed ectopic Cushing's syndrome (ECS, n=18). Cortisol and ACTH increase (in percentage above basal (%B)) at each time point, maximal increase (Δmax %B), and area under the curve (AUC %B) were analyzed using receiver operator characteristics (ROC) curve analyses. Cortisol suppression (%B) after 8 mg of dexamethasone was evaluated as a supplementary criterion. RESULTS An increase in ACTH of ≥ 43%B at 15 min after CRH was the strongest predictor of CD, with a positive likelihood ratio of 14.0, a sensitivity of 83%, a specificity of 94%, a positive predictive value of 98% and a negative predictive value of 58%. All of the other criteria of stimulated ACTH and cortisol levels were not superior in predicting CD in response to CRH injection. The addition of cortisol suppression by dexamethasone did not increase the discriminatory power. However, the combination of a positive ACTH response at 15 min and a positive HDDS test excluded ECS in all cases. CONCLUSION The present findings support the use of plasma ACTH levels 15 min after the injection of human CRH as a response criterion for distinguishing between CD and ECS. The addition of the HDDS test is helpful for excluding ECS when both tests are positive.
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Affiliation(s)
- Katrin Ritzel
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Christina Berr
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Harald Schneider
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jürgen Honegger
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Lucas L Geyer
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of NeurosurgeryUniversity of Tuebingen, Tuebingen, GermanyInstitut für klinische RadiologieKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
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Li L, Chen Y, Li S, Liu H, Huang C, Qin Y. [Primary Neuroendocrine Carcinoma of Thymus Caused Cushing Syndrome: Surgical Treatment and Prognosis Analysis]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2015; 18:451-6. [PMID: 26182871 PMCID: PMC6000246 DOI: 10.3779/j.issn.1009-3419.2015.07.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
背景与目的 胸腺原发神经内分泌癌为一种罕见疾病,部分肿瘤可以分泌促肾上腺皮质激素导致库欣综合征,手术切除肿瘤是治疗的关键。本研究回顾性总结并探讨胸腺原发神经内分泌癌所致库欣综合征临床诊断及手术治疗方法,并行预后分析,提高对此罕见病种的认识及诊疗水平。 方法 回顾性分析北京协和医院1987年11月-2013年6月间收治的14例由胸腺原发神经内分泌癌导致的库欣综合征患者的临床资料。 结果 14例患者,男性8例,女性6例,中位年龄29岁,中位病程4.0个月(1个月-44个月),术前多项内分泌检查及影像学检查诊断并定位胸腺病变,经手术切除后血皮质醇及血促肾上腺皮质激素均下降(P < 0.01)。围手术期死亡1例。经术后综合治疗及随访,中位生存期为38个月。 结论 胸腺原发神经内分泌癌所致库欣综合征为一种罕见疾病,侵袭性强,目前治疗效果欠佳。早期诊断及早期治疗对临床医师而言存在很大难度,胸部增强计算机断层扫描(computed tomography, CT)是诊断并定位的重要手段,需要多种检查手段及多学科医师共同会诊并制定以手术为主的综合诊治方案。
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Affiliation(s)
- Li Li
- Department of Thoracic Surgery, Endocrine Key Laboratory of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yeye Chen
- Department of Thoracic Surgery, Endocrine Key Laboratory of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Shanqing Li
- Department of Thoracic Surgery, Endocrine Key Laboratory of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Endocrine Key Laboratory of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Cheng Huang
- Department of Thoracic Surgery, Endocrine Key Laboratory of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yingzhi Qin
- Department of Thoracic Surgery, Endocrine Key Laboratory of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
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Affiliation(s)
- David J Torpy
- Endocrine and Metabolic UnitRoyal Adelaide Hospital, University of Adelaide, Adelaide, South Australia 5000, Australia
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40
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Abstract
The dexamethasone (DXM) test has been widely used for diagnosing Cushing's disease (CD). The purpose of this paper is to review its diagnostic merit based on calculation of data extracted from earlier publications. Studies presenting individual values for patients with CD and normal subjects were identified through PubMed searches and references in pertinent studies. Calculation of the retrieved data demonstrated huge variation in the relative suppressibility, negative suppression being common. Furthermore, in almost each study retrieved, the pre and post DXM values were closely correlated. Finally, the generally accepted view that DXM causes less suppression in Cushing's disease than in euadrenal controls appears unfounded. A central issue in the definition of so-called "pseudo-Cushing's states" is failure to suppress cortisol secretion with DXM. From analysis of the literature it appears quite possible that this does not reflect a specific endocrine deficit, but a physiological "stress" reaction. The above issues question the diagnostic value of the test, in particular in clinically and biochemically borderline cases.
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Affiliation(s)
- J Lindholm
- Department of Endocrinology, Aalborg University Hospital, 9000, Aalborg, Denmark,
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Sakihara S, Kageyama K, Yamagata S, Terui K, Daimon M, Suda T. A case of ectopic ACTH syndrome treated with intermittent administration of dopamine agonists. Endocrinol Diabetes Metab Case Rep 2014; 2014:140001. [PMID: 24683487 PMCID: PMC3965275 DOI: 10.1530/edm-14-0001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/24/2014] [Accepted: 03/03/2014] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED ACTH-dependent Cushing's syndrome includes Cushing's disease and ectopic ACTH syndrome (EAS). The differential diagnosis of Cushing's disease from EAS in cases of ACTH-dependent Cushing's syndrome is a challenging problem. We report here a case of EAS with an unknown source of ACTH secretion. Extensive imaging procedures, involving computed tomography (neck to pelvis), pituitary magnetic resonance imaging, and whole-body (18)F-fluorodeoxyglucose-positron emission tomography, failed to reveal the source of ACTH secretion. Intermittent administration of bromocriptine, a short-acting and nonselective dopamine agonist, has afforded adequate suppression of plasma ACTH and cortisol levels over the long term. LEARNING POINTS Tumor excision is the primary treatment for EAS. However, when surgery is impossible, medical therapy is needed to treat hypercortisolism.In cases where the source of ACTH secretion is unknown, inhibitors of steroidogenesis, such as metyrapone, mitotane, ketoconazole, and etomidate, are mostly used to suppress cortisol secretion.Medications that suppress ACTH secretion are less effective, therefore less popular, as standard treatments.In the present case, short-term treatment with dopamine agonists was effective for the long-term suppression of both ACTH and cortisol levels.
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Affiliation(s)
- Satoru Sakihara
- Department of Endocrinology and Metabolism Hirosaki University Graduate School of Medicine 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Kazunori Kageyama
- Department of Endocrinology and Metabolism Hirosaki University Graduate School of Medicine 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Satoshi Yamagata
- Department of Endocrinology and Metabolism Hirosaki University Graduate School of Medicine 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Ken Terui
- Department of Endocrinology and Metabolism Hirosaki University Graduate School of Medicine 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Makoto Daimon
- Department of Endocrinology and Metabolism Hirosaki University Graduate School of Medicine 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Toshihiro Suda
- Department of Endocrinology and Metabolism Hirosaki University Graduate School of Medicine 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
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Liburt NR, McKeever KH, Malinowski K, Smarsh DN, Geor RJ. Response of the hypothalamic-pituitary-adrenal axis to stimulation tests before and after exercise training in old and young Standardbred mares1. J Anim Sci 2013; 91:5208-19. [DOI: 10.2527/jas.2013-6329] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- N. R. Liburt
- Equine Science Center, Rutgers, The State University of New Jersey, New Brunswick 08901
| | - K. H. McKeever
- Equine Science Center, Rutgers, The State University of New Jersey, New Brunswick 08901
| | - K. Malinowski
- Equine Science Center, Rutgers, The State University of New Jersey, New Brunswick 08901
| | - D. N. Smarsh
- Equine Science Center, Rutgers, The State University of New Jersey, New Brunswick 08901
| | - R. J. Geor
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing 48824
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Günes M, Celik O, Kadioglu P. Reliability of the diagnostic tests for Cushing's syndrome performed in a tertiary referral center. Pituitary 2013; 16:139-45. [PMID: 22466318 DOI: 10.1007/s11102-012-0387-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The study aimed to retrospectively evaluate the reliability of the diagnostic and location tests in Cushing's Syndrome (CS). Eighty-seven patients diagnosed with CS between 1995 and 2007 by Endocrinology Metabolism Department of Cerrahpasa Medical School were included in the study. The control group consisted of 91 patients who presented to the outpatient clinic because of obesity. The diagnostic tests were as follows: 1 mg dexamethasone suppression test (DST), 24-h urinary free cortisol (UFC), midnight cortisol level (MCL), ACTH level and overnight 8 mg DST. The sensitivity and specificity of UFC were 81 and 66 % respectively for the cut-off point of 50 μg/day, whereas they were 64 and 76 % respectively for the cut-off point of 100 μg/day. For the cut-off value of 1.8/μg/dL for MCL and 1 mDST, the sensitivity rates were 100 and 98 %, while the specificity rates were 88 and 33 %, respectively. Among the location tests, the sensitivity and specificity of ACTH under 10 pg/mL for adrenal CS were 92 and 94 % respectively. The sensitivity and specificity of ACTH higher than 30 pg/mL for ACTH-dependent CS were 69 and 100 % respectively. The sensitivity rates of 8 mg DST for 50 and 60 % suppressions were 83 and 79 % respectively, whereas the specificity rates were 75 and 88 % respectively. 1 mg DST (cut-off <1.8 μg/dL) and UFC (50 μg/24 h) are appropriate tests for screening CS. Overnight 8 mg DST with 60 % suppression for Cushing's Disease (CD) and ACTH levels <10 pg/mL for adrenal CS, ACTH levels >30 pg/mL for ACTH dependency were identified as the best tests for the differential diagnosis of the subtypes.
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Affiliation(s)
- Mutlu Günes
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey
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Alexandraki KI, Kaltsas GA, Isidori AM, Storr HL, Afshar F, Sabin I, Akker SA, Chew SL, Drake WM, Monson JP, Besser GM, Grossman AB. Long-term remission and recurrence rates in Cushing's disease: predictive factors in a single-centre study. Eur J Endocrinol 2013; 168:639-48. [PMID: 23371975 DOI: 10.1530/eje-12-0921] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the early and late outcomes of patients with Cushing's disease (CD) submitted to a neurosurgical procedure as first-line treatment. DESIGN In this single-centre retrospective case notes study, 131 patients with CD with a minimum follow-up period of 6 years (124 operated by transsphenoidal surgery (TSS) and seven by the transcranial approach) were studied. Apparent immediate cure: post-operative 0900 h serum cortisol level <50 nmol/l; remission: cortisol insufficiency or restoration of 'normal' cortisol levels with resolution of clinical features; and recurrence: dexamethasone resistance and relapse of hypercortisolaemic features. RESULTS In patients operated by TSS, remission of hypercortisolaemia was found in 72.8% of 103 microadenomas and 42.9% of 21 macroadenomas, with recurrence rates 22.7 and 33.3% respectively with a 15-year mean follow-up (range, 6-29 years). Of 27 patients with microadenomas operated after 1991, with positive imaging and pathology, 93% obtained remission with 12% recurrence. In multivariate analysis, the time needed to achieve recovery of hypothalamo-pituitaryadrenal axis was the only significant predictor of recurrence; all patients who recurred showed recovery within 3 years from surgery: 31.3% of patients had total hypophysectomy with no recurrence; 42% of patients with selective adenomectomy and 26.5% with hemi-hypophysectomy showed recurrence rates of 31 and 13% respectively (χ(2)=6.275, P=0.03). Strict remission criteria were not superior in terms of the probability of recurrence compared with post-operative normocortisolaemia. CONCLUSIONS Lifelong follow-up for patients with CD appears essential, particularly for patients who have shown rapid recovery of their axis. The strict criteria previously used for 'apparent cure' do not appear to necessarily predict a lower recurrence rate.
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Affiliation(s)
- Krystallenia I Alexandraki
- Department of Endocrinology, St Bartholomew’s Hospital, Barts and the London NHS Trust, Barts and the London School of Medicine, London, UK
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Tung SC, Wang PW, Liu RT, Chen JF, Hsieh CJ, Kuo MC, Yang JW, Lee WC, Cheng MH, Lee TC. Clinical Characteristics of Endogenous Cushing's Syndrome at a Medical Center in Southern Taiwan. Int J Endocrinol 2013; 2013:685375. [PMID: 24062770 PMCID: PMC3766604 DOI: 10.1155/2013/685375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/11/2013] [Accepted: 07/18/2013] [Indexed: 11/18/2022] Open
Abstract
From January 1987 to December 2011, over a total of 25 years, 84 patients with Cushing's syndrome (CS) were identified at a medical center in southern Taiwan. We observed a higher incidence of ACTH-independent CS (75%) than ACTH-dependent CS (25%). A higher incidence of adrenocortical adenoma (58.3%) than Cushing's disease (CD, 21.4%) was also found. The sensitivity of the definitive diagnostic tests for CS, including loss of plasma cortisol circadian rhythm, a baseline 24 h urinary free cortisol (UFC) value >80 μ g, and overnight and 2-day low-dose dexamethasone suppression test, was between 94.4% and 100%. For the 2-day high-dose dexamethasone suppression test for the differential diagnosis of CD, the sensitivity of 0800 h plasma cortisol and 24 h UFC was 44.4% and 85.7%, respectively. For the differential diagnosis of adrenal CS, the sensitivities of the 0800 h plasma cortisol and 24 h UFC were 95.5% and 88.9%, respectively. In patients with ACTH-independent CS and ACTH-dependent CS, the baseline plasma ACTH levels were all below 29 pg/mL and above 37 pg/mL, respectively. The postsurgical hospitalization stay following retroperitoneoscopic adrenalectomy was shorter than that observed for transabdominal adrenalectomy (4.3 ± 1.6 versus 8.8 ± 3.7 days, P < 0.001). It was easy to develop retroperitoneal and peritoneal seeding of adrenocortical carcinoma via laparoscopic adrenalectomy.
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Affiliation(s)
- Shih-Chen Tung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
- *Shih-Chen Tung:
| | - Pei-Wen Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Rue-Tsuan Liu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Jung-Fu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Ching-Jung Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Ming-Chun Kuo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Joseph W. Yang
- Division of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Wei-Ching Lee
- Division of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Min-Hsiung Cheng
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
| | - Tao-Chen Lee
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 83301, Taiwan
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Juszczak A, Grossman A. The investigation of Cushing syndrome: essentials in optimizing appropriate diagnosis and management. Ann Saudi Med 2012; 32:455-61. [PMID: 22871612 PMCID: PMC6080996 DOI: 10.5144/0256-4947.2012.455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The investigation of Cushing syndrome (CS) should start with careful history taking and clinical examination, and exogenous steroid usage must be excluded. It is essential to confirm hypercortisolism before further investigations are undertaken. The recommended first-line tests include midnight salivary cortisol and/or the 1 mg overnight or low-dose dexamethasone suppression tests. The next step is to differentiate adrenocorticotrophin (ACTH)-dependent from ACTH-independent CS by measuring ACTH. With ACTH-dependence, further investigations should differentiate pituitary-dependent from ectopic ACTH-dependent CS. Many dynamic tests may be considered, but we suggest that bilateral inferior petrosal sinus sampling should be performed in almost all patients with ACTH-dependent CS, except for patients with a pituitary macroadenoma. Imaging should include MR scanning of the pituitary, and CT scanning of the chest and abdomen to look for an ectopic source. Confirmation of the diagnosis of CS and accurate localization of its source are vital to optimize therapy for this complex disorder.
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Lau JHG, Sze WCC, Reznek RH, Matson M, Sahdev A, Carpenter R, Berney DM, Akker SA, Chew SL, Grossman AB, Monson JP, Drake WM. A prospective evaluation of postural stimulation testing, computed tomography and adrenal vein sampling in the differential diagnosis of primary aldosteronism. Clin Endocrinol (Oxf) 2012; 76:182-8. [PMID: 21895732 DOI: 10.1111/j.1365-2265.2011.04202.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT In primary aldosteronism (PA), discriminating unilateral from bilateral disease is crucial because adrenalectomy is frequently curative in the former case but rarely helps in the latter. Various series have reported the utility of postural stimulation testing (PST), cross-sectional imaging and adrenal vein sampling (AVS) in the assessment of PA, but most of these studies were retrospective. OBJECTIVE To prospectively determine the diagnostic utility of PST, AVS and computed tomography (CT) using a radiological scoring system in the assessment of PA in a tertiary centre, as well as to document the incidence of autonomous cortisol cosecretion. DESIGN AND SETTING Fifty consecutive patients with PA underwent PST, CT, AVS and a low-dose dexamethasone suppression test with measurement of serum cortisol at 48 h. For patients who underwent surgery, histological confirmation, and a normal postoperative serum aldosterone concentration and plasma renin activity were taken as evidence for unilateral disease. For other patients, results from successful adrenal vein sampling were the diagnostic evidence against which CT and PST were assessed. RESULTS Postural stimulation testing had a sensitivity and specificity of 44-56% and 71-75%, respectively. CT had an overall sensitivity and specificity of 77% and 80%, respectively, rising to 100% sensitivity and specificity if there was a single, discrete macronodule with an unequivocally normal contralateral gland. Evidence of cosecretion of cortisol occurred in 14% of patients. CONCLUSIONS Preliminary experience is presented of an objective radiological scoring system for selecting patients with PA for AVS. PST provides little, if any, useful additional information. A significant minority of patients with PA exhibit evidence of cortisol cosecretion, which may have implications for perioperative management.
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Affiliation(s)
- Jeshen H G Lau
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
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Ma Y, Aitelli C, Dobson RW, Konduri K. Ectopic adrenocorticotropic hormone syndrome: a diagnostic challenge and review of the literature. Proc (Bayl Univ Med Cent) 2011; 23:426-8. [PMID: 21240327 DOI: 10.1080/08998280.2010.11928663] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We present a case of a 60-year-old woman who initially presented with pneumonia and abdominal pain and was diagnosed with ectopic adrenocorticotropic hormone (ACTH) syndrome secondary to small cell lung cancer. We review published literature and summarize the typical challenges in the diagnosis and treatment of ectopic ACTH syndrome. Recent research has shed new light on the mechanism of ectopic ACTH production and provided a potential new target for treatment.
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Affiliation(s)
- Yanjun Ma
- Departments of Medical Oncology (Ya, Aitelli, Konduri) and Pathology (Dobson), Baylor Charles A. Sammons Cancer Center and Baylor University Medical Center at Dallas
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Storr HL, Alexandraki KI, Martin L, Isidori AM, Kaltsas GA, Monson JP, Besser GM, Matson M, Evanson J, Afshar F, Sabin I, Savage MO, Grossman AB. Comparisons in the epidemiology, diagnostic features and cure rate by transsphenoidal surgery between paediatric and adult-onset Cushing's disease. Eur J Endocrinol 2011; 164:667-74. [PMID: 21310872 DOI: 10.1530/eje-10-1120] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE There are few published comparisons between paediatric and adult-onset Cushing's disease (CD). We compare the epidemiology, diagnostic features and cure rate by transsphenoidal surgery (TSS) in these groups. DESIGN Retrospective review of patient databases in a single university hospital centre. PATIENTS Totally, 41 paediatric (mean age 12.3 ± 3.5 years; range 5.7-17.8) and 183 adult (mean age 40 ± 13 years; range 18.0-95.0) patients with CD were investigated. RESULTS Paediatric CD was characterised by male (63%) and adult CD by a female predominance (79%, P<0.0001). There were small but significant differences in clinical presentation. Biochemical features of CD were comparable except the serum cortisol increase during a CRH test: mean change (105%, n=39) in paediatric and (54%, n=123) in adult subjects (P<0.0001). Macroadenomas were more common in adult (15%, 28/183) than in paediatric (2%, 1/41, P=0.04) CD. Corticotroph microadenomas were more easily visualised by pituitary magnetic resonance imaging (MRI) in adult (76%, 50/66) compared with paediatric (55%, 21/38, P=0.045) CD with poorer concordance of imaging with surgical findings in children (P=0.058). The incidence of ACTH lateralisation by bilateral simultaneous inferior petrosal sinus sampling was comparable in paediatric (76%, 25/33) and adult (79%, 46/58; P=0.95) patients with good surgical concordance in both (82% paediatric and 79% adult). Cure rates by TSS were comparable, with a paediatric cure rate of 69%. CONCLUSION Several features of paediatric CD are distinct: increased frequency of prepubertal CD in males, the different clinical presentation, the decreased presence of macroadenomas and the frequent absence of radiological evidence of an adenoma on MRI.
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Affiliation(s)
- H L Storr
- Department of Paediatric Endocrinology, Barts and The London School of Medicine and Dentistry, London EC1A 7BE, UK.
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