1
|
Zdrojowy-Wełna A, Valassi E. Cushing's Syndrome in the Elderly. Exp Clin Endocrinol Diabetes 2024. [PMID: 38698635 DOI: 10.1055/a-2317-8821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Management of Cushing's syndrome (CS) can be particularly challenging in older patients, compared with younger individuals, due to the lack of several clinical features associated with cortisol excess along with a greater burden of associated comorbidities. Moreover, the interpretation of diagnostic tests could be influenced by age-related physiological changes in cortisol secretion. While mortality is higher and quality of life is more impaired in the elderly with CS as compared with the younger, there is currently no agreement on the most effective therapeutic options in aged individuals, and safety data concerning medical treatment are scanty. In this review, we summarize the current knowledge about age-related differences in CS etiology, clinical presentation, treatment, and outcomes and describe the potential underlying mechanisms.
Collapse
Affiliation(s)
- Aleksandra Zdrojowy-Wełna
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
- Endocrinology Department, Wroclaw University Hospital, Wroclaw, Poland
| | - Elena Valassi
- Endocrinology and Nutrition Department, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
- School of Medicine, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| |
Collapse
|
2
|
Sawamura T, Kometani M, Karashima S, Yoneda T. Violaceous abdominal striae noted on physical examination: a clue to the diagnosis of Cushing's syndrome. BMJ Case Rep 2024; 17:e259687. [PMID: 38458764 PMCID: PMC10928762 DOI: 10.1136/bcr-2024-259687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Affiliation(s)
- Toshitaka Sawamura
- Internal Medicine, Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Mitsuhiro Kometani
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shigehiro Karashima
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Takashi Yoneda
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| |
Collapse
|
3
|
Ho KKY, Fleseriu M, Wass J, Katznelson L, Raverot G, Little AS, Castaño JP, Reincke M, Lopes MB, Kaiser UB, Chanson P, Gadelha M, Melmed S. A proposed clinical classification for pituitary neoplasms to guide therapy and prognosis. Lancet Diabetes Endocrinol 2024; 12:209-214. [PMID: 38301678 DOI: 10.1016/s2213-8587(23)00382-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 02/03/2024]
Abstract
No comprehensive classification system that guides prognosis and therapy of pituitary adenomas exists. The 2022 WHO histopathology-based classification system can only be applied to lesions that are resected, which represent few clinically significant pituitary adenomas. Many factors independent of histopathology provide mechanistic insight into causation and influence prognosis and treatment of pituitary adenomas. We propose a new approach to guide prognosis and therapy of pituitary adenomas by integrating clinical, genetic, biochemical, radiological, pathological, and molecular information for all adenomas arising from anterior pituitary cell lineages. The system uses an evidence-based scoring of risk factors to yield a cumulative score that reflects disease severity and can be used at the bedside to guide pituitary adenoma management. Once validated in prospective studies, this simple manageable classification system could provide a standardised platform for assessing disease severity, prognosis, and effects of therapy on pituitary adenomas.
Collapse
Affiliation(s)
- Ken K Y Ho
- The Garvan Institute of Medical Research, University of New South Wales, Sydney, NSW, Australia.
| | | | | | - Laurence Katznelson
- Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Gerald Raverot
- Hospices Civils de Lyon, Groupement Hospitalier Est, Université Claude Bernard Lyon, Bron, France
| | | | - Justo P Castaño
- Maimónides Biomedical Research Institute of Córdoba, University of Córdoba, Reina Sofia University Hospital, Córdoba, Spain
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikumder Universität, Ludwig-Maximilians-Universität, München, Germany
| | - M Beatriz Lopes
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Ursula B Kaiser
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | |
Collapse
|
4
|
Erkan B, Bayındır M, Akpınar E, Tanrıverdi O, Haşimoğlu O, Postalcı LŞ, Bugün DA, Tekin D, Çiftçi S, Çakır İ, Mert M, Günaldı Ö, Hatipoğlu E. Medium and Long-Term Data from a Series of 96 Endoscopic Transsphenoidal Surgeries for Cushing Disease. J Korean Neurosurg Soc 2024; 67:237-248. [PMID: 38449382 PMCID: PMC10924914 DOI: 10.3340/jkns.2023.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/06/2023] [Accepted: 11/06/2023] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVE Postoperative data on Cushing's disease (CD) are equivocal in the literature. These discrepancies may be attributed to different series with different criteria for remission and variable follow-up durations. Additional data from experienced centers may address these discrepancies. In this study, we present the results obtained from 96 endoscopic transsphenoidal surgeries (ETSSs) for CD conducted in a well-experienced center. METHODS Pre- and postoperative data of 96 ETSS in 87 patients with CD were included. All cases were handled by the same neurosurgical team between 2014 and 2022. We obtained data on remission status 3-6 months postoperatively (medium-term) and during the latest follow-up (long-term). Additionally, magnetic resonance imaging (MRI) and pathology results were obtained for each case. RESULTS The mean follow-up duration was 39.5±3.2 months. Medium and long-term remission rates were 77% and 82%, respectively. When only first-time operations were considered, the medium- and long-term remission rates were 78% and 82%, respectively. The recurrence rate in this series was 2.5%. Patients who showed remission between 3-6 months had higher longterm remission rates than did those without initial remission. Tumors >2 cm and extended tumor invasion of the cavernous sinus (Knosp 4) were associated with lower postoperative remission rates. CONCLUSION Adenoma size and the presence/absence of cavernous sinus invasion on preopera-tive MRI may predict long-term postoperative remission. A tumor size of 2 cm may be a supporting criterion for predicting remission in Knosp 4 tumors. Further studies with larger patient populations are necessary to support this finding.
