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Kakizawa K, Yamashita M, Kawauchi Y, Ikeya A, Ohba K, Matsushita A. Evaluating the usefulness of plasma chromogranin A measurement in cyclic ACTH-dependent Cushing's syndrome. Endocr J 2024; 71:995-1002. [PMID: 38925945 DOI: 10.1507/endocrj.ej24-0128] [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] [Indexed: 06/28/2024] Open
Abstract
Cushing's syndrome, a clinical condition characterized by hypercortisolemia, exhibits distinct clinical signs and is associated with cyclic cortisol secretion in some patients. The clinical presentation of cyclic Cushing's syndrome can be ambiguous and its diagnosis is often challenging. We experienced a 72-year-old woman with cyclic ACTH-dependent Cushing's syndrome caused by a pulmonary carcinoid tumor. Diagnosis was challenging because of the extended trough periods, and the responsible lesion was initially unidentified. A subsequent follow-up computed tomography revealed a pulmonary lesion, and ectopic ACTH secretion from this lesion was confirmed by pulmonary artery sampling. Despite the short peak secretion period of ACTH (approximately one week), immunostaining of the surgically removed tumor confirmed ACTH positivity. Interestingly, stored plasma chromogranin A levels were elevated during both peak and trough periods. The experience in evaluating this patient prompted us to investigate the potential use of plasma chromogranin A as a diagnostic marker of ACTH-dependent Cushing's syndrome. A retrospective study was conducted to determine the efficacy of plasma chromogranin A in three patients with ectopic ACTH syndrome (EAS), including the present case, and six patients with Cushing's disease (CD) who visited our hospital between 2018 and 2021. Notably, plasma chromogranin A levels were higher in patients with EAS than in those with CD. Additionally, a chromogranin A level in the present case during the trough phase was lower than that in the peak phase, and was similar to those in CD patients. The measurement of plasma chromogranin A levels could aid in differentiating EAS from CD.
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Affiliation(s)
- Keisuke Kakizawa
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
| | - Miho Yamashita
- International Center, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
| | - Yuto Kawauchi
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
| | - Akira Ikeya
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
| | - Kenji Ohba
- Medical Education Center, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
| | - Akio Matsushita
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
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Song L, Miao H, Zhu Z, Zhu H, Wang J, Xing X, Zhu Z, Jiang Y, Feng R, Xiao Y, Duan L, Sui X, Liu Q, Wang L, Chen S, Song W, Jin Z, Lu L. Differentiating lung neuroendocrine neoplasms from tumor-like infection using CT in patients with ectopic ACTH syndrome. Insights Imaging 2024; 15:187. [PMID: 39090485 PMCID: PMC11294316 DOI: 10.1186/s13244-024-01775-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/07/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVES Pulmonary neuroendocrine neoplasms (NENs) are the most frequent cause of ectopic adrenocorticotropic hormone syndrome (EAS); lung infection is common in EAS. An imaging finding of infection in EAS patients can mimic NENs. This retrospective study investigated EAS-associated pulmonary imaging indicators. METHODS Forty-five pulmonary NENs and 27 tumor-like infections from 59 EAS patients (45 NEN and 14 infection patients) were included. Clinical manifestations, CT features, 18F-FDG, or 68Ga-DOTATATE-PET/CT images and pathological results were collected. RESULTS High-sensitivity C-reactive protein (p < 0.001) and expectoration occurrence (p = 0.04) were higher, and finger oxygen saturation (p = 0.01) was lower in the infection group than the NENs group. Higher-grade NENs were underrepresented in our cohort. Pulmonary NENs were solitary primary tumors, 80% of which were peripheral tumors. Overlying vessel sign and airway involvement were more frequent in the NENs group (p < 0.001). Multifocal (p = 0.001) and peripheral (p = 0.02) lesions, cavity (p < 0.001), spiculation (p = 0.01), pleural retraction (p < 0.001), connection to pulmonary veins (p = 0.02), and distal atelectasis or inflammatory exudation (p = 0.001) were more frequent in the infection group. The median CT value increment between the non-contrast and arterial phases was significantly higher in NENs lesions (p < 0.001). Receiver operating characteristic curve analysis indicated a moderate predictive ability at 48.3 HU of delta CT value (sensitivity, 95.0%; specificity, 54.1%). CONCLUSION Chest CT scans are valuable for localizing and characterizing pulmonary lesions in rare EAS, thereby enabling prompt differential diagnosis and treatment. CRITICAL RELEVANCE STATEMENT: Thin-slice CT images are valuable for the localization and identification of pulmonary ectopic adrenocorticotropic hormone syndrome lesions, leading to prompt differential diagnosis and effective treatment. KEY POINTS Lung tumor-like infections can mimic neuroendocrine neoplasms (NENs) in ectopic adrenocorticotropic hormone syndrome (EAS) patients. NENs are solitary lesions, whereas infections are multiple peripheral pseudotumors each with identifying imaging findings. Typical CT signs aid in localization and creating an appropriate differential diagnosis.
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Affiliation(s)
- Lan Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Hui Miao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Zhenchen Zhu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- 4+4 Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jinhua Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhaohui Zhu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yuanyuan Jiang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ruie Feng
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yu Xiao
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lian Duan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xin Sui
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Qingxing Liu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Linjie Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Shi Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Wei Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Zhengyu Jin
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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3
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Ragnarsson O, Juhlin CC, Torpy DJ, Falhammar H. A clinical perspective on ectopic Cushing's syndrome. Trends Endocrinol Metab 2024; 35:347-360. [PMID: 38143211 DOI: 10.1016/j.tem.2023.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 12/26/2023]
Abstract
Cushing's syndrome (CS) refers to the clinical features of prolonged pathological glucocorticoid excess. About 10-20% of individuals with CS have ectopic CS (ECS), that is, an adrenocorticotropin (ACTH)-producing tumour outside the pituitary gland. ACTH-secreting neuroendocrine neoplasia (NENs) can arise from many organs, although bronchial NEN, small cell lung cancer (SCLC), pancreatic NEN, thymic NEN, medullary thyroid cancer (MTC), and pheochromocytoma are the most common. Patients with ECS frequently present with severe hypercortisolism. The risk of life-threatening complications is high in severe cases, unless the hypercortisolism is effectively treated. A good outcome in ECS requires a methodical approach, incorporating prompt diagnosis, tumour localization, control of cortisol excess, and resection of the primary tumour when possible.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, SE-413 90 Gothenburg, Sweden
| | - C Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Pathology and Cancer Diagnostics, Karolinska University Hospital Solna, Stockholm, Sweden
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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4
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Murakami M, Hirahata K, Fujimori N, Yamamoto T, Oda Y, Kozono S, Ueda K, Ito T, Nakamura M, Ogawa Y. Two cases of pancreatic neuroendocrine tumors with ectopic ACTH syndrome during their disease course. Clin J Gastroenterol 2024; 17:363-370. [PMID: 38244178 DOI: 10.1007/s12328-023-01908-5] [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: 11/02/2023] [Accepted: 12/08/2023] [Indexed: 01/22/2024]
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are rare malignant tumors that occur in the pancreas. They are divided into functioning and non-functioning tumors based on the presence or absence of their specific hormonal hyper-expression symptoms. Adrenocorticotropic hormone (ACTH)-producing PanNETs are rare, functional tumors, and their clinical characteristics and outcomes have not been well reported.Here, we report the cases of two patients with PanNETs who presented with ectopic ACTH syndrome (EAS) during the course of their disease. Case 1 involved a non-functioning PanNET at the time of surgery. During treatment for recurrent liver metastases, the patient presented with EAS and tumor-associated hypercalcemia, probably due to ACTH and parathyroid hormone-related peptide (PTHrP) production from the liver tumor. Case 2 was a gastrinoma, and similar to Case 1, this patient presented with EAS during the treatment of recurrent liver metastases.It is not uncommon for patients with PanNETs to have multiple hormones and develop secondary hormone secretion during their disease course, although tumor phenotypes differ between primary and metastatic sites. In patients with functioning PanNETs, symptom control with anti-hormonal therapy is essential, in addition to anti-tumor therapy, especially for EAS, which is an endocrine emergency disease that requires prompt diagnosis and treatment.
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Affiliation(s)
- Masatoshi Murakami
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keisuke Hirahata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Takeo Yamamoto
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shingo Kozono
- Department of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Keijiro Ueda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Testuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital, Fukuoka, Japan
- Department of Gastroenterology, Graduate School of Medical Sciences, International University of Health and Welfare, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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5
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Ramirez-Renteria C. Ectopic Hormonal Syndromes: Cushing's Syndrome and Acromegaly. Arch Med Res 2023; 54:102898. [PMID: 38007384 DOI: 10.1016/j.arcmed.2023.102898] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/13/2023] [Accepted: 10/09/2023] [Indexed: 11/27/2023]
Abstract
Ectopic hormone production may be present in neuroendocrine and non-endocrine neoplasms. Ectopic sources of growth hormone, adrenocorticotropin (ACTH), or their releasing factors are uncommon but clinically relevant. Ectopic ACTH tumors have been studied more than the rest, but there are still no comprehensive multidisciplinary guidelines that include all the pitfalls in the diagnosis and management of ectopic hormonal syndromes and the neoplasms associated with ectopic Cushing or acromegaly. The frequency of neuroendocrine neoplasms and other neoplasms with neuroendocrine differentiation has been increasing in recent decades. The review of the available data on these tumors, their classification, and improvements in diagnostic and therapeutic procedures is important to understand the relevance of ectopic Cushing's syndrome and acromegaly in clinical practice.
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Affiliation(s)
- Claudia Ramirez-Renteria
- Experimental Endocrinology Unit, Endocrine Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
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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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7
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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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Bostan H, Duger H, Akhanli P, Calapkulu M, Turkmenoglu TT, Erdol AK, Duru SA, Sencar ME, Kizilgul M, Ucan B, Ozbek M, Cakal E. Cushing's syndrome due to adrenocorticotropic hormone-secreting metastatic neuroendocrine tumor of unknown primary origin: a case report and literature review. Hormones (Athens) 2022; 21:147-154. [PMID: 34478059 PMCID: PMC8414022 DOI: 10.1007/s42000-021-00316-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/24/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In this article, we present a case of neuroendocrine neoplasm of unknown primary origin (UPO NEN), which is a rare cause of ectopic Cushing's syndrome (ECS) presenting numerous challenges, together with a literature review. CASE REPORT A 43-year-old male patient presented with clinical features consistent with Cushing's syndrome (CS) and adrenocorticotropic hormone (ACTH)-dependent hypercortisolemia. Despite a suspicious lesion on pituitary MRI, the high-dose dexamethasone suppression test and bilateral inferior petrosal sinus sampling results were not compatible with Cushing's disease. Bilateral non-homogeneous opacities were observed in the thorax CT of the patient, who also had a history of COVID-19 infection, but no tumoral lesion was detected. When 68Ga-SSTR PET/CT and 18FDG-PET/CT were performed, multiple metastatic foci were detected in mediastinal and hilar lymph nodes and the axial skeleton. Paratracheal-subcarinal lymph nodes were excised mediastinoscopically, and the diagnosis of NEN was made. Histopathological findings indicated that the possible origin was an atypical pulmonary carcinoid with a low Ki-67 labeling index. After controlling hypercortisolemia, a regimen of somatostatin analogs and capecitabine plus temozolomide was decided upon as treatment by a multidisciplinary council. CONCLUSION This is a challenging case of UPO NEN presenting with ECS and confounding factors, such as previous infection and incidental lesions, during the diagnosis process. The case in question highlighted the fact that atypical pulmonary carcinoid with a low proliferation index may cause visible metastases even when radiologically undetectable.
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Affiliation(s)
- Hayri Bostan
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey.
| | - Hakan Duger
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
| | - Pinar Akhanli
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
| | - Murat Calapkulu
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
| | - Tugba Taskin Turkmenoglu
- Department of Pathology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ayse Kevser Erdol
- Department of Chest Diseases, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Serap Akcali Duru
- Department of Chest Diseases, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Muhammed Erkam Sencar
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
| | - Muhammed Kizilgul
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
| | - Bekir Ucan
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
| | - Mustafa Ozbek
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
| | - Erman Cakal
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şht. Ömer Halisdemir Blv. No. 1, 6110, Ankara, Turkey
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Zhang B, He Q, Long Y, Zhang Y, Wang X, Chen Z, Liu J, Zhang X. Comparison of diagnostic efficacy of 18F-FDG PET/CT and 68Ga-DOTANOC PET/CT in ectopic adrenocorticotropic hormone syndrome. Front Endocrinol (Lausanne) 2022; 13:962800. [PMID: 36213295 PMCID: PMC9538925 DOI: 10.3389/fendo.2022.962800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Fluorine-18 (18F)-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and gallium-68 (68Ga)-somatostatin analog (SSA) PET/CT imaging have been increasingly used in ectopic adrenocorticotropic hormone syndrome (EAS); however, the diagnostic efficacies of these two methods in patients with EAS remain unclear. Our study aimed to compare the diagnostic efficacies of 18F-FDG PET/CT and 68Ga-DOTANOC PET/CT in EAS. METHODS The clinical and imaging data of 68 patients with EAS who underwent 18F-FDG PET/CT and 68Ga-DOTANOC PET/CT examinations from December 2016 to April 2021 were analyzed retrospectively, and the diagnostic efficacies of these methods were compared. RESULTS In 37 cases, imaging was performed to locate the primary tumor lesion (localization group), and in 31 to evaluate tumor load or metastasis (staging group). Primary tumors were detected in 48.65% (18/37) of the localization group patients. According to scan-based analysis, the tumor lesion detection rates and false positive rates of 18F-FDG PET/CT imaging and 68Ga-DOTANOC PET/CT imaging were 18.92% vs. 45.95% (p < 0.05) and 21.62% vs. 2.70% (p < 0.05) respectively. For lesion-based analysis, the tumor lesion detection rates and false positive rates were 24.13% vs. 58.62% (p >0.05) and 31.04% vs. 3.45% (p < 0.05). In 90.32% (28/31) of the staging group patients, 286 of 292 lesions were confirmed as tumor lesions. Based on scan analysis, the detection rates and false positive rates of 18F-FDG PET/CT imaging and 68Ga-DOTANOC PET/CT imaging were 83.87% vs. 67.74% (p > 0.05) and 12.90% vs. 9.68% (p > 0.05) respectively. Based on lesion analysis, the detection rate and false positive rates were 93.84% vs. 54.80% (p < 0.05) and 1.37% vs. 1.03%(p > 0.05). CONCLUSION 68Ga-DOTANOC PET/CT imaging may be more suitable than 18F-FDG PET/CT for identifying the primary tumor in patients with EAS, while 18F-FDG PET/CT may be more advantageous than 68Ga-DOTANOC PET/CT for patients with suspected metastasis.
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Affiliation(s)
| | | | | | | | | | | | - Jianbo Liu
- *Correspondence: Xiangsong Zhang, ; Jianbo Liu,
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Liu Q, Zang J, Yang Y, Ling Q, Wu H, Wang P, Lu L, Zhu Z. Head-to-head comparison of 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT in localizing tumors with ectopic adrenocorticotropic hormone secretion: a prospective study. Eur J Nucl Med Mol Imaging 2021; 48:4386-4395. [PMID: 34146130 DOI: 10.1007/s00259-021-05370-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Localizing the source of ectopic adrenocorticotropic hormone secretion (EAS) is challenging. This study compared the diagnostic value of 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT in tumors with EAS. METHODS Thirty-six patients with a suspicion of EAS were enrolled to undergo both 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT within 4 weeks for comparison. Twenty-three underwent surgical resection or biopsy. Immunohistochemical staining for SSTR2 and Ki-67 was performed to correlate with 68Ga-DOTATATE uptake and 18F-FDG uptake, respectively. RESULTS EAS tumors were observed in 20/23 patients. Among the 20 patients with histologically proven EAS tumors, 68Ga-DOTATATE PET/CT correctly identified the tumor in 15 (75.0%), with an SUVmax ranging from 1.4 to 20.7 (6.7 ± 5.5). 18F-FDG PET/CT correctly identified the tumor in 12 (60.0%) patients, with an SUVmax ranging from 1.8 to 10.0 (4.0 ± 2.1). Moreover, 68Ga-DOTATATE PET/CT unmasked the sources of EAS in 6 patients with negative 18F-FDG uptake, and 18F-FDG PET/CT unmasked the sources in 3 patients with negative 68Ga-DOTATATE uptake, resulting in EAS tumors being identified in 18 (90%) patients by combining 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT. CONCLUSIONS 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT are complementary in localizing and discriminating the source of EAS. 68Ga-DOTATATE PET/CT combined with 18F-FDG PET/CT had higher detection rate than each alone. TRIAL REGISTRATION 68Ga-DOTATATE PET/CT in Neuroendocrine Tumors (NCT04041882) URL OF REGISTRY: https://clinicaltrials.gov/ct2/show/NCT04041882.
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Affiliation(s)
- Qingxing Liu
- Department of Nuclear Medicine, 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
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Jie Zang
- Department of Nuclear Medicine, 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
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Yingying Yang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qing Ling
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Pengyan Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Zhaohui Zhu
- Department of Nuclear Medicine, 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.
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China.
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Ding L, Wang B, Chen T, Li P, Guo W, Fan Y, Fang F, Cui J, Dong Z, He Q, Liu M. Development and validation of a novel index for the differential diagnosis of corticotropin-dependent Cushing syndrome. Pituitary 2021; 24:507-516. [PMID: 33502672 DOI: 10.1007/s11102-021-01126-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE To develop an index for the differential diagnosis of corticotropin-dependent Cushing syndrome (CS). METHODS The development cohort included 112 consecutive patients with clinicopathologically confirmed corticotropin-dependent CS at the Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, from December 2004 to May 2020, and data of 126 patients from studies published from 2016 to August 2020, identified through search in PubMed, Embase and the Cochrane Library, was extracted for external validation. The index was calculated as the product of plasma adrenocorticotropic hormone (ACTH, pmol/L) and urinary free cortisol (UFC, nmol/24 h) divided by 10,000. The discriminative ability was tested using receiver operating characteristics (ROC) curve analysis. RESULTS In development cohort, area under curve of ROC analysis of the ACTH-UFC index in identifying Cushing disease (CD) was 0.977. The diagnostic accuracy of ACTH-UFC index ≤ 11 was comparable to that of 48 h 8 mg/d high-dose dexamethasone test (HDDST) in identifying CD, with sensitivity, specificity, positive and negative likelihood ratios of 96.6%, 87.5%, 7.73, and 0.04, respectively. The sensitivity of ACTH-UFC index ≤ 11 in parallel combination with pituitary magnetic resonance imaging (MRI) was 100% for identifying CD. The performance of the ACTH-UFC index in parallel or serial combination with pituitary MRI was similar in the validation cohort. CONCLUSIONS ACTH-UFC index provides a rapid, convenient and non-invasive adjunctive approach for the differential diagnosis of corticotropin-dependent CS, with no risk of aggravating metabolic disturbances. Investigations for ectopic causes of corticotropin-dependent CS should be performed with ACTH-UFC index > 11 and negative contrasted pituitary MRI.
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Affiliation(s)
- Li Ding
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Baoping Wang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Tingting Chen
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Ping Li
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Weihong Guo
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Yuxin Fan
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Fang Fang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Jingqiu Cui
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Zuoliang Dong
- Department of Clinical Laboratory, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China
| | - Qing He
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China.
| | - Ming Liu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, No. 154, Anshan, Road, Heping District, Tianjin, 300052, China.
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Novruzov F, Aliyev A, Wan MYS, Syed R, Mehdi E, Aliyeva I, Giammarile F, Bomanji JB, Kayani I. The value of [68Ga]Ga-DOTA-TATE PET/CT in diagnosis and management of suspected pituitary tumors. Eur J Hybrid Imaging 2021; 5:10. [PMID: 34181114 PMCID: PMC8218063 DOI: 10.1186/s41824-021-00104-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background Gallium 68-tetraazacyclododecane-tetraacetic acid-octreotate ([68Ga]Ga-DOTA-TATE) is a selective somatostatin analogue ligand, which shows increased affinity for somatostatin receptor subtype (SSTR) 2 and has been used routinely for imaging neuroendocrine tumors with PET/CT. We investigated the utility of [68Ga]Ga-DOTA-TATE positron emission tomography/computed tomography (PET/CT) in patients with suspected pituitary pathology. We reviewed imaging for twenty consecutive patients (8 men, 12 women, mean age of 48.2, range 14–78) with suspected pituitary pathology who were referred for [68Ga]Ga-DOTA-TATE PET/CT. Results Nine patients presented with recurrent Cushing’s syndrome following surgical resection of pituitary adenomas due to recurrent Cushing’s disease (seven patients) and ectopic ACTH secreting tumor (2 patients). All seven patients with recurrent Cushing’s disease showed positive pituitary [68Ga]Ga-DOTA-TATE uptake while both cases of ectopic hormonal secretion had absented pituitary uptake. In 1 of these 2 patients, [68Ga]Ga-DOTA-TATE was able to localize the source of ectopic ACTH tumor. Six patients presented de novo with Cushing’s due to ectopic ACTH secretion; [68Ga]Ga-DOTA-TATE PET/CT was able to localize ectopic tumors in six of eight patients (3 lungs, 2 pancreases, 1 mid-gut) There was high uptake [68Ga]Ga-DOTA-TATE in 3 cases of recurrent central hyperthyroidism (SUVmax 6.6–14.3) and 2 cases of prolactinoma (SUVmax 5.5 and 11.3). Conclusion Absent [68Ga]Ga-DOTA-TATE activity in the pituitary fossa is useful in excluding pituitary disease in recurrent Cushing’s. Recurrent pituitary thyrotropinomas and prolactinomas showed moderate to high pituitary activity. In addition, in Cushing’s syndrome, [68Ga]Ga-DOTA-TATE is useful for detection of ectopic sources of ACTH production, especially where anatomic imaging is negative.
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Affiliation(s)
- Fuad Novruzov
- Department of Nuclear Medicine, Azerbaijan National Centre of Oncology, M. Xiyabani street 137, AZ 1011, Baku, Azerbaijan. .,Institute of Nuclear Medicine, University College London Hospital, London, UK.
| | - Aziz Aliyev
- Department of Head and Neck Surgery, Azerbaijan National Centre of Oncology, Baku, Azerbaijan
| | - Ming Young S Wan
- Institute of Nuclear Medicine, University College London Hospital, London, UK
| | - Rizwan Syed
- Institute of Nuclear Medicine, University College London Hospital, London, UK
| | - Elnur Mehdi
- Department of Nuclear Medicine, Azerbaijan National Centre of Oncology, M. Xiyabani street 137, AZ 1011, Baku, Azerbaijan
| | - Irada Aliyeva
- Department of Internal Medicine, Azerbaijan Medical University, Baku, Azerbaijan
| | | | - Jamshed B Bomanji
- Institute of Nuclear Medicine, University College London Hospital, London, UK
| | - Irfan Kayani
- Institute of Nuclear Medicine, University College London Hospital, London, UK
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Miao H, Lu L, Zhu H, Du H, Xing X, Zhang X, Song L, Song W, Liu Q, Cheng X, Zhu Z, Chen S, Tong A, Pan H, Wang R, Lu Z. Experience of Ectopic Adrenocorticotropin Syndrome: 88 Cases With Identified Causes. Endocr Pract 2021; 27:866-873. [PMID: 33705970 DOI: 10.1016/j.eprac.2021.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Ectopic adrenocorticotropic hormone syndrome (EAS) is a rare cause of Cushing's syndrome and diagnosis and management remain challenging. The aim of this study was to present the clinical spectrum of a group of EAS cases in a single center to explore better management strategies. METHODS A retrospective study was conducted to identify 88 confirmed EAS cases at our hospital from 1984 to 2019. The clinical, biochemical, imaging, and pathological features were analyzed. RESULTS Of the 88 eligible patients with EAS, 38 (43.2%) cases of pulmonary neuroendocrine tumors (NETs) and a larger number of thymic/mediastinal NETs (29 cases, 33%) were identified. The clinical and biological features of EAS and Cushing's disease overlapped but were more severe in EAS. Inferior petrosal sinus sampling (97.4%) and computed tomography (85.4%) provided the highest positive diagnostic accuracy. Computed tomography is also a useful tool to identify tumors in chest cavity compared with nonchest lesions (91.2% vs 57.1%). Although a greater tumor size (4.54 cm vs 1.44 cm) and higher rate of insuppressible high-dose dexamethasone suppression test (83.3% vs 51.5%) were found in thymic/mediastinum NETs than in pulmonary NETs, the level of hormone production had no difference. CONCLUSION EAS had more common and severe clinical presentations than Cushing's disease, and multiple imaging approaches are required for reliable diagnosis. A higher proportion of thymic/mediastinal NETs was found in our study. For patients without a certain tumor source, long-term follow-up and further evaluations are needed.
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Affiliation(s)
- Hui Miao
- 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, 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, 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, Beijing, China.
| | - Hanze Du
- 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, Beijing, China
| | - Xiaoping Xing
- 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, Beijing, China
| | - Xiaobo Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lan Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qingxing Liu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xin Cheng
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Zhaohui Zhu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 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, Beijing, China
| | - Anli Tong
- 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, 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, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Zhaolin 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, Beijing, China
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Moszczyńska E, Pasternak-Pietrzak K, Prokop-Piotrkowska M, Śliwińska A, Szymańska S, Szalecki M. Ectopic ACTH production by thymic and appendiceal neuroendocrine tumors - two case reports. J Pediatr Endocrinol Metab 2021; 34:141-146. [PMID: 33185577 DOI: 10.1515/jpem-2020-0442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Ectopic adrenocorticotropic syndrome (EAS) causes approximately 10-18% of cases of Cushing's syndrome (CS) in adults, while in children it occurs much less frequently. CASE PRESENTATION We report two cases of neuroendocrine tumors (of the thymus and the appendix) in a 12-year-old boy and a 15-year-old girl who presented with the clinical features of CS. Elevated serum cortisol, ACTH, and chromogranin levels were observed in both patients. Diagnoses were made on the basis of a mass in the thymus/appendix region visualized with chest/abdominal CT scan and radiotracer accumulation in scintigraphy in the same areas. Histopathological examinations confirmed the diagnoses of NET. CONCLUSION EAS is an extremely rare endocrine disorder. However, it should be taken into consideration in the diagnostic process of every case of ACTH-dependent CS.
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Affiliation(s)
- Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Monika Prokop-Piotrkowska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Anna Śliwińska
- Department of Nuclear Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Sylwia Szymańska
- Department of Pathology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute, Warsaw, Poland.,Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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15
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Senanayake R, Gillett D, MacFarlane J, Van de Meulen M, Powlson A, Koulouri O, Casey R, Bashari W, Gurnell M. New types of localization methods for adrenocorticotropic hormone-dependent Cushing's syndrome. Best Pract Res Clin Endocrinol Metab 2021; 35:101513. [PMID: 34045044 DOI: 10.1016/j.beem.2021.101513] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The management of endogenous Cushing's syndrome (CS) typically involves two key steps: (i) confirmation of autonomous hypercortisolism and (ii) localization of the cause to guide treatment. Adrenocorticotropic hormone (ACTH)-dependent CS is most commonly due to a pituitary corticotrope tumor which may be so small as to evade detection on conventional magnetic resonance imaging (MRI). Although biochemical testing (e.g., corticotropin stimulation; dexamethasone suppression) can provide an indication of the likely origin of ACTH excess, bilateral inferior petrosal sinus catheterization offers greater accuracy to distinguish pituitary-driven CS [Cushing's Disease (CD)] from the ectopic ACTH syndrome [EAS, e.g., due to a bronchial or pancreatic neuroendocrine tumor (NET)]. In patients with CD, 40-50% may not have a pituitary adenoma (PA) readily visualized on standard clinical MRI. In these subjects, alternative MR sequences (e.g., dynamic, volumetric, fluid attenuation inversion recovery) and higher magnetic field strength (7T > 3T > 1.5T) may aid tumor localization but carry a risk of identifying coincidental (non-causative) pituitary lesions. Molecular imaging is therefore increasingly being deployed to detect small ACTH-secreting PA, with hybrid imaging [e.g., positron emission tomography (PET) combined with MRI] allowing precise anatomical localization of sites of radiotracer (e.g., 11C-methionine) uptake. Similarly, small ACTH-secreting NETs, missed on initial cross-sectional imaging, may be detected using PET tracers targeting abnormal glucose metabolism (e.g., 18F-fluorodeoxyglucose), somatostatin receptor (SSTR) expression (e.g., 68Ga-DOTATATE), amine precursor (e.g., 18F-DOPA) or amino acid (e.g., 11C-methionine) uptake. Therefore, modern management of ACTH-dependent CS should ideally be undertaken in specialist centers which have an array of cross-sectional and functional imaging techniques at their disposal.
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Affiliation(s)
- Russell Senanayake
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Daniel Gillett
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - James MacFarlane
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Merel Van de Meulen
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Andrew Powlson
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Olympia Koulouri
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Ruth Casey
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Waiel Bashari
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Mark Gurnell
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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16
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Paleń-Tytko JE, Przybylik-Mazurek EM, Rzepka EJ, Pach DM, Sowa-Staszczak AS, Gilis-Januszewska A, Hubalewska-Dydejczyk AB. Ectopic ACTH syndrome of different origin-Diagnostic approach and clinical outcome. Experience of one Clinical Centre. PLoS One 2020; 15:e0242679. [PMID: 33237923 PMCID: PMC7688153 DOI: 10.1371/journal.pone.0242679] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 11/08/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Ectopic Cushing Syndrome (EAS) is a rare condition responsible for about 5-20% of all Cushing syndrome cases. It increases the mortality of affected patients thus finding and removal of the ACTH-producing source allows for curing or reduction of symptoms and serum cortisol levels. The aim of this study is to present a 20-year experience in the diagnosis and clinical course of patients with EAS in a single Clinical Centre in Southern Poland as well as a comparison of clinical course and outcomes depending on the source of ectopic ACTH production-especially neuroendocrine tumors with other neoplasms. METHODS Twenty-four patients were involved in the clinical study with EAS diagnosed at the Department of Endocrinology between years 2000 and 2018. The diagnosis of EAS was based on the clinical presentation, hypercortisolemia with high ACTH levels, high dose dexamethasone suppression test and/or corticotropin-releasing hormone tests. To find the source of ACTH various imaging studies were performed. RESULTS Half of the patients were diagnosed with neuroendocrine tumors, whereby muscle weakness was the leading symptom. Typical cushingoid appearance was seen in merely a few patients, and weight loss was more common than weight gain. Patients with neuroendocrine tumors had significantly higher midnight cortisol levels than the rest of the group. Among patients with infections, we observed a significantly higher concentrations of cortisol 2400 levels in gastroenteropancreatic neuroendocrine tumors. Chromogranin A correlated significantly with potassium in patients with neuroendocrine tumors and there was a significant correlation between ACTH level and severity of hypokalemia. CONCLUSION EAS is not common, but if it occurs it increases the mortality of patients; therefore, it should be taken into consideration in the case of coexistence of severe hypokalemia with hypertension and muscle weakness, especially when weight loss occurs. Because the diagnosis of gastroenteropancreatic neuroendocrine tumor worsens the prognosis-special attention should be paid to these patients.
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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: 57] [Impact Index Per Article: 14.3] [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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18
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Abstract
PURPOSE OF REVIEW Ectopic adrenocorticotropic hormone (ACTH)-secreting tumors are commonly small, yet they often lead to fulminant forms of Cushing syndrome. High-resolution functional imaging modalities, such as [Ga]-DOTATATE, have been recently introduced in clinical practice for the identification of neuroendocrine tumors. In this review, we focus on the performance of [Ga]-DOTATATE as a tool for localizing primary and metastatic sources of ectopic Cushing syndrome (ECS). RECENT FINDINGS Prompt surgical removal of ectopic ACTH-secreting tumors is the mainstay of therapy in patients with ECS. Detecting such tumors with conventional cross-sectional imaging is often unsuccessful, owing to their small size. [Ga]-DOTATATE has been approved in 2016 by the Federal Drug Administration for imaging well differentiated neuroendocrine tumors. Data regarding the performance of [Ga]-DOTATATE for detecting ectopic ACTH-secreting tumors remain limited, in part owing to the recent introduction of this imaging modality in clinical practice, and in part because of the low prevalence of ECS. Nevertheless, [Ga]-DOTATATE has been reported to be useful in identifying primary and metastatic ectopic ACTH-secreting lesions that were not apparent on other imaging studies, impacting the clinical care of many patients with ECS. SUMMARY [Ga]-DOTATATE-based imaging, which targets the somatostatin receptors abundantly expressed in neuroendocrine tumors, has generally high, although variable resolution in detecting the source(s) of ECS.
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Affiliation(s)
- Seda Grigoryan
- Department of Internal Medicine, Michigan State University, East Lasing
| | | | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
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Bélissant Benesty O, Nataf V, Ohnona J, Michaud L, Zhang-Yin J, Bertherat J, Chanson P, Reznik Y, Talbot JN, Montravers F. 68Ga-DOTATOC PET/CT in detecting neuroendocrine tumours responsible for initial or recurrent paraneoplastic Cushing's syndrome. Endocrine 2020; 67:708-717. [PMID: 31583575 DOI: 10.1007/s12020-019-02098-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Paraneoplastic Cushing's syndrome (PCS) is frequently caused by neuroendocrine tumours (NETs). Approximately 20% of tumours are still occult years later. Gallium-68 somatostatin receptor-PET/CT is promising for the detection of the causal primary NET, but its role in case of recurrent PCS is rarely reported. We report our experience with DOTATOC PET/CT in localising the causal NET in cases of initial but also recurrent PCS, and its clinical impact. METHODS A retrospective review of all DOTATOC PET/CTs performed in consecutive patients referred for PCS to our centre, between January 2011 and June 2017, was done. Nineteen patients underwent 26 PET/CTs, 13 for detection of a primary NET, seven for persistent or recurrent PCS after resection, and six for surveillance after resection of NETs previously detected on a DOTATOC PET/CT in our centre. RESULTS Among the 13 PET/CTs performed to search for primary NET, five were positive: four carcinoid lung tumours were confirmed after resection and one lung focus was not confirmed since surgery would have carried a high risk. Clinical impact was 23% (3/13). Among the seven PET/CTs performed for persistent or recurrent PCS, six were true-positive, with confirmation of metastatic lymph nodes after resection. Clinical impact was 57% (4/7). All PET/CTs performed for surveillance were true-negative. CONCLUSIONS DOTATOC PET/CT seems to be a valuable tool for detection of the NET responsible for persistent or recurrent PCS after surgery. In this context, DOTATOC PET/CT was more effective than for the detection of the causal tumour in initial PCS.
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Affiliation(s)
| | - Valérie Nataf
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Jessica Ohnona
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Laure Michaud
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Jules Zhang-Yin
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Jérôme Bertherat
- Endocrinology, Hôpital Cochin APHP and Paris Descartes University, Paris, France
| | - Philippe Chanson
- Endocrinology, Hôpital Bicêtre APHP and Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Yves Reznik
- Endocrinology, Centre Hospitalo-Universitaire de Caen and Université de Caen Normandie, Caen, France
| | - Jean-Noël Talbot
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
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Ectopic Cushing's Syndrome Unveiling a Metastatic Parotid Carcinoma. Case Rep Endocrinol 2019; 2019:3196283. [PMID: 31737376 PMCID: PMC6815534 DOI: 10.1155/2019/3196283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/23/2019] [Indexed: 12/05/2022] Open
Abstract
Introduction Adrenocorticotropic hormone (ACTH) ectopic production is a rare cause of Cushing syndrome (CS). The most commonly associated tumours are small-cell lung carcinoma along with bronchial and thymic carcinoids. To date, only 5 cases have been published in the literature featuring ectopic ACTH secretion from metastatic acinic cell carcinoma (ACC) of the parotid gland. We hereby describe a very uncommon case of ectopic CS (ECS) unveiling a metastatic parotid ACC. Case Presentation A 46-year-old man with hypertension and dyslipidemia diagnosed 4-months before, as well as new-onset diabetes mellitus unveiled 1-month earlier, was referred to emergency department for hypokalemia. Hormonal study and dynamic biochemical tests performed indicated ECS. Imaging and cytological findings pointed toward a likely primary right parotid malignancy with liver metastases. Somatostatin receptor scintigraphy has shown an increased uptake in the parotid gland and mild expression in liver metastasis. The patient underwent right parotidectomy, and histopathologic examination confirmed ACC. Meanwhile, hypercortisolism was managed with metyrapone, ketoconazole, and lanreotide. Despite chemotherapy onset, a rapid disease progression and clinical course deterioration was observed. Conclusion The present report highlights a rare ECS, exposing a metastatic parotid ACC, with an aggressive and challenging clinical course, representing the first case whose diagnosis of ECS came prior to ACC.
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Wannachalee T, Turcu AF, Bancos I, Habra MA, Avram AM, Chuang HH, Waguespack SG, Auchus RJ. The Clinical Impact of [ 68 Ga]-DOTATATE PET/CT for the Diagnosis and Management of Ectopic Adrenocorticotropic Hormone - Secreting Tumours. Clin Endocrinol (Oxf) 2019; 91:288-294. [PMID: 31066920 PMCID: PMC6689243 DOI: 10.1111/cen.14008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/17/2019] [Accepted: 05/07/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Localization of ectopic ACTH-secreting tumours causing Cushing syndrome (ECS) is essential for clinical management, yet often difficult. [68 Ga]-DOTATATE PET/CT ([68 Ga]-DOTA-(Tyr3 )-octreotate)] is an FDA-approved high-resolution diagnostic tool for imaging neuroendocrine tumours. Data on the clinical utility of [68 Ga]-DOTATATE in patients with ECS, however, are scarce. The objectives of this study were to determine the efficacy for ECS localization and the clinical benefit of [68 Ga]-DOTATATE imaging. METHOD We conducted a retrospective review of all cases with ECS evaluated with [68 Ga]-DOTATATE from November 2016 through October 2018 at three referral centres. The clinical benefit of [68 Ga]-DOTATATE was based on detection of new tumours and resultant changes in management. RESULTS Over the study period, 28 patients with ECS underwent [68 Ga]-DOTATATE: 17 for identification of the primary tumour and 11 during follow-up. [68 Ga]-DOTATATE identified the suspected primary ECS in 11/17 patients (65%). Of these, nine patients underwent surgery: eight with confirmed ECS (5 bronchial, 1 thymic, 1 pancreatic and 1 metastatic neuroendocrine tumour of unknown primary origin) and one patient with a false-positive scan (adrenal gland). Of the 11 patients with ECS who underwent [68 Ga]-DOTATATE evaluation during follow-up, the study led to changes in clinical management in 7/11 (64%) patients. CONCLUSIONS [68 Ga]-DOTATATE is sensitive in detecting primary and metastatic ECS, often identifies occult tumours after conventional imaging, and impacts clinical care in the majority of patients.
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Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
- Division of Endocrinology and Metabolism, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Adina F. Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic Rochester, MN, USA
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anca M. Avram
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Hubert H. Chuang
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven G. Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard J. Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
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22
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Araujo Castro M, Palacios García N, Aller Pardo J, Izquierdo Alvarez C, Armengod Grao L, Estrada García J. Ectopic Cushing syndrome: Report of 9 cases. ACTA ACUST UNITED AC 2018; 65:255-264. [PMID: 29655957 DOI: 10.1016/j.endinu.2018.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/29/2018] [Accepted: 02/03/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Ectopic Cushing's syndrome (ECS) is a rare condition caused by ACTH secretion by extrapituitary tumors. Its low frequency makes it difficult to acquire experience in its management. The aim of this study was to describe patients with ECS seen at the endocrinology department of a tertiary hospital over 15 years. METHODS This was a retrospective study of the clinical, biochemical and radiographic data, treatment, and course of patients with ECS seen from 2000 to 2015. RESULTS Nine patients (6 of them female) with a mean age of 47 years were included in the study. The clinical syndrome developed in less than 3 months in all cases but one, and most patients also had edema, hyperpigmentation and/or hypokalemia. Mean urinary free cortisol and ACTH levels were 2,840μg/24h and 204pg/mL respectively. The ectopic origin was confirmed by a combination of dynamic non-invasive tests and radiographic studies in most cases. The tumor responsible could be identified in 8 cases, and 7 patients had metastatic dissemination. Primary treatment was surgery in one patient, surgery combined with systemic therapy in 3, and chemotherapy in the other 3 patients. Bilateral adrenalectomy was required in 4 patients to control hypercortisolism. After a mean follow-up of 40 months, 3 patients died, 5 were still alive, and one had been lost to follow-up. CONCLUSIONS Our study confirms that ECS covers a wide spectrum of tumors of different aggressiveness and nature. The ectopic origin of Cushing's syndrome can usually, be suspected and confirmed in most cases without the need for invasive tests. Control of both hypercortisolism and the tumor requires multiple treatment modalities, and multidisciplinary management is recommended.
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Affiliation(s)
- Marta Araujo Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | - Nuria Palacios García
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Javier Aller Pardo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | | | - Laura Armengod Grao
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Javier Estrada García
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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Aljassem G, Aljasem H. Case report: Ectopic Cushing's syndrome in a young male with hidden lung carcinoid tumor. Int J Surg Case Rep 2017; 42:13-16. [PMID: 29202350 PMCID: PMC5723367 DOI: 10.1016/j.ijscr.2017.11.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/10/2017] [Accepted: 11/12/2017] [Indexed: 11/29/2022] Open
Abstract
Ectopic Cushing’s syndrome is a form of Cushing’s in which a tumor outside the pituitary gland produces a hormone called (ACTH). Small cell carcinoma and carcinoid of the lung comprises half of its cases. Ectopic cushing syndrome is a complicated medical problem especially when it comes to identification of the ectopic spot. The surgical treatment could be curative when the spot is determined.
Introduction Ectopic Cushing syndrome is a form of Cushing’s in which a tumor outside the pituitary gland produces adrenocorticotropic hormone (ACTH). Small cell carcinoma and carcinoid of the lung comprises half of its cases. The main purpose of this study is to present a case of ectopic Cushing syndrome caused by a hidden lung carcinoid and how to manage it. Presentation of case Here we present a case of a 26 year old young male complains of increased weight and appetite, proximal muscle weakness, easy bruising and appearing of purple striae on his abdomen, with a final diagnosis of ACTH secreting lung carcinoid. Discussion The diagnosis was made by non-invasive radiological procedures (CT scan and MRI) and serological tests. The management consisted of medical treatment which was not useful, then bilateral adrenalectomy to limit the patient symptoms. The ectopic spot was finally detected and excised surgically through thoracotomy. After six months of follow up there was no recurrence, signs and symptoms of Cushing syndrome begin to disappear. Conclusion Ectopic cushing syndrome is a complicated medical problem especially when it comes to identification of the ectopic spot. The surgical treatment could be curative when the spot is determined.
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Affiliation(s)
| | - Hazem Aljasem
- Department of Surgery, Damascus University Hospital, Syria.
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24
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Ceccato F, Trementino L, Barbot M, Antonelli G, Plebani M, Denaro L, Regazzo D, Rea F, Frigo AC, Concettoni C, Boscaro M, Arnaldi G, Scaroni C. Diagnostic accuracy of increased urinary cortisol/cortisone ratio to differentiate ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 2017; 87:500-507. [PMID: 28590513 DOI: 10.1111/cen.13391] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/09/2017] [Accepted: 06/01/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Differential diagnosis between Cushing's Disease (CD) and Ectopic ACTH Syndrome (EAS) may be a pitfall for endocrinologists. The increasing use in clinical practice of chromatography and mass spectrometry improves the measurement of urinary free cortisol (UFF) and cortisone (UFE). We have recently observed that cortisol to cortisone ratio (FEr) was higher in a small series of EAS; in this study we collected a larger number of ACTH-dependent Cushing's Syndrome (CS) to study the role of FEr to characterize the source of corticotropin secretion. MATERIALS AND METHODS High-pressure liquid chromatography with UV detection (HPLC-UV, n=35) or liquid chromatography-tandem mass spectrometry (LC-MS/MS, n=72) were used to measure UFF, UFE and FEr in 83 patients with CD and 24 with EAS. RESULTS UFF, UFE and FEr levels were higher in EAS than in CD (UFF: 6671 vs 549 nmol/24 hours; UFE: 2069 vs 464 nmol/24 hours; FEr: 4.13 vs 0.97; all P<.001). FEr >1.15 (the best ROC-based threshold) was able to distinguish CD from EAS with 75% sensitivity (SE) and 75% specificity (SP), AUC 0.811; results were similar between HPLC-UV (SE 73%, SP 79%, AUC 0.708) and LC-MS/MS (SE 77%, SP 73%, AUC 0.834; P=.727). The diagnostic accuracy of FEr was similar to that of CRH test or high-dose dexamethasone suppression test (respectively P=.171 and P=.683), also combined. Finally, FEr was able to increase the number of correct diagnosis in patients with discordant dynamic tests. CONCLUSIONS Urinary FEr >1.15 was able to suggest EAS, with a diagnostic accuracy similar to that of other dynamic tests proposed to study ACTH-dependent CS.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
| | - Laura Trementino
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
| | - Giorgia Antonelli
- Laboratory Medicine, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Laboratory Medicine, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
| | - Luca Denaro
- Neurosurgery, Department of Neurosciences DNS, University Hospital of Padova, Padova, Italy
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padova, Padova, Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padova, Padova, Italy
| | | | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
| | - Giorgio Arnaldi
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
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Abstract
Cushing syndrome (CS) is caused by chronic exposure to excess glucocorticoids. Early recognition and treatment of hypercortisolemia can lead to decreased morbidity and mortality. The diagnosis of CS and thereafter, establishing the cause can often be difficult, especially in patients with mild and cyclic hypercortisolism. Surgical excision of the cause of excess glucocorticoids is the optimal treatment for CS. Medical therapy (steroidogenesis inhibitors, medications that decrease adrenocorticotropic hormone [ACTH] levels or glucocorticoid antagonists) and pituitary radiotherapy may be needed as adjunctive treatment modalities in patients with residual, recurrent or metastatic disease, in preparation for surgery, or when surgery is contraindicated. A multidisciplinary team approach, individualized treatment plan and long-term follow-up are important for optimal management of hypercortisolemia and the comorbidities associated with CS. ABBREVIATIONS ACTH = adrenocorticotropic hormone; BIPSS = bilateral inferior petrosal sinus sampling; CBG = corticosteroid-binding globulin; CD = Cushing disease; CRH = corticotropin-releasing hormone; CS = Cushing syndrome; Dex = dexamethasone; DST = dexamethasone suppression test; EAS = ectopic ACTH syndrome; FDA = U.S. Food & Drug Administration; HDDST = high-dose DST; IPS/P = inferior petrosal sinus to peripheral; MRI = magnetic resonance imaging; NET = neuroendocrine tumor; PET = positron emission tomography; UFC = urinary free cortisol.
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Kim KJ, Yu JH, Kim NH, Kim YH, Kim YS, Seo JA. A Case of Pulmonary Carcinoid Tumor with a Superimposed Aspergilloma Presenting As a Covert Ectopic Adrenocorticotropic Hormone Syndrome. Front Endocrinol (Lausanne) 2017; 8:123. [PMID: 28642733 PMCID: PMC5462915 DOI: 10.3389/fendo.2017.00123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ectopic adrenocorticotropic hormone (ACTH) syndrome is a challenging diagnosis only responsible for approximately 10% of Cushing syndrome cases. It has been associated with a variety of benign and malignant tumors including a carcinoid tumor accompanied by aspergilloma in our case that was significantly difficult to be detected. We report a patient over 70 years old with uncontrolled hypertension and hypokalemia presenting with generalized edema. Laboratory results revealed ACTH-dependent Cushing syndrome, but imaging studies did not show any discrete lesions secreting ACTH. The petrosal to peripheral ACTH gradient resulted in no evidence of pituitary adenoma. As the only lesion suspicious for ectopic ACTH secretion was a right lower round cystic lesion that did not appear to be a carcinoid tumor on computed tomography scan of the chest, the patient underwent video-assisted thoracic surgical resection to provide a definitive diagnosis. The final diagnosis was a small ectopic ACTH-secreting carcinoid tumor with unusual superimposed aspergilloma in the periphery of the lung. Postoperatively, the abnormal endocrine levels were normalized, and all of the clinical symptoms and signs were ameliorated. This is an informative case of ectopic ACTH syndrome (EAS) that was the cause of hypokalemia, hypertension, metabolic alkalosis, and hypercortisolism despite its poorly specific cushingoid morphology and uncommon imaging findings. Therefore, we recommend that clinicians investigate any possible lesion as a potential source of EAS.
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Affiliation(s)
- Kyoung Jin Kim
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Ji Hee Yu
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Nan Hee Kim
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Young Hye Kim
- Department of Pathology, Gil Medical Center, Gachon University, Incheon, South Korea
| | - Young Sik Kim
- Department of Pathology, Korea University College of Medicine, Seoul, South Korea
| | - Ji A Seo
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
- *Correspondence: Ji A Seo,
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Flynn E, Baqar S, Liu D, Ekinci EI, Farrell S, Zajac JD, De Luise M, Seeman E. Bowel perforation complicating an ACTH-secreting phaeochromocytoma. Endocrinol Diabetes Metab Case Rep 2016; 2016:EDM160061. [PMID: 28203371 PMCID: PMC5291089 DOI: 10.1530/edm-16-0061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 07/19/2016] [Indexed: 11/24/2022] Open
Abstract
ACTH-secreting phaeochromocytoma (ASP) is a rare cause of ACTH-dependent
Cushing’s syndrome (CS). We report the case of a 63-year-old female presenting
with CS secondary to an ASP complicated by bowel perforation. This case report
highlights ASP as an uncommon but important cause of ectopic ACTH secretion (EAS).
There have been 29 cases of ASP, all of which were unilateral and benign, but
associated with significant complications. Patients presenting with ASP have the
potential for cure with unilateral adrenalectomy. Given this promising prognosis if
recognised, ASP should be considered in the diagnostic workup of ACTH-dependent CS.
As this case demonstrates, gastrointestinal complications can arise from severe
hypercortisolaemia associated with CS. Early medical and surgical intervention is
imperative as mortality approaches 50% once bowel perforation occurs.
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Affiliation(s)
- Elise Flynn
- Austin Health , Heidelberg, Victoria , Australia
| | - Sara Baqar
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Dorothy Liu
- University of Melbourne , Parkville, Victoria , Australia
| | - Elif I Ekinci
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | | | - Jeffrey D Zajac
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | | | - Ego Seeman
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
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Machado MC, Fragoso MCBV, Moreira AC, Boguszewski CL, Vieira L, Naves LA, Vilar L, de Araújo LA, Czepielewski MA, Gadelha MR, Musolino NRC, Miranda PAC, Bronstein MD, Ribeiro-Oliveira A. Recommendations of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism for the diagnosis of Cushing's disease in Brazil. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:267-86. [PMID: 27355856 PMCID: PMC10522300 DOI: 10.1590/2359-3997000000174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/10/2016] [Indexed: 11/22/2022]
Abstract
Although it is a rare condition, the accurate diagnosis and treatment of Cushing's disease is important due to its higher morbidity and mortality compared to the general population, which is attributed to cardiovascular diseases, diabetes mellitus and infections. Screening for hypercortisolism is recommended for patients who present multiple and progressive clinical signs and symptoms, especially those who are considered to be more specific to Cushing's syndrome, abnormal findings relative to age (e.g., spinal osteoporosis and high blood pressure in young patients), weight gain associated with reduced growth rate in the pediatric population and for those with adrenal incidentalomas. Routine screening is not recommended for other groups of patients, such as those with obesity or diabetes mellitus. Magnetic resonance imaging (MRI) of the pituitary, the corticotropin-releasing hormone (CRH) test and the high-dose dexamethasone suppression test are the main tests for the differential diagnosis of ACTH-dependent Cushing's syndrome. Bilateral and simultaneous petrosal sinus sampling is the gold standard method and is performed when the triad of initial tests is inconclusive, doubtful or conflicting. The aim of this article is to provide information on the early detection and establishment of a proper diagnosis of Cushing's disease, recommending follow-up of these patients at experienced referral centers. Arch Endocrinol Metab. 2016;60(3):267-86.
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Affiliation(s)
- Márcio Carlos Machado
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Maria Candida Barisson Vilares Fragoso
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Ayrton Custódio Moreira
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasilDivisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil;
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e MetabologiaHospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrasilServiço de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil;
| | - Leonardo Vieira
- Serviço de EndocrinologiaHospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrasilServiço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF/UFRJ), Rio de Janeiro, RJ, Brasil;
| | - Luciana A. Naves
- Serviço de EndocrinologiaHospital Universitário de BrasíliaUniversidade de BrasíliaBrasíliaDFBrasilServiço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil;
| | - Lucio Vilar
- Serviço de EndocrinologiaHospital de ClínicasUniversidade Federal de PernambucoRecifePEBrasilServiço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil;
| | | | - Mauro A. Czepielewski
- Hospital de Clínicas de Porto AlegreFaculdade de MedicinaUniversidade Federal do Rio Grande do SulPorto AlegreRSBrasilServiço de Endocrinologia, Hospital de Clínicas de Porto Alegre (HCPA), Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil;
| | - Monica R. Gadelha
- Serviço de EndocrinologiaHospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrasilServiço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF/UFRJ), Rio de Janeiro, RJ, Brasil;
| | - Nina Rosa Castro Musolino
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Divisão de Neurocirurgia Funcional, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP;Brasil
| | - Paulo Augusto C Miranda
- Serviço de EndocrinologiaSanta Casa de Belo HorizonteBelo HorizonteMGBrasilServiço de Endocrinologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil;
| | - Marcello Delano Bronstein
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Antônio Ribeiro-Oliveira
- Universidade Federal de Minas GeraisServiço de EndocrinologiaHospital de ClínicasBelo HorizonteMGBrasilServiço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brasil
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Li WY, Liu XD, Li WN, Dong SY, Qu XH, Gong SL, Shao MR, Zhang L. Paraneoplastic Cushing's syndrome associated with bronchopulmonary carcinoid tumor in youth: A case report and review of the literature. Oncol Lett 2016; 12:69-72. [PMID: 27347101 PMCID: PMC4906826 DOI: 10.3892/ol.2016.4572] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/22/2016] [Indexed: 12/17/2022] Open
Abstract
Paraneoplastic Cushing's syndrome (CushingPS) caused by bronchopulmonary carcinoid tumors presents a diagnostic challenge for clinicians. The present study reports the case of an 18-year-old male patient presenting with rapid weight gain, polyuria, polydipsia and progressive muscle weakness. Chemical and imaging findings suggested ectopic secretion of adrenocorticotropin. Whole-body 18fluorine-fluorodeoxyglucose (18FDG-PET/CT) positron-emission tomography revealed an increased uptake of 18FDG-PET/CT in the right middle lung mass and lobar lymph node. Postoperative pathology confirmed the presence of a typical carcinoid, as well as a lobar lymph node metastasis. The patient underwent a right middle lobectomy with mediastinal lymph node resection, which resulted in symptom clearance, followed by rapid weight loss. No CushingPS or tumor recurrence was observed at the 3-month postoperative follow-up.
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Affiliation(s)
- Wen-Ya Li
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Xu-Dong Liu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Wei-Nan Li
- Department of Pathology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Si-Yuan Dong
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Xiao-Han Qu
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Shu-Lei Gong
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Ming-Rui Shao
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Lin Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
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30
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Goroshi MR, Jadhav SS, Lila AR, Kasaliwal R, Khare S, Yerawar CG, Hira P, Phadke U, Shah H, Lele VR, Malhotra G, Bandgar T, Shah NS. Comparison of 68Ga-DOTANOC PET/CT and contrast-enhanced CT in localisation of tumours in ectopic ACTH syndrome. Endocr Connect 2016; 5:83-91. [PMID: 27006371 PMCID: PMC5002954 DOI: 10.1530/ec-16-0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/22/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Localising ectopic adrenocorticotrophic hormone (ACTH) syndrome (EAS) tumour source is challenging. Somatostatin receptor-based PET imaging has shown promising results, but the data is limited to case reports and small case series. We reviewed here the performance of (68)Ga-DOTANOC positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) in our cohort of 12 consecutive EAS patients. MATERIALS AND METHODS Retrospective data analysis of 12 consecutive patients of EAS presenting to a single tertiary care centre in a period between January 2013 and December 2014 was done. CECT and (68)Ga-DOTANOC PET/CT were reported (blinded) by an experienced radiologist and a nuclear medicine physician, respectively. The performance of CECT and (68)Ga-DOTANOC PET/CT was compared. RESULTS Tumours could be localised in 11 out of 12 patients at initial presentation (overt cases), whereas in one patient, tumour remained occult. Thirteen lesions were identified in 11 patients as EAS source (true positives). CECT localised 12 out of these 13 lesions (sensitivity 92.3%) and identified five false-positive lesions (positive predictive value (PPV) 70.5%). Compared with false-positive lesions, true-positive lesions had greater mean contrast enhancement at 60s (33.2 vs 5.6 Hounsfield units (HU)). (68)Ga-DOTANOC PET/CT was able to identify 9 out of 13 lesions (sensitivity 69.2%) and reported no false-positive lesions (PPV 100%). CONCLUSION CECT remains the first-line investigation in localisation of EAS. The contrast enhancement pattern on CECT can further aid in characterisation of the lesions. (68)Ga-DOTANOC PET/CT can be added to CECT, to enhance positive prediction of the suggestive lesions.
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Affiliation(s)
- Majunath R Goroshi
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Swati S Jadhav
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Anurag R Lila
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rajeev Kasaliwal
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shruti Khare
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Chaitanya G Yerawar
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Priya Hira
- Department of RadiologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Hina Shah
- Department of Nuclear Medicine and Positron Emission Tomography/Computed TomographyJaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Vikram R Lele
- Department of Nuclear Medicine and Positron Emission Tomography/Computed TomographyJaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Gaurav Malhotra
- Radiation Medicine CentreBhabha Atomic Research Centre, Tata Memorial Centre, Annexe, Parel, Mumbai, Maharashtra, India
| | - Tushar Bandgar
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini S Shah
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
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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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Paun DL, Vija L, Stan E, Banica A, Bobeica E, Terzea D, Poiana C, Badiu C, Paun S. Cushing syndrome secondary to ectopic adrenocorticotropic hormone secretion from a Meckel diverticulum neuroendocrine tumor: case report. BMC Endocr Disord 2015; 15:72. [PMID: 26610855 PMCID: PMC4661995 DOI: 10.1186/s12902-015-0070-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 11/17/2015] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Ectopic production of adrenocorticotropic hormone (ACTH) by neuroendocrine tumours (NET) is a rare condition, occult presentations often hampering the diagnosis. Although NET are relatively frequent in the ileon and Meckel diverticulum, we describe the first Cushing's syndrome due to ectopic adrenocorticotropic syndrome (CS-EAS) arising from a Meckel diverticulum. CASE PRESENTATION A 44-year-old man was admitted with recent onset of diabetes, myopathy, edema and hypokalemic metabolic alkalosis consistent with Cushing's syndrome. Both basal and dynamic laboratory evaluation suggested CS-EAS. Laboratory testing also showed high serum levels of chromogranin A (CgA) and urinary 5-hydroxyindoleacetic acid (5HIAA). Pituitary and neck/thorax/abdomen/pelvis imaging proved to be normal, while somatostatin analogue ((99m)Tc-HYNIC-TOC) scintigraphy revealed increased focalized ileum uptake on the right iliac fossa. Pre-operative ketoconazole and sandostatin treatment controlled the hypercortisolism within a month. Pathological analysis of the resected submucosal 1.8 cm tumour of the Meckel diverticulum and a metastatic local lymph node confirmed a well differentiated neuroendocrine tumour (grade I), whereas immunohistochemistry was positive for ACTH, chromogranin A and synaptophysin. Post-operative clinical and biochemical resolution of Cushing's syndrome was followed by normalization of both CgA and 5HIAA, which were maintained at the 6 month follow-up. CONCLUSION The identification, characterization and follow-up of this rare cause of ectopic ACTH secretion is important in order to assess the long-term prognostic and management.
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Affiliation(s)
- Diana Loreta Paun
- "C.I. Parhon" National Institute of Endocrinology, 34-36, Aviatorilor Boulevard, sector 1, 011863, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Lavinia Vija
- "C.I. Parhon" National Institute of Endocrinology, 34-36, Aviatorilor Boulevard, sector 1, 011863, Bucharest, Romania.
| | - Emilia Stan
- Braila Department Hospital, Braila, Bucharest, Romania
| | - Alexandra Banica
- "C.I. Parhon" National Institute of Endocrinology, 34-36, Aviatorilor Boulevard, sector 1, 011863, Bucharest, Romania
| | - Elena Bobeica
- "C.I. Parhon" National Institute of Endocrinology, 34-36, Aviatorilor Boulevard, sector 1, 011863, Bucharest, Romania
| | - Dana Terzea
- "C.I. Parhon" National Institute of Endocrinology, 34-36, Aviatorilor Boulevard, sector 1, 011863, Bucharest, Romania
| | - Catalina Poiana
- "C.I. Parhon" National Institute of Endocrinology, 34-36, Aviatorilor Boulevard, sector 1, 011863, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Corin Badiu
- "C.I. Parhon" National Institute of Endocrinology, 34-36, Aviatorilor Boulevard, sector 1, 011863, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Sorin Paun
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- General Surgery Department, Bucharest Emergency Hospital, Bucharest, Romania
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Abstract
Cushing syndrome due to endogenous hypercortisolism may cause significant morbidity and mortality. The source of excess cortisol may be adrenal, pituitary, or ectopic. Ectopic Cushing syndrome is sometimes difficult to localize on conventional imaging like CT and MRI. After performing a multilevel thoracoabdominal imaging with CT, the evidence regarding the use of radiotracers for PET imaging is unclear due to significant molecular and etiological heterogeneity of potential causes of ectopic Cushing's syndrome. In our systematic review of literature, it appears that GalLium-based (Ga68) somatostatin receptor analogs have better sensitivity in diagnosis of bronchial carcinoids causing Cushing syndrome and FDG PET appears superior for small-cell lung cancers and other aggressive tumors. Further large-scale studies are needed to identify the best PET tracer for this condition.
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Affiliation(s)
- Prasanna Santhanam
- Section of Endocrinology, Department of Internal Medicine, Joan C Edwards School of Medicine, Marshall University, Huntington, WV, 25701, USA.
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France.
- Marseille Cancerology Research Center, Institut Paoli-Calmettes, Marseille, France.
| | - Luca Giovanella
- Nuclear Medicine and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, Switzerland.
| | - Giorgio Treglia
- Nuclear Medicine and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, Switzerland.
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34
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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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Abstract
Chronic exposure to excess glucorticoids results in diverse manifestations of Cushing's syndrome, including debilitating morbidities and increased mortality. Genetic and molecular mechanisms responsible for excess cortisol secretion by primary adrenal lesions and adrenocorticotropic hormone (ACTH) secretion from corticotroph or ectopic tumours have been identified. New biochemical and imaging diagnostic approaches and progress in surgical and radiotherapy techniques have improved the management of patients. The therapeutic goal is to normalise tissue exposure to cortisol to reverse increased morbidity and mortality. Optimum treatment consisting of selective and complete resection of the causative tumour is necessay to allow eventual normalisation of the hypothalamic-pituitary-adrenal axis, maintenance of pituitary function, and avoidance of tumour recurrence. The development of new drugs offers clinicians several choices to treat patients with residual cortisol excess. However, for patients affected by this challenging syndrome, the long-term effects and comorbidities associated with hypercortisolism need ongoing care.
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Affiliation(s)
- André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada.
| | - Richard A Feelders
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Lynnette K Nieman
- Program on Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
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Sharma ST, Nieman LK, Feelders RA. Cushing's syndrome: epidemiology and developments in disease management. Clin Epidemiol 2015; 7:281-93. [PMID: 25945066 PMCID: PMC4407747 DOI: 10.2147/clep.s44336] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cushing’s syndrome is a rare disorder resulting from prolonged exposure to excess glucocorticoids. Early diagnosis and treatment of Cushing’s syndrome is associated with a decrease in morbidity and mortality. Clinical presentation can be highly variable, and establishing the diagnosis can often be difficult. Surgery (resection of the pituitary or ectopic source of adrenocorticotropic hormone, or unilateral or bilateral adrenalectomy) remains the optimal treatment in all forms of Cushing’s syndrome, but may not always lead to remission. Medical therapy (steroidogenesis inhibitors, agents that decrease adrenocorticotropic hormone levels or glucocorticoid receptor antagonists) and pituitary radiotherapy may be needed as an adjunct. A multidisciplinary approach, long-term follow-up, and treatment modalities customized to each individual are essential for optimal control of hypercortisolemia and management of comorbidities.
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Affiliation(s)
- Susmeeta T Sharma
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Lynnette K Nieman
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Richard A Feelders
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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Abstract
Diagnosis of Cushing's disease frequently remains a challenge. In this review we critically appraise the clinical features, biochemical tests, and imaging modalities used for this purpose. We outline recommendations for approaches to clinical investigation, with a particular focus on developments made within the last two years.
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Affiliation(s)
- Eleni Daniel
- Academic Unit of Endocrinology, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK
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Ducry J, Gomez F, Prior JO, Boubaker A, Matter M, Monti M, Pu Y, Pitteloud N, Portmann L. Mid-gut ACTH-secreting neuroendocrine tumor unmasked with (18)F-dihydroxyphenylalanine-positron emission tomography. Endocrinol Diabetes Metab Case Rep 2015; 2015:140104. [PMID: 25861450 PMCID: PMC4361871 DOI: 10.1530/edm-14-0104] [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] [Received: 02/10/2015] [Accepted: 02/23/2015] [Indexed: 11/08/2022] Open
Abstract
Ectopic ACTH Cushing's syndrome (EAS) is often caused by neuroendocrine tumors (NETs) of lungs, pancreas, thymus, and other less frequent locations. Localizing the source of ACTH can be challenging. A 64-year-old man presented with rapidly progressing fatigue, muscular weakness, and dyspnea. He was in poor condition and showed facial redness, proximal amyotrophy, and bruises. Laboratory disclosed hypokalemia, metabolic alkalosis, and markedly elevated ACTH and cortisol levels. Pituitary was normal on magnetic resonance imaging (MRI), and bilateral inferior petrosal sinus blood sampling with corticotropin-releasing hormone stimulation showed no significant central-to-periphery gradient of ACTH. Head and neck, thoracic and abdominal computerized tomography (CT), MRI, somatostatin receptor scintigraphy (SSRS), and 18F-deoxyglucose-positron emission tomography (FDG-PET) failed to identify the primary tumor. 18F-dihydroxyphenylalanine (F-DOPA)-PET/CT unveiled a 20-mm nodule in the jejunum and a metastatic lymph node. Segmental jejunum resection showed two adjacent NETs, measuring 2.0 and 0.5 cm with a peritoneal metastasis. The largest tumor expressed ACTH in 30% of cells. Following surgery, after a transient adrenal insufficiency, ACTH and cortisol levels returned to normal values and remain normal over a follow-up of 26 months. Small mid-gut NETs are difficult to localize on CT or MRI, and require metabolic imaging. Owing to low mitotic activity, NETs are generally poor candidates for FDG-PET, whereas SSRS shows poor sensitivity in EAS due to intrinsically low tumor concentration of type-2 somatostatin receptors (SST2) or to receptor down regulation by excess cortisol. However, F-DOPA-PET, which is related to amine precursor uptake by NETs, has been reported to have high positive predictive value for occult EAS despite low sensitivity, and constitutes a useful alternative to more conventional methods of tumor localization.
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Affiliation(s)
- Julien Ducry
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
| | - Fulgencio Gomez
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
| | - John O Prior
- Nuclear Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Ariane Boubaker
- Nuclear Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Maurice Matter
- Visceral Surgery , Lausanne University Hospital , Lausanne , Switzerland
| | - Matteo Monti
- Internal Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Yan Pu
- Institute of Pathology, Lausanne University Hospital , Lausanne, CH-1011 , Switzerland
| | - Nelly Pitteloud
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
| | - Luc Portmann
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
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Raff H, Carroll T. Cushing's syndrome: from physiological principles to diagnosis and clinical care. J Physiol 2015; 593:493-506. [PMID: 25480800 DOI: 10.1113/jphysiol.2014.282871] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/27/2014] [Indexed: 01/17/2023] Open
Abstract
The physiological control of cortisol synthesis in the adrenal cortex involves stimulation of adrenocorticotrophic hormone (ACTH) by hypothalamic corticotrophin-releasing hormone (CRH) and then stimulation of the adrenal by ACTH. The control loop of the hypothalamic-pituitary-adrenal (HPA) axis is closed by negative feedback of cortisol on the hypothalamus and pituitary. Understanding this system is required to master the diagnosis, differential diagnosis and treatment of endogenous hypercortisolism--Cushing's syndrome. Endogenous Cushing's syndrome is caused either by excess ACTH secretion or by autonomous cortisol release from the adrenal cortex. Diagnosis of cortisol excess exploits three physiological principles: failure to achieve the normal nadir in the cortisol diurnal rhythm, loss of sensitivity of ACTH-secreting tumours to cortisol negative feedback, and increased excretion of free cortisol in the urine. Differentiating a pituitary source of excess ACTH (Cushing's disease) from an ectopic source is accomplished by imaging the pituitary and sampling for ACTH in the venous drainage of the pituitary. With surgical removal of ACTH or cortisol-secreting tumours, secondary adrenal insufficiency ensues because of the prior suppression of the HPA axis by glucocorticoid negative feedback. Medical therapy is targeted to the anatomical location of the dysregulated component of the HPA axis. Future research will focus on new diagnostics and treatments of Cushing's syndrome. These are elegant examples of translational research: understanding basic physiology informs the development of new approaches to diagnosis and treatment. Appreciating pathophysiology generates new areas for inquiry of basic physiological and biochemical mechanisms.
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Affiliation(s)
- Hershel Raff
- Departments of Medicine, Surgery, and Physiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA; Endocrine Research Laboratory, Aurora St Luke's Medical Center, Aurora Research Institute, Milwaukee, WI, 53215, USA
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Sekiguchi Y, Miyamoto Y, Kasahara I, Hara Y, Tani Y, Doi M, Hirata Y. Ectopic ACTH syndrome caused by desmopressin-responsive thymic neuroendocrine tumor. Endocr J 2015; 62:441-7. [PMID: 25819222 DOI: 10.1507/endocrj.ej14-0455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 32-year-old Chinese woman with rapid weight gain and progressive edema was found to have typical Cushingoid features. Her endocrine data were consistent with a diagnosis of ACTH-dependent Cushing's syndrome. To differentiate ectopic ACTH syndrome (EAS) from Cushing's disease (CD), various dynamic endocrine and imaging tests were performed. Her ACTH response was negative to corticotropin-releasing hormone (CRH) and positive to desmopressin. Magnetic resonance imaging of the pituitary showed no mass lesion. Computed tomography scan of the chest revealed a large mass (21 × 15 mm) in the anterior mediastinum, where positron emission tomography showed accumulation of [(18)F] fluorodeoxyglucose. Selective venous sampling showed marked step-up in ACTH level in the internal thoracic vein but not in the cavernous sinus after CRH stimulation. These data are compatible with the diagnosis of EAS. The resected tumor was pathologically consistent with thymic neuroendocrine tumor (NET) positive for ACTH by immunohistochemistry and abundant V1b receptor gene expression by RT-PCR. Postoperatively, her circulating ACTH/cortisol levels became normalized, and responded to stimulation with CRH but not with desmopressin. Her Cushingoid appearance gradually disappeared, and she was free from recurrence 5 years after surgery. This is a rare case of desmopressin-responsive EAS caused by thymic NET with predominant V1b gene expression, which was successfully localized by imaging modalities combined with selective venous sampling.
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Affiliation(s)
- Yoshihiro Sekiguchi
- Division of Endocrinology and Diabetology, Ohme Municipal General Hospital, Ohme 198-0042, Japan
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Raff H, Sharma ST, Nieman LK. Physiological basis for the etiology, diagnosis, and treatment of adrenal disorders: Cushing's syndrome, adrenal insufficiency, and congenital adrenal hyperplasia. Compr Physiol 2014; 4:739-69. [PMID: 24715566 DOI: 10.1002/cphy.c130035] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is a classic neuroendocrine system. One of the best ways to understand the HPA axis is to appreciate its dynamics in the variety of diseases and syndromes that affect it. Excess glucocorticoid activity can be due to endogenous cortisol overproduction (spontaneous Cushing's syndrome) or exogenous glucocorticoid therapy (iatrogenic Cushing's syndrome). Endogenous Cushing's syndrome can be subdivided into ACTH-dependent and ACTH-independent, the latter of which is usually due to autonomous adrenal overproduction. The former can be due to a pituitary corticotroph tumor (usually benign) or ectopic ACTH production from tumors outside the pituitary; both of these tumor types overexpress the proopiomelanocortin gene. The converse of Cushing's syndrome is the lack of normal cortisol secretion and is usually due to adrenal destruction (primary adrenal insufficiency) or hypopituitarism (secondary adrenal insufficiency). Secondary adrenal insufficiency can also result from a rapid discontinuation of long-term, pharmacological glucocorticoid therapy because of HPA axis suppression and adrenal atrophy. Finally, mutations in the steroidogenic enzymes of the adrenal cortex can lead to congenital adrenal hyperplasia and an increase in precursor steroids, particularly androgens. When present in utero, this can lead to masculinization of a female fetus. An understanding of the dynamics of the HPA axis is necessary to master the diagnosis and differential diagnosis of pituitary-adrenal diseases. Furthermore, understanding the pathophysiology of the HPA axis gives great insight into its normal control.
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Affiliation(s)
- Hershel Raff
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Aurora Research Institute and Departments of Medicine, Surgery, and Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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A challenging case of an ectopic cushing syndrome. Case Rep Med 2014; 2014:413136. [PMID: 25431598 PMCID: PMC4241739 DOI: 10.1155/2014/413136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/15/2014] [Accepted: 10/21/2014] [Indexed: 11/25/2022] Open
Abstract
Bronchopulmonary carcinoids are rare pulmonary neoplasms although they account for most cases of ectopic ACTH syndromes. When feasible, the mainstay treatment is surgical resection of the tumor. We report the case of a 52-year-old woman with signs and symptoms suggestive of hypercortisolism for 12 months, admitted to our department because of community acquired pneumonia. Blood hormone analysis showed increased levels of ACTH and urinary free cortisol and nonsuppressibility to high- and low-dose dexamethasone tests. Pituitary MRI showed no lesion and no central-to-peripheral ACTH gradient was present in bilateral inferior petrosal sinus sampling. CRH stimulation test suggested an ectopic ACTH source. Thoracic CT scan revealed a nodular region measuring 12 mm located in the inferior lingular lobule of the left superior lung with negative uptake by 18-FDG-PET scan and negative SRS. The patient was successfully treated with an atypical lung resection and histology revealed an atypical bronchial carcinoid tumor with positive ACTH immunoreactivity. This was an interesting case because the patient was admitted due to pneumonia that may have been associated with her untreated and chronic hypercortisolism and a challenging case of ectopic ACTH syndrome due to conflicting results on the diagnostic exams.
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Abstract
Overproduction of corticotropin by the pituitary gland or extrapituitary tumors leads to hypercortisolism or Cushing syndrome. Diagnosis of suspected Cushing syndrome involves 3 major steps: confirmation of hypercortisolism, differentiation between corticotropin-independent and corticotropin-dependent causes of Cushing syndrome, and distinction between pituitary and ectopic corticotropin production. A definitive diagnosis of ectopic corticotropin secretion requires stringent criteria, including reversal of the clinical picture after resection of the tumor and/or demonstration of corticotropin immunohistochemical staining within the tumor tissue.
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Kakade HR, Kasaliwal R, Jagtap VS, Bukan A, Budyal SR, Khare S, Lila AR, Bandgar T, Menon PS, Shah NS. Ectopic ACTH-secreting syndrome: a single-center experience. Endocr Pract 2014; 19:1007-14. [PMID: 24013993 DOI: 10.4158/ep13171.or] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Ectopic adrenocorticotropic hormone (ACTH)-secreting syndrome (EAS) is a rare cause of ACTH-dependent endogenous hypercortisolism. The objective of this study was to analyze clinical, biochemical, and imaging characteristics; management strategies; and outcomes of EAS patients. METHOD We screened the records (1993-2012) of ACTH-dependent endogenous hypercortisolism cases managed at a tertiary care center. RESULTS Of the 218 patients, 17 were diagnosed with EAS. The median 8:00 AM serum cortisol was 36 μg/dL (11.4-82.7 μg/dL), and the median basal plasma ACTH was 156 pg/mL (53.5-468 pg/mL). Notably, ACTH levels below 100 pg/mL were found in 4 patients. Suspicious microadenoma was found on magnetic resonance imaging (MRI) of the pituitary in 5 patients, and all of them underwent transsphenoidal surgery (TSS). Inferior petrosal sinus sampling (IPSS) was performed in 8 patients, and the results were suggestive of a peripheral source in all 8. Computed tomography (CT) localized the lesion in 15/17 patients. In 2 patients with negative CTs, gallium DOTATATE positron emission tomography (PET) scans localized the lesion. Despite difficulties localizing bronchial carcinoids, the cure rate was high (72%). In contrast, thymic carcinoids were easily localized but had poor outcomes. CONCLUSION EAS cannot be ruled out on the basis of marginally elevated ACTH. In cases with an equivocal MRI pituitary finding, prior IPSS can help avoid unnecessary TSS. CT is a useful modality for localization of an ectopic source. Functional imaging may help in cases where anatomical imaging fails.
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Affiliation(s)
- Harshal R Kakade
- Department of Endocrinology, Seth G S Medical College, KEM Hospital, Mumbai, India
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de Herder WW. GEP-NETS update: functional localisation and scintigraphy in neuroendocrine tumours of the gastrointestinal tract and pancreas (GEP-NETs). Eur J Endocrinol 2014; 170:R173-83. [PMID: 24723670 DOI: 10.1530/eje-14-0077] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
For patients with neuroendocrine tumours (NETs) of the gastrointestinal tract and pancreas (GEP) (GEP-NETs), excellent care should ideally be provided by a multidisciplinary team of skilled health care professionals. In these patients, a combination of nuclear medicine imaging and conventional radiological imaging techniques is usually mandatory for primary tumour visualisation, tumour staging and evaluation of treatment. In specific cases, as in patients with occult insulinomas, sampling procedures can provide a clue as to where to localise the insulin-hypersecreting pancreatic NETs. Recent developments in these fields have led to an increase in the detection rate of primary GEP-NETs and their metastatic deposits. Radiopharmaceuticals targeted at specific tumour cell properties and processes can be used to provide sensitive and specific whole-body imaging. Functional imaging also allows for patient selection for receptor-based therapies and prediction of the efficacy of such therapies. Positron emission tomography/computed tomography (CT) and single-photon emission CT/CT are used to map functional images with anatomical localisations. As a result, tumour imaging and tumour follow-up strategies can be optimised for every individual GEP-NET patient. In some cases, functional imaging might give indications with regard to future tumour behaviour and prognosis.
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Affiliation(s)
- Wouter W de Herder
- Section of Endocrinology, Department of Internal Medicine, Erasmus MC, 's Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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Chabre O. [Cushing syndrome: Physiopathology, etiology and principles of therapy]. Presse Med 2014; 43:376-92. [PMID: 24656295 DOI: 10.1016/j.lpm.2014.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 02/03/2014] [Indexed: 11/15/2022] Open
Abstract
The most frequent cause of Cushing's syndrome is iatrogenic, as Cushing's syndrome is the unavoidable consequence of long-term glucocorticoid treatment using more than 7.5 mg prednisone per day. The most frequent cause of endogenous Cushing's syndrome is Cushing's disease (CD), which is an ACTH dependent hypercortisolism linked to a pituitary corticotroph adenoma. This adenoma is often very small, its diagnosis may require bilateral inferior petrosal sinus sampling and the first line treatment of CD is transsphenoidal surgery by an expert neurosurgeon. The second line treatments include drugs that can act either on the pituitary adenoma or on adrenal steroidogenesis, pituitary radiotherapy or bilateral adrenalectomy. Ectopic ACTH dependent Cushing's syndrome is linked either to poorly differentiated endocrine tumors with a very poor prognosis, such as small cell lung cancer, or to well differentiated endocrine tumors, such as bronchial carcinoid tumors, which have a good prognosis when treated by surgery, but may be very difficult to localize. Adrenal Cushing's syndromes, which are independent of pituitary ACTH secretion, include adrenal cortex carcinoma, which requires abdominal surgery with extended adrenalectomy by an expert surgeon, adrenal adenoma which is treated by laparoscopic unilateral adrenalectomy and bilateral macronodular hyperplasia, whose surgical treatment may require unilateral or bilateral adrenalectomy. Treatment of Cushing's syndrome generally leads to spectacular clinical results, which must not hide the fact that the reversibility of some signs is actually incomplete. This underlines the need for a timely multidisciplinary management of the patients by an expert team.
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Affiliation(s)
- Olivier Chabre
- CHU de Grenoble, Hôpital Nord, Service d'Endocrinologie-Diabétologie-Nutrition, BP 217, 38043 Grenoble cedex 9, France; Faculté de Médecine, Université Joseph Fourier, Grenoble-1, 38042 Grenoble cedex 9, France.
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A rare case of ectopic adrenocorticotropic hormone syndrome caused by a metastatic neuroendocrine tumor of the pancreas detected by 68Ga-DOTANOC and 18F-FDG PET/CT. Clin Nucl Med 2014; 38:e306-8. [PMID: 23486330 DOI: 10.1097/rlu.0b013e318279ec68] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a rare case of ectopic adrenocorticotropic hormone (ACTH) syndrome caused by a metastatic neuroendocrine tumor (NET) of the pancreas detected by PET/CT using different tracers. A 43-year-old female patient with Cushing syndrome (CS) by suspected ectopic ACTH secretion underwent a 68Ga-DOTANOC and a 18F-FDG PET/CT. Both these functional imaging techniques revealed increased tracer uptake in a pancreatic mass and multiple liver metastases. Histology showed the presence of a mildly differentiated pancreatic NET. 68Ga-DOTANOC PET/CT may be a useful functional imaging method, complementary to 18F-FDG PET/CT, in detecting ACTH-secreting pancreatic NETs.
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Özkan ZG, Kuyumcu S, Balköse D, Ozkan B, Aksakal N, Yılmaz E, Sanlı Y, Türkmen C, Aral F, Adalet I. The value of somatostatin receptor imaging with In-111 Octreotide and/or Ga-68 DOTATATE in localizing Ectopic ACTH producing tumors. Mol Imaging Radionucl Ther 2013; 22:49-55. [PMID: 24003397 PMCID: PMC3759309 DOI: 10.4274/mirt.69775] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 06/19/2013] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the value of somatostatin receptor imaging (SRI) with In-111 octreotide and Ga-68 DOTATATE in localizing ectopic ACTH producing tumors. METHODS Nineteen patients who had In-111 octreotide somatostatin receptor scintigraphy (SRS) and/or Ga-68 DOTATATE PET-CT to localize ectopic ACTH producing tumors between the years 2000 and 2012 were included retrospectively in our study. The results of SRI were compared with clinical onset, radiological findings and surgical data of the patients. RESULTS Sixteen In-111 octreotide SRS and five Ga-68 DOTATATE PET-CT were performed in 19 patients. In eight out of 19 patients, ectopic ACTH secretion site could be detected. In five patients, SRS showed pathologic uptake. In four of these patients, surgery revealed pulmonary carcinoid tumors and in one patient pancreatic neuroendocrine tumor. In one patient, Ga-68 DOTATATE PET-CT revealed pathologic uptake in lung nodule which came out to be pulmonary carcinoid tumor. In another patient who had resection of metastases of atypical carcinoid tumor prior to scans, new metastatic foci were detected both with SRS and Ga-68 DOTATATE PET-CT imaging. In one patient, although SRS was negative, CT which was performed three years later showed a lung nodule diagnosed as pulmonary carcinoid tumor. In 11 patients, ectopic ACTH secretion site could not be detected. In 10 of those patients, scintigraphic and radiological imaging did not show any lesions and in one patient, Ga-68 DOTATATE PET-CT was false positive. CONCLUSION SRI has a complementary role with radiological imaging in localizing ectopic ACTH secretion sites. PET-CT imaging with Ga-68 peptide conjugates is a promising new modality for this indication. CONFLICT OF INTEREST None declared.
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Affiliation(s)
- Zeynep Gözde Özkan
- İstanbul University İstanbul Medical Faculty, Nuclear Medicine Department, İstanbul, Turkey
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Sakuma I, Saito J, Matsuzawa Y, Omura M, Matsui S, Maehara T, Hasegawa N, Nishikawa T. Pulmonary arterial sampling was useful for localizing ectopic ACTH production in a patient with bronchial carcinoid causing Cushing syndrome. Hormones (Athens) 2013; 12:449-53. [PMID: 24121386 DOI: 10.1007/bf03401310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We report a 44-year old man with ectopic adrenocorticotropic hormone (ACTH) syndrome caused by bronchial carcinoid that developed Cushing syndrome. METHODS We performed several imaging studies, including chest and abdominal CT, for exploration of nodules and selective pulmonary arterial sampling for localizing a source of ectopic ACTH production. RESULTS The patient was diagnosed as Cushing syndrome due to ectopic production of ACTH without identification of its source(s). After 2 years' follow-up with repeated CT scans every 6-12 months and treatment with metyrapone, chest CT revealed two small nodules respectively in the segment (S) 4 and 10 of the right lung. We performed selective pulmonary arterial sampling from branches of the right pulmonary artery to obtain blood from the nodules in a reverse flow fashion: wedged sampling from the basal branch (A8, 9 and 10) revealed significant elevation of ACTH, whereas sampling from the lateral branch (A4) did not, indicating that the S10 nodule produced ACTH ectopically. The video-assisted thoracoscopic surgery removing the right inferior lobe normalized plasma ACTH, serum cortisol and 24-hour urinary free cortisol. The S10 nodule was histologically diagnosed as atypical bronchial carcinoid containing immunoreactive ACTH. CONCLUSIONS Selective pulmonary arterial sampling was useful for localizing the lesion of ectopic ACTH production and helped make the decision for its surgical removal. This procedure should be considered once lung nodules suspicious for ectopic ACTH production are identified in patients with EAS.
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Affiliation(s)
- Ikki Sakuma
- Endocrinology & Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
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Neary NM, Booker OJ, Abel BS, Matta JR, Muldoon N, Sinaii N, Pettigrew RI, Nieman LK, Gharib AM. Hypercortisolism is associated with increased coronary arterial atherosclerosis: analysis of noninvasive coronary angiography using multidetector computerized tomography. J Clin Endocrinol Metab 2013; 98:2045-52. [PMID: 23559084 PMCID: PMC3644598 DOI: 10.1210/jc.2012-3754] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Observational studies show that glucocorticoid therapy and the endogenous hypercortisolism of Cushing's syndrome (CS) are associated with increased rates of cardiovascular morbidity and mortality. However, the causes of these findings remain largely unknown. OBJECTIVE To determine whether CS patients have increased coronary atherosclerosis. DESIGN A prospective case-control study was performed. SETTING Subjects were evaulated in a clinical research center. SUBJECTS Fifteen consecutive patients with ACTH-dependent CS, 14 due to an ectopic source and 1 due to pituitary Cushing's disease were recruited. Eleven patients were studied when hypercortisolemic; 4 patients were eucortisolemic due to medication (3) or cyclic hypercortisolism (1). Fifteen control subjects with at least one risk factor for cardiac disease were matched 1:1 for age, sex, and body mass index. PRIMARY OUTCOME VARIABLES Agatston score a measure of calcified plaque and non-calcified coronary plaque volume were quantified using a multidetector CT (MDCT) coronary angiogram scan. Additional variables included fasting lipids, blood pressure, history of hypertension or diabetes, and 24-hour urine free cortisol excretion. RESULTS CS patients had significantly greater noncalcified plaque volume and Agatston score (noncalcified plaque volume [mm(3)] median [interquartile ranges]: CS 49.5 [31.4, 102.5], controls 17.9 [2.6, 25.3], P < .001; Agatston score: CS 70.6 [0, 253.1], controls 0 [0, 7.6]; P < .05). CS patients had higher systolic and diastolic blood pressures than controls (systolic: CS 143 mm Hg [135, 173]; controls, 134 [123, 136], P < .02; diastolic CS: 86 [80, 99], controls, 76 [72, 84], P < .05). CONCLUSIONS Increased coronary calcifications and noncalcified coronary plaque volumes are present in patients with active or previous hypercortisolism. Increased atherosclerosis may contribute to the increased rates of cardiovascular morbidity and mortality in patients with glucocorticoid excess.
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Affiliation(s)
- Nicola M Neary
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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