Collapse
Affiliation(s)
- Buruç Erkan
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
| | - Muhammed Bayındır
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ebubekir Akpınar
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Osman Tanrıverdi
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ozan Haşimoğlu
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | | | - Didem Acarer Bugün
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Dilara Tekin
- Endocrinology and Metabolism Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Sema Çiftçi
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - İlkay Çakır
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Meral Mert
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ömür Günaldı
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
| | - Esra Hatipoğlu
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| |
Collapse
|
5
|
Puglisi S, Perini AME, Botto C, Oliva F, Terzolo M. Long-Term Consequences of Cushing Syndrome: A Systematic Literature Review. J Clin Endocrinol Metab 2024; 109:e901-e919. [PMID: 37536275 DOI: 10.1210/clinem/dgad453] [Citation(s) in RCA: 1] [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: 05/08/2023] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023]
Abstract
It is held that the condition of endogenous chronic hypersecretion of cortisol (Cushing syndrome, CS), causes several comorbidities, including cardiovascular and metabolic disorders, musculoskeletal alterations, as well as cognitive and mood impairment. Therefore, CS has an adverse impact on the quality of life and life expectancy of affected patients. What remains unclear is whether disease remission may induce a normalization of the associated comorbid conditions. In order to retrieve updated information on this issue, we conducted a systematic search using the Pubmed and Embase databases to identify scientific papers published from January 1, 2000, to December 31, 2022. The initial search identified 1907 potentially eligible records. Papers were screened for eligibility and a total of 79 were included and classified by the main topic (cardiometabolic risk, thromboembolic disease, bone impairment, muscle damage, mood disturbances and quality of life, cognitive impairment, and mortality). Although the limited patient numbers in many studies preclude definitive conclusions, most recent evidence supports the persistence of increased morbidity and mortality even after long-term remission. It is conceivable that the degree of normalization of the associated comorbid conditions depends on individual factors and characteristics of the conditions. These findings highlight the need for early recognition and effective management of patients with CS, which should include active treatment of the related comorbid conditions. In addition, it is important to maintain a surveillance strategy in all patients with CS, even many years after disease remission, and to actively pursue specific treatment of comorbid conditions beyond cortisol normalization.
Collapse
Affiliation(s)
- Soraya Puglisi
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
| | - Anna Maria Elena Perini
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
| | - Cristina Botto
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
| | - Francesco Oliva
- Clinical Psychology Unit, Department of Clinical and Biological Sciences, University Hospital "Città della Salute e della Scienza di Torino", University of Turin, 10126 Turin, Italy
| | - Massimo Terzolo
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
| |
Collapse
|
6
|
Webb KL, Hinkle ML, Walsh MT, Bancos I, Shinya Y, Van Gompel JJ. Inferior Petrosal Sinus Sampling Tumor Lateralization and the Surgical Treatment of Cushing Disease: A Meta-Analysis and Systematic Review. World Neurosurg 2024; 182:e712-e720. [PMID: 38081579 DOI: 10.1016/j.wneu.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVE To determine whether accurate inferior petrosal sinus sampling (IPSS) tumor lateralization is associated with improved clinical outcomes following the surgical treatment of Cushing disease. METHODS The presented study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data regarding patient demographics, IPSS tumor lateralization, and postoperative endocrinologic outcomes were abstracted and pooled with random effects meta-analysis models. Additional meta-regression models were used to examine the association between the accuracy of IPSS tumor lateralization and postoperative outcomes (recurrence/persistence or remission/cure). Statistical analyses were performed using the Comprehensive Meta-Analysis software (significance of P < 0.05). RESULTS Seventeen eligible articles were identified, yielding data on 461 patients. Within average follow-up duration (∼59 months), the rate of correct IPSS tumor lateralization was 69% [95% confidence interval: 61%, 76%], and the rate of postoperative remission/cure was 78% [67%, 86%]. Preoperative IPSS tumor lateralization was concordant with magnetic resonance imaging lateralization for 53% of patients [40%, 66%]. There was no significant association between the rate of correct IPSS tumor lateralization and postoperative remission/cure among study-level data (P = 0.735). Additionally, there was no association among subgroup analyses for studies using stimulatory agents during IPSS (corticotropin-releasing hormone or desmopressin, P = 0.635), nor among subgroup analyses for adult (P = 0.363) and pediatric (P = 0.931) patients. CONCLUSIONS Limited data suggest that the rate of correct IPSS tumor lateralization may not be positively associated with postoperative remission or cure in patients with Cushing disease. These findings bring into question the utility of IPSS tumor lateralization in the context of preoperative planning and surgical approach rather than confirming a pituitary source.
Collapse
Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
7
|
Findlay MC, Drexler R, Azab M, Karbe A, Rotermund R, Ricklefs FL, Flitsch J, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Marino AC, Knappe UJ, Uksul N, Rzaev JA, Bervitskiy AV, Schroeder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Antunes ACM, Couldwell WT, Budohoski KP, Rennert RC, Karsy M. Crooke Cell Adenoma Confers Poorer Endocrinological Outcomes Compared with Corticotroph Adenoma: Results of a Multicenter, International Analysis. World Neurosurg 2023; 180:e376-e391. [PMID: 37757948 DOI: 10.1016/j.wneu.2023.09.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Crooke cell adenomas (CCAs) are a rare, aggressive subset of secretory pituitary corticotroph adenomas (sCTAs) found in 5%-10% of patients with Cushing disease. Multiple studies support worse outcomes in CCAs but are limited by small sample size and single-institution databases. We compared outcomes in CCA and sCTA using a multicenter, international retrospective database of high-volume skull base centers. METHODS Patients surgically treated for pituitary adenoma from January 2017 through December 2020 were included. RESULTS Among 2826 patients from 12 international centers, 20 patients with CCA and 480 patients with sCTA were identified. No difference in baseline demographics, tumor characteristics, or postoperative complications was seen. Microsurgical approaches (60% CCA vs. 62.3% sCTA) were most common. Gross total resection was higher in CCA patients (100% vs. 83%, P = 0.05). Among patients with gross total resection according to intraoperative findings, fewer CCA patients had postoperative hormone normalization of pituitary function (50% vs. 77.8%, P < 0.01) and remission of hypersecretion by 3-6 months (75% vs. 84.3%, P < 0.01). This was the case despite CCA having better local control rates (100% vs. 96%, P < 0.01) and fewer patients with remnant on magnetic resonance imaging (0% vs. 7.2%, P < 0.01). A systematic literature review of 35 studies reporting on various treatment strategies reiterated the high rate of residual tumor, persistent hypercortisolism, and tumor-related mortality in CCA patients. CONCLUSIONS This modern, multicenter series of patients with CCA reflects their poor prognosis and reduced postsurgical hormonal normalization. Further work is necessary to better understand the pathophysiology of CCA to devise more targeted treatment approaches.
Collapse
Affiliation(s)
- Matthew C Findlay
- School of Medicine, University of Utah, Salt Lake City, Utah, USA; Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA; Boise State University, Boise, Idaho, USA
| | - Arian Karbe
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Alexandria C Marino
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Jamil A Rzaev
- Federal Center of Neurosurgery, Novosibirsk, Russia; Novosibirsk State Medical University, Novosibirsk, Russia
| | - Anatoliy V Bervitskiy
- Federal Center of Neurosurgery, Novosibirsk, Russia; Novosibirsk State Medical University, Novosibirsk, Russia
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt, Germany
| | - Apio C M Antunes
- Departments of Neurosurgery Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Robert C Rennert
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Michael Karsy
- Global Neurosciences Institute, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
8
|
Mondin A, Ceccato F, Voltan G, Mazzeo P, Manara R, Denaro L, Scaroni C, Barbot M. Complications and mortality of Cushing's disease: report on data collected over a 20-year period at a referral centre. Pituitary 2023; 26:551-560. [PMID: 37495935 PMCID: PMC10539191 DOI: 10.1007/s11102-023-01343-2] [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] [Accepted: 07/14/2023] [Indexed: 07/28/2023]
Abstract
CONTEXT Cushing's disease (CD) is rare condition burdened by several systemic complications correlated to higher mortality rates. The primary goal of clinicians is to achieve remission, but it is unclear if treatment can also increase life expectancy. AIM To assess the prevalence of cortisol-related complications and mortality in a large cohort of CD patients attending a single referral centre. MATERIALS AND METHODS The clinical charts of CD patients attending a referral hospital between 2001 and 2021 were reviewed. RESULTS 126 CD patients (median age at diagnosis 39 years) were included. At the last examination, 78/126 (61.9%) of the patients were in remission regardless of previous treatment strategies. Patients in remission showed a significant improvement in all the cardiovascular (CV) comorbidities (p < 0.05). The CV events were more frequent in older patients (p = 0.003), smokers and persistent CD groups (p < 0.05). Most of the thromboembolic (TE) and infective events occurred during active stages of the disease. The CV events were the most frequent cause of death. The standardized mortality ratio (SMR) resulted increased in persistent cases at the last follow-up (SMR 4.99, 95%CI [2.15; 9.83], p < 0.001) whilst it was not higher in those in remission (SMR 1.66, 95%CI [0.34; 4.85], p = 0.543) regardless of the timing or number of treatments carried out. A younger age at diagnosis (p = 0.005), a microadenoma (p = 0.002), and remission status at the last follow-up (p = 0.027) all increased survival. Furthermore, an elevated number of comorbidities, in particular arterial hypertension, increased mortality rates. CONCLUSIONS Patients with active CD presented a poor survival outcome. Remission restored the patients' life expectancy regardless of the timing or the types of treatments used to achieve it. Persistent CD-related comorbidities remained major risk factors.
Collapse
Affiliation(s)
- Alessandro Mondin
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Giacomo Voltan
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Pierluigi Mazzeo
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Renzo Manara
- Neuroradiology Unit, University Hospital of Padova, Padua, Italy
| | - Luca Denaro
- Academic Neurosurgery, Department of Neurosciences, University of Padova, Padua, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
| |
Collapse
|
9
|
Fleseriu M, Varlamov EV, Hinojosa-Amaya JM, Langlois F, Melmed S. An individualized approach to the management of Cushing disease. Nat Rev Endocrinol 2023; 19:581-599. [PMID: 37537306 DOI: 10.1038/s41574-023-00868-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
Cushing disease caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary corticotroph adenoma leads to hypercortisolaemia with high mortality due to metabolic, cardiovascular, immunological, neurocognitive, haematological and infectious conditions. The disorder is challenging to diagnose because of its common and heterogenous presenting features and the biochemical pitfalls of testing levels of hormones in the hypothalamic-pituitary-adrenal axis. Several late-night salivary cortisol and 24-h urinary free cortisol tests are usually required as well as serum levels of cortisol after a dexamethasone suppression test. MRI might only identify an adenoma in 60-75% of patients and many adenomas are small. Therefore, inferior petrosal sinus sampling remains the gold standard for confirmation of ACTH secretion from a pituitary source. Initial treatment is usually transsphenoidal adenoma resection, but preoperative medical therapy is increasingly being used in some countries and regions. Other management approaches are required if Cushing disease persists or recurs following surgery, including medications to modulate ACTH or block cortisol secretion or actions, pituitary radiation, and/or bilateral adrenalectomy. All patients require lifelong surveillance for persistent comorbidities, clinical and biochemical recurrence, and treatment-related adverse effects (including development of treatment-associated hypopituitarism). In this Review, we discuss challenges in the management of Cushing disease in adults and provide information to guide clinicians when planning an integrated and individualized approach for each patient.
Collapse
Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Elena V Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Jose M Hinojosa-Amaya
- Division of Endocrinology, Department of Medicine, Hospital Universitario "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
10
|
Mehlich A, Bolanowski M, Mehlich D, Witek P. Medical treatment of Cushing's disease with concurrent diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1174119. [PMID: 37139336 PMCID: PMC10150952 DOI: 10.3389/fendo.2023.1174119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
Abstract
Cushing's disease (CD) is a severe endocrine disorder characterized by chronic hypercortisolaemia secondary to an overproduction of adrenocorticotropic hormone (ACTH) by a pituitary adenoma. Cortisol excess impairs normal glucose homeostasis through many pathophysiological mechanisms. The varying degrees of glucose intolerance, including impaired fasting glucose, impaired glucose tolerance, and Diabetes Mellitus (DM) are commonly observed in patients with CD and contribute to significant morbidity and mortality. Although definitive surgical treatment of ACTH-secreting tumors remains the most effective therapy to control both cortisol levels and glucose metabolism, nearly one-third of patients present with persistent or recurrent disease and require additional treatments. In recent years, several medical therapies demonstrated prominent clinical efficacy in the management of patients with CD for whom surgery was non-curative or for those who are ineligible to undergo surgical treatment. Cortisol-lowering medications may have different effects on glucose metabolism, partially independent of their role in normalizing hypercortisolaemia. The expanding therapeutic landscape offers new opportunities for the tailored therapy of patients with CD who present with glucose intolerance or DM, however, additional clinical studies are needed to determine the optimal management strategies. In this article, we discuss the pathophysiology of impaired glucose metabolism caused by cortisol excess and review the clinical efficacy of medical therapies of CD, with particular emphasis on their effects on glucose homeostasis.
Collapse
Affiliation(s)
- Anna Mehlich
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Marek Bolanowski
- Chair and Department of Endocrinology, Diabetes, and Isotope Treatment, Wroclaw Medical University, Wroclaw, Poland
| | - Dawid Mehlich
- Laboratory of Molecular OncoSignalling, International Institute of Molecular Mechanisms and Machines (IMol) Polish Academy of Sciences, Warsaw, Poland
- Doctoral School of Medical University of Warsaw, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Experimental Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Przemysław Witek,
| |
Collapse
|
11
|
Analysis of Function Role and Long Noncoding RNA Expression in Chronic Heart Failure Rats Treated with Hui Yang Jiu Ji Decoction. JOURNAL OF HEALTHCARE ENGINEERING 2023; 2023:7438567. [PMID: 36704572 PMCID: PMC9873466 DOI: 10.1155/2023/7438567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/25/2022] [Accepted: 12/13/2022] [Indexed: 01/19/2023]
Abstract
Hui Yang Jiu Ji (HYJJ) decoction has been applied as a prescription of traditional Chinese medicine for the treatment of chronic heart failure (CHF). However, its comprehensive molecular mechanism remains unclear now. Our study aimed to explore the possible function and lncRNA-miRNA regulation networks of HYJJ on CHF induced by doxorubicin (DOX) in rats. Our study showed that HYJJ could recover cardiac function and alleviate myocardial injury of DOX-induced CHF. Besides, HYJJ had an effect on restraining myocardial apoptosis in CHF rats. Moreover, RNA-sequencing and bioinformatics analysis indicated that among a total of 548 significantly up- and down-regulated differentially expressed (DE) long noncoding RNA (lncRNA), 511 up- and down-regulated DE miRNAs were identified. Cushing's syndrome and Adrenergic signaling in cardiomyocytes were common pathways between DE-lncRNAs-enriched pathways and DE-miRNAs-enriched pathways. Finally, we observed a new pathway-MSTRG.598.1/Lilrb2 pathway with the HYJJ treatment; however, it needs further studies. In conclusion, this study provided evidence that HYJJ may be a suitable medicine for treating CHF. Moreover, several pivotal miRNAs may serve important roles in these processes by regulating some key miRNAs or pathways in CHF.
Collapse
|
12
|
Gumaste N, Shah L, Cheesman KC, Geer EB. Evaluating Patient-Reported Outcomes in Cushing's Syndrome. Endocrinol Metab Clin North Am 2022; 51:691-707. [PMID: 36244687 DOI: 10.1016/j.ecl.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The importance of the patient's perspective on disease has increasingly gained traction among clinical investigators and clinicians. Patient-reported outcomes (PROs) are those which pertain to a patient's health, quality of life, or functional status (associated with health care or treatment) that are reported directly by the patient, without interpretation by a clinician. In this article, we will review PROs as they relate to the signs, symptoms, health-related quality of life, and comorbidities of active Cushing's syndrome (CS), and CS after treatment with surgery, radiotherapy, and medical therapy. We will explore long-term outcomes in the setting of remission, persistence, and recurrence in this population.
Collapse
Affiliation(s)
- Namrata Gumaste
- Department of Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, 505 East 70th Street, Suite 450, New York, NY 10021, USA
| | - Leena Shah
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1055, New York, NY 10029, USA
| | - Khadeen Christi Cheesman
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1055, New York, NY 10029, USA
| | - Eliza B Geer
- Department of Medicine, Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, David H. Koch Center for Cancer Care, 530 East 74th Street, Box 19, New York, NY 10021, USA; Department of Neurosurgery, Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, David H. Koch Center for Cancer Care, 530 East 74th Street, Box 19, New York, NY 10021, USA.
| |
Collapse
|
13
|
Sulu C, Karadayi Kaynak G, Koskun T, Koca O, Icli TB, Kavla Y, Ozkaya HM, Turan S, Eskin M, Kadioglu P. Problem-solving therapy can reduce psychological distress in patients with Cushing's disease: a randomized controlled trial. Pituitary 2022; 25:891-902. [PMID: 36050587 DOI: 10.1007/s11102-022-01275-3] [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] [Accepted: 08/09/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To evaluate the effects of online group problem-solving therapy (PST) for reducing negative problem orientation (NPO), psychological distress, and increasing quality of life in patients with Cushing's disease (CD). METHODS In this randomized trial, we allocated 55 eligible patients to either PST (n = 28) or treatment as usual (TAU) (n = 27) groups. The analyses primarily relied on intent-to-treat (ITT) principle and were repeated with intervention completers (per-protocol analyses). Social problem-solving inventory-revised short form, Beck Depression Inventory (BDI), General Health Questionnaire-12 (GHQ-12), Perceived Stress Scale (PSS), The Satisfaction with Life Scale, and Cushing's Quality of Life scale were used. Pre-test, post-test, and follow-up measures were obtained. Linear mixed models were used to compare PST and treatment as usual (TAU) groups across time. RESULTS Of the total 55 patients with CD, the mean age was 46 ± 12 years, 49 patients (89%) were female, and 41 patients (74.5%) were in remission. The patients within the PST and TAU groups were similar in terms of age, sex, and disease activity. ITT analyses showed a greater reduction of NPO scores in patients who received PST as compared to patients who received usual care (df = 45.9, p = 0.029, Cohen's d = 0.47). The decrease in NPO was sustained at follow-up (mean difference: - 2.2, p = 0.007). Results of the ITT analyses revealed no superior benefits of the intervention for psychological distress. However, per-protocol analyses demonstrated that PST provided a greater decrease in BDI, PSS, and GHQ-12 scores. CONCLUSION PST may decrease NPO and improve the psychological well-being of patients with CD.
Collapse
Affiliation(s)
- Cem Sulu
- Division of Endocrinology, Metabolism, and Diabetes-Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Tolga Koskun
- Department of Psychology, Aydin Adnan Menderes University, Aydin, Turkey
| | - Oguzhan Koca
- Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Tevhide Betul Icli
- Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Yasin Kavla
- Department of Psychiatry, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Division of Endocrinology, Metabolism, and Diabetes-Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Senol Turan
- Department of Psychiatry, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Eskin
- Department of Psychology, College of Social Sciences and Humanities, Koc University, Istanbul, Turkey
| | - Pinar Kadioglu
- Division of Endocrinology, Metabolism, and Diabetes-Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey.
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey.
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53 Fatih, 34098, Istanbul, Turkey.
| |
Collapse
|
14
|
Valassi E, Castinetti F, Ferriere A, Tsagarakis S, Feelders RA, Netea-Maier RT, Droste M, Strasburger CJ, Maiter D, Kastelan D, Chanson P, Webb SM, Demtröder F, Pirags V, Chabre O, Franz H, Santos A, Reincke M. Corticotroph tumor progression after bilateral adrenalectomy: data from ERCUSYN. Endocr Relat Cancer 2022; 29:681-691. [PMID: 36197784 DOI: 10.1530/erc-22-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022]
Abstract
Corticotroph tumor progression after bilateral adrenalectomy/Nelson's syndrome (CTP-BADX/NS) is a severe complication of bilateral adrenalectomy (BADX). The aim of our study was to investigate the prevalence, presentation and outcome of CTP-BADX/NS in patients with Cushing's disease (CD) included in the European Registry on Cushing's Syndrome (ERCUSYN). We examined data on 1045 CD patients and identified 85 (8%) who underwent BADX. Of these, 73 (86%) had follow-up data available. The median duration of follow-up since BADX to the last visit/death was 7 years (IQR 2-9 years). Thirty-three patients (45%) experienced CTP-BADX/NS after 3 years (1.5-6) since BADX. Cumulative progression-free survival was 73% at 3 years, 66% at 5 years and 46% at 10 years. CTP-BADX/NS patients more frequently had a visible tumor at diagnosis of CD than patients without CTP-BADX/NS (P < 0.05). Twenty-seven CTP-BADX/NS patients underwent surgery, 48% radiotherapy and 27% received medical therapy. The median time since diagnosis of CTP-BADX/NS to the last follow-up visit was 2 years (IQR, 1-5). Control of tumor progression was not achieved in 16 of 33 (48%) patients, of whom 8 (50%) died after a mean of 4 years. Maximum adenoma size at diagnosis of CD was associated with further tumor growth in CTP-BADX/NS despite treatment (P = 0.033). Diagnosis of CTP-BADX/NS, older age, greater UFC levels at diagnosis of CD and initial treatment predicted mortality. In conclusion, CTP-BADX/NS was reported in 45% of the ERCUSYN patients who underwent BADX, and control of tumor growth was reached in half of them. Future studies are needed to establish effective strategies for prevention and treatment.
Collapse
Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
- Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Frédéric Castinetti
- Department of Endocrinology, Aix Marseille University, AP-HM, INSERM, Marseille Medical Genetics, Marmara Institute, La Conception Hospital, Marseille, France
| | - Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University of Bordeaux, Bordeaux, France
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Richard A Feelders
- Erasmus Medical Center, Division of Endocrinology, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Romana T Netea-Maier
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Droste
- Praxis für Endokrinologie Dr. med. Michael Droste, Oldenburg, Germany
| | - Christian J Strasburger
- Division of Clinical Endocrinology, Department of Medicine CCM, Charité-Universitätsmedizin, Berlin, Germany
| | - Dominique Maiter
- Service d'Endocrinologie et Nutrition, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Philippe Chanson
- Institut National de la Santé et de la Recherche Médicale, U1185, Le Kremlin, Bicêtre, Paris, France
| | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Frank Demtröder
- Zentrum für Endokrinologie, Diabetologie, Rheumatologie Dr. Demtröder & Kollegen, Dortmund, Germany
| | - Valdis Pirags
- Paula Stradiņa klīniskā universitātes slimnīca, Riga, Latvia
| | | | - Holger Franz
- Lohmann & Birkner Health Care Consultimg GmbH, Berlin, Germany
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Martin Reincke
- Medizinische Klinik UND Poliklinik IV, Campus Innestadt, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| |
Collapse
|
15
|
Braun LT, Vogel F, Reincke M. Long-term morbidity and mortality in patients with Cushing's syndrome. J Neuroendocrinol 2022; 34:e13113. [PMID: 35312199 DOI: 10.1111/jne.13113] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 11/28/2022]
Abstract
Increased multisystem morbidity and mortality in patients with Cushing's syndrome comprise clinical problems and challenges, both at the time of diagnosis and in remission. Relevant comorbidities and clinical problems include hypertension, diabetes, overweight, myopathy and a high risk for acute complications such as infections and venous thrombembolism. Although there are therapy recommendations for most of these comorbidities, there is a lack of large, prospective studies to confirm and optimise them. Mortality is especially high during active disease and within the first year after diagnosis, as a result of cardiovascular events, infections and suicide. All in all, interdisciplinary therapy management is important for reducing morbidity and mortality over the long-term.
Collapse
Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| |
Collapse
|
16
|
Clayton RN. Cardiovascular complications of Cushings syndrome: Impact on morbidity and mortality. J Neuroendocrinol 2022; 34:e13175. [PMID: 35764311 PMCID: PMC9541180 DOI: 10.1111/jne.13175] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Richard N. Clayton
- PlymouthUK (no current academic affiliation, formerly University of Keele, Stoke on Trent, UK)
| |
Collapse
|
17
|
Guignat L, Bertherat J. Long-term follow-up and predictors of recurrence of Cushing's disease. J Neuroendocrinol 2022; 34:e13186. [PMID: 35979714 DOI: 10.1111/jne.13186] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery is the first-line treatment for Cushing's disease to selectively remove the tumor. The rate of postoperative remission is estimated around 70%-80% in expert centers. However, the long-term remission rate is lower because of recurrence during follow-up that can be observed in 15% to 25% of the patients depending on the studies and duration of follow-up. There is no significant predictive factor of recurrence before surgery, but postoperative corticotroph insufficiency and its duration has been found to be a protective factor for recurrence in many studies. The persistence of a positive response to desmopressin after surgery is associated with a higher rate of recurrence. Long term monitoring for recurrence with annual clinical and hormonal investigations after the hypothalamic-pituitary-adrenal axis postoperative recovery is advised. The biological tests used for the diagnosis of Cushing's syndrome (24 h-urinary-free cortisol [UFC], late-night salivary or serum cortisol, 1 mg dexamethasone suppression test) can be used to screen for recurrence. Several studies report that increased late night cortisol and alterations of dynamic testing can be observed before the increased 24 h-UFC. For this reason it is suggested that late-night salivary cortisol would be a very sensitive tool to diagnose recurrence, pending the realization of several assays in case of borderline or discrepant result. This review will summarize the knowledge about recurrence of Cushing's disease after pituitary surgery and the current recommendations for its monitoring and diagnosis.
Collapse
Affiliation(s)
- Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
| |
Collapse
|
18
|
Valassi E, Chiodini I, Feelders RA, Andela CD, Abou-Hanna M, Idres S, Tabarin A. Unmet needs in Cushing's syndrome: the patients' perspective. Endocr Connect 2022; 11:EC-22-0027. [PMID: 35904235 PMCID: PMC9254293 DOI: 10.1530/ec-22-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cushing's syndrome (CS) is a rare condition of chronically elevated cortisol levels resulting in diverse comorbidities, many of which endure beyond successful treatment affecting the quality of life. Few data are available concerning patients' experiences of diagnosis, care and persistent comorbidities. OBJECTIVE To assess CS patients' perspectives on the diagnostic and care journey to identify unmet therapeutic needs. METHODS A 12-item questionnaire was circulated in 2019 by the World Association for Pituitary Organisations. A parallel, 13-item questionnaire assessing physician perceptions on CS patient experiences was performed. RESULTS Three hundred twenty CS patients from 30 countries completed the questionnaire; 54% were aged 35-54 and 88% were female; 41% were in disease remission. The most burdensome symptom was obesity/weight gain (75%). For 49% of patients, time to diagnosis was over 2 years. Following treatment, 88.4% of patients reported ongoing symptoms including, fatigue (66.3%), muscle weakness (48.8%) and obesity/weight gain (41.9%). Comparisons with delay in diagnosis were significant for weight gain (P = 0.008) and decreased libido (P = 0.03). Forty physicians completed the parallel questionnaire which showed that generally, physicians poorly estimated the prevalence of comorbidities, particularly initial and persistent cognitive impairment. Only a minority of persistent comorbidities (occurrence in 1.3-66.3%; specialist treatment in 1.3-29.4%) were managed by specialists other than endocrinologists. 63% of patients were satisfied with treatment. CONCLUSION This study confirms the delay in diagnosing CS. The high prevalence of persistent comorbidities following remission and differences in perceptions of health between patients and physicians highlight a probable deficiency in effective multidisciplinary management for CS comorbidities.
Collapse
Affiliation(s)
- Elena Valassi
- Endocrinology Department, Germans Trias i Pujol Hospital and Research Institute, Badalona, Barcelona, Spain
- IRCCS, Istituto Auxologico Italiano, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Correspondence should be addressed to E Valassi:
| | - Iacopo Chiodini
- IRCCS, Istituto Auxologico Italiano, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Richard A Feelders
- Division of Endocrinology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Cornelie D Andela
- Division of Endocrinology and Centre for Endocrine Tumours, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - Antoine Tabarin
- Department of Endocrinology and INSERM U862 University and CHU of Bordeaux, Pessac, France
| |
Collapse
|
19
|
Moreno-Moreno P, Ibáñez-Costa A, Venegas-Moreno E, Fuentes-Fayos AC, Alhambra-Expósito MR, Fajardo-Montañana C, García-Martínez A, Dios E, Vázquez-Borrego MC, Remón-Ruiz P, Cámara R, Lamas C, Carlos Padillo-Cuenca J, Solivera J, Cano DA, Gahete MD, Herrera-Martínez AD, Picó A, Soto-Moreno A, Gálvez-Moreno MÁ, Castaño JP, Luque RM. Integrative Clinical, Radiological, and Molecular Analysis for Predicting Remission and Recurrence of Cushing Disease. J Clin Endocrinol Metab 2022; 107:e2938-e2951. [PMID: 35312002 DOI: 10.1210/clinem/dgac172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Adrenocorticotropin (ACTH)-secreting pituitary tumors (ACTHomas) are associated with severe comorbidities and increased mortality. Current treatments mainly focus on remission and prevention of persistent disease and recurrence. However, there are still no useful biomarkers to accurately predict the clinical outcome after surgery, long-term remission, or disease relapse. OBJECTIVES This work aimed to identify clinical, biochemical, and molecular markers for predicting long-term clinical outcome and remission in ACTHomas. METHODS A retrospective multicenter study was performed with 60 ACTHomas patients diagnosed between 2004 and 2018 with at least 2 years' follow-up. Clinical/biochemical variables were evaluated yearly. Molecular expression profile of the somatostatin/ghrelin/dopamine regulatory systems components and of key pituitary factors and proliferation markers were evaluated in tumor samples after the first surgery. RESULTS Clinical variables including tumor size, time until diagnosis/first surgery, serum prolactin, and postsurgery cortisol levels were associated with tumor remission and relapsed disease. The molecular markers analyzed were distinctly expressed in ACTHomas, with some components (ie, SSTR1, CRHR1, and MKI67) showing instructive associations with recurrence and/or remission. Notably, an integrative model including selected clinical variables (tumor size/postsurgery serum cortisol), and molecular markers (SSTR1/CRHR1) can accurately predict the clinical evolution and remission of patients with ACTHomas, generating a receiver operating characteristic curve with an area under the curve of 1 (P < .001). CONCLUSION This study demonstrates that the combination of a set of clinical and molecular biomarkers in ACTHomas is able to accurately predict the clinical evolution and remission of patients. Consequently, the postsurgery molecular profile represents a valuable tool for clinical evaluation and follow-up of patients with ACTHomas.
Collapse
Affiliation(s)
- Paloma Moreno-Moreno
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Service of Endocrinology and Nutrition, IMIBIC, HURS, 14004 Cordoba, Spain
| | - Alejandro Ibáñez-Costa
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| | - Eva Venegas-Moreno
- Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
| | - Antonio C Fuentes-Fayos
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| | - María R Alhambra-Expósito
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Service of Endocrinology and Nutrition, IMIBIC, HURS, 14004 Cordoba, Spain
| | - Carmen Fajardo-Montañana
- Department of Endocrinology, Hospital Universitario de La Ribera, Alzira, 46600, Valencia, Spain
| | - Araceli García-Martínez
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain
| | - Elena Dios
- Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
| | - Mari C Vázquez-Borrego
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| | - Pablo Remón-Ruiz
- Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
| | - Rosa Cámara
- Department of Endocrinology and Nutrition, Polytechnic University Hospital La Fe, 46026, Valencia, Spain
| | - Cristina Lamas
- Department of Endocrinology and Nutrition, Albacete University Hospital, 02006, Albacete, Spain
| | - José Carlos Padillo-Cuenca
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Service of Endocrinology and Nutrition, IMIBIC, HURS, 14004 Cordoba, Spain
| | | | - David A Cano
- Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
| | - Manuel D Gahete
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| | - Aura D Herrera-Martínez
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Service of Endocrinology and Nutrition, IMIBIC, HURS, 14004 Cordoba, Spain
| | - Antonio Picó
- Department of Endocrinology and Nutrition, Alicante General University Hospital. Institute for Health and Biomedical Research (ISABIAL). University Miguel Hernandez, CIBER Rare Diseases, 03010, Alicante, Spain
| | - Alfonso Soto-Moreno
- Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
| | - María Ángeles Gálvez-Moreno
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Service of Endocrinology and Nutrition, IMIBIC, HURS, 14004 Cordoba, Spain
| | - Justo P Castaño
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| | - Raúl M Luque
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| |
Collapse
|
20
|
Bengtsson D, Ragnarsson O, Berinder K, Dahlqvist P, Edén Engström B, Ekman B, Höybye C, Järås J, Valdemarsson S, Burman P, Wahlberg J. Increased mortality persists after treatment of Cushing’s disease: A matched nationwide cohort study. J Endocr Soc 2022; 6:bvac045. [PMID: 35480633 PMCID: PMC9037134 DOI: 10.1210/jendso/bvac045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
Whether biochemical remission normalizes life expectancy in Cushing’s disease (CD) patients remains unclear. Previous studies evaluating mortality in CD are limited by using the expected number of deaths in the background population instead of the actual number in matched controls.
Objective and setting
To study mortality by time-to-event analysis in an unselected nationwide CD patient cohort.
Design and participants
Longitudinal data from the Swedish Pituitary Register of 371 patients diagnosed with CD from 1991-2018 and information from the Swedish Cause of Death Register were evaluated. Four controls per patient (n=1484) matched at the diagnosis date by age, sex and residential area were included.
Main outcome measures
Mortality and causes of death.
Results
The median diagnosis age was 44 years (interquartile range [IQR] 32-56), and the median follow-up was 10.6 years (5.7-18). At the 1-, 5-, 10-, 15- and 20-year follow-ups, the remission rates were 80%, 92%, 96%, 91% and 97%, respectively. Overall mortality was increased in CD patients compared with matched controls (hazard ratio [HR] 2.1 [95% confidence interval {CI} 1.5-2.8]). The HRs were 1.5 (1.02-2.2) for patients in remission at the last follow-up (n=303), 1.7 (1.03-2.8) for those in remission after a single pituitary surgery (n=177), and 5.6 (2.7-11.6) for those not in remission (n=31). Cardiovascular diseases (32/66) and infections (12/66) were overrepresented causes of death.
Conclusions
Mortality was increased in CD patients despite biochemical remission compared to matched controls. The study highlights the importance of careful comorbidity monitoring, regardless of remission status.
Collapse
Affiliation(s)
- Daniel Bengtsson
- Department of Internal Medicine, Kalmar, Region of Kalmar County, 39 185, Kalmar, Sweden and Department of Biomedical and Clinical Sciences, Linköping University, 581 85, Linköping, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Katarina Berinder
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 85 Umeå, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Department of Endocrinology and Diabetes, Uppsala University Hospital, 751 85, Uppsala, Sweden
| | - Bertil Ekman
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, 581 85, Linköping, Sweden
| | - Charlotte Höybye
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Jacob Järås
- Regional Cancer Centre, Stockholm/Gotland, 102 39, Stockholm, Sweden
| | - Stig Valdemarsson
- Department of Clinical Sciences, Skåne University Hospital, University of Lund, 221 85 Lund, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, University of Lund, 205 02 Malmö, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, 581 85, Linköping, Sweden
- Faculty of Medical Sciences, Örebro University, 589 41, Örebro, Sweden
| |
Collapse
|
21
|
Armignacco R, Jouinot A, Bouys L, Septier A, Lartigue T, Neou M, Gaspar C, Perlemoine K, Braun L, Riester A, Bonnet-Serrano F, Blanchard A, Amar L, Scaroni C, Ceccato F, Rossi GP, Williams TA, Larsen CK, Allassonnière S, Zennaro MC, Beuschlein F, Reincke M, Bertherat J, Assié G. Identification of glucocorticoid-related molecular signature by whole blood methylome analysis. Eur J Endocrinol 2022; 186:297-308. [PMID: 34914631 PMCID: PMC8789024 DOI: 10.1530/eje-21-0907] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/16/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cushing's syndrome represents a state of excessive glucocorticoids related to glucocorticoid treatments or to endogenous hypercortisolism. Cushing's syndrome is associated with high morbidity, with significant inter-individual variability. Likewise, adrenal insufficiency is a life-threatening condition of cortisol deprivation. Currently, hormone assays contribute to identify Cushing's syndrome or adrenal insufficiency. However, no biomarker directly quantifies the biological glucocorticoid action. The aim of this study was to identify such markers. DESIGN We evaluated whole blood DNA methylome in 94 samples obtained from patients with different glucocorticoid states (Cushing's syndrome, eucortisolism, adrenal insufficiency). We used an independent cohort of 91 samples for validation. METHODS Leukocyte DNA was obtained from whole blood samples. Methylome was determined using the Illumina methylation chip array (~850 000 CpG sites). Both unsupervised (principal component analysis) and supervised (Limma) methods were used to explore methylome profiles. A Lasso-penalized regression was used to select optimal discriminating features. RESULTS Whole blood methylation profile was able to discriminate samples by their glucocorticoid status: glucocorticoid excess was associated with DNA hypomethylation, recovering within months after Cushing's syndrome correction. In Cushing's syndrome, an enrichment in hypomethylated CpG sites was observed in the region of FKBP5 gene locus. A methylation predictor of glucocorticoid excess was built on a training cohort and validated on two independent cohorts. Potential CpG sites associated with the risk for specific complications, such as glucocorticoid-related hypertension or osteoporosis, were identified, needing now to be confirmed on independent cohorts. CONCLUSIONS Whole blood DNA methylome is dynamically impacted by glucocorticoids. This biomarker could contribute to better assessment of glucocorticoid action beyond hormone assays.
Collapse
Affiliation(s)
- Roberta Armignacco
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
- Correspondence should be addressed to R Armignacco or G Assié; or
| | - Anne Jouinot
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
| | - Lucas Bouys
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
| | - Amandine Septier
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
| | - Thomas Lartigue
- ARAMIS Project-Team, Inria Paris, France
- CMAP, UMR 7641, CNRS, École polytechnique, I.P. Paris, France
| | - Mario Neou
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
| | - Cassandra Gaspar
- Sorbonne Université, Inserm, UMS Pass, Plateforme Post-génomique de la Pitié-Salpêtrière, P3S, Paris, France
| | - Karine Perlemoine
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Fidéline Bonnet-Serrano
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Service d’Hormonologie, Paris, France
| | - Anne Blanchard
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Centre d’Investigations Cliniques 9201, Paris, France
| | - Laurence Amar
- Université de Paris, PARCC, INSERM, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité Hypertension Artérielle, Paris, France
| | - Carla Scaroni
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - Filippo Ceccato
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - Gian Paolo Rossi
- Clinica dell’Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Tracy Ann Williams
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | | | - Maria-Christina Zennaro
- Université de Paris, PARCC, INSERM, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jérôme Bertherat
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Service d’Endocrinologie, Center for Rare Adrenal Diseases, Paris, France
| | - Guillaume Assié
- Université de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Service d’Endocrinologie, Center for Rare Adrenal Diseases, Paris, France
- Correspondence should be addressed to R Armignacco or G Assié; or
| |
Collapse
|
22
|
Abstract
Cushing's disease (CD) is the most prevalent cause of endogenous hypercortisolism. CD is responsible for multiple co-morbidities and increased mortality. Accurate and prompt diagnosis and optimal treatment are essential to improve the prognosis of CD. However, the diagnosis of CD is probably one of the most difficult in endocrinology and, therefore, diagnostic workup should be performed in an experienced center. Transsphenoidal surgery performed by an expert surgeon is the only therapeutic option that can offer definitive cure and remains the first-line treatment in most patients. Second-line treatments include pharmacotherapy, pituitary radiotherapy and bilateral adrenalectomy. The second-line therapeutic strategy is complex, must be individualized and performed in a multidisciplinary expert center. Symptomatic treatments of persisting co-morbidities after remission, which are responsible for increased mortality and impaired quality of life is an important part of medical management.
Collapse
Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France; INSERM U1215, NeuroCentre Magendie, University of Bordeaux, France.
| |
Collapse
|
23
|
Sagara R, Inoue T, Sonoda N, Yano C, Motoya M, Umakoshi H, Sakamoto R, Ogawa Y. Association between cortisol and left ventricular diastolic dysfunction in patients with diabetes mellitus. J Diabetes Investig 2021; 13:344-350. [PMID: 34465012 PMCID: PMC8847151 DOI: 10.1111/jdi.13653] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 01/14/2023] Open
Abstract
Aims/Introduction Diabetes mellitus is a major risk factor for the development of cardiovascular diseases. Heart failure with preserved ejection fraction is characterized by left ventricular diastolic dysfunction (LVDD). It has been reported that excess cortisol found in patients with Cushing's syndrome was associated with the development of LVDD. However, the relationship between cortisol concentration and LVDD in patients with diabetes mellitus has not been addressed. Materials and Methods We enrolled 109 patients with diabetes mellitus and 104 patients without diabetes mellitus who had undergone echocardiographic examination at Kyushu University Hospital, Fukuoka, Japan, between November 2016 and March 2019. Left ventricular function was evaluated and the ratio of early diastolic velocity from transmitral inflow to early diastolic velocity (E/eʹ) was used as an index of diastolic function. Plasma cortisol concentrations, glycemic control, lipid profiles, treatment with antidiabetic drugs and other clinical characteristics were evaluated, and their associations with E/eʹ were determined using univariate and multivariate analyses. Results Multivariate linear regression analysis showed that log E/eʹ was positively correlated with age (P = 0.017), log systolic blood pressure (P = 0.004) and cortisol (P = 0.037), and negatively correlated with estimated glomerular filtration rate (P = 0.016) and the use of sodium–glucose cotransporter 2 inhibitors (P = 0.042) in patients with diabetes mellitus. Multivariate analysis showed that cortisol was positively correlated with age (P = 0.016) and glycated hemoglobin (P = 0.011). There was no association between E/eʹ and cortisol in patients without diabetes mellitus. Conclusions Increased cortisol levels might increase the risk of developing LVDD in diabetes mellitus patients.
Collapse
Affiliation(s)
- Rikako Sagara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoaki Inoue
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriyuki Sonoda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Chieko Yano
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Misato Motoya
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hironobu Umakoshi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryuichi Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
24
|
Chen C, Hu Y, Lyu L, Yin S, Yu Y, Jiang S, Zhou P. Incidence, demographics, and survival of patients with primary pituitary tumors: a SEER database study in 2004-2016. Sci Rep 2021; 11:15155. [PMID: 34312470 PMCID: PMC8313564 DOI: 10.1038/s41598-021-94658-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/09/2021] [Indexed: 02/05/2023] Open
Abstract
Comprehensive investigations on the incidence and prognosis of pituitary tumors are still lacking. The present study aims to summarize the incidence, demographics, and survival outcome of pituitary adenoma on a population-based level. This study includes all pituitary adenomas reported in the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2016 in the United States. Extensive clinical and demographic characteristics were extracted and submitted to group comparisons. The standardized incidence rate was calculated and stratified by year at diagnosis, age/sex and age/treatment groups. The Kaplan–Meier analysis and multivariable regressions were performed to identify the factors associated with overall survival. A total of 47,180 pituitary tumors were identified, including 47,030 typical adenomas, 111 uncertain behavior pituitary adenomas, and 39 pituitary carcinomas. The overall standardized incidence rate was 4.8 cases per 100,000 person-years and the annual incidence rate continually trended upwards, with a peak seen in 2015. We noticed a bimodal age-related distribution in females and a unimodal distribution in males. In the multivariate regression analysis, the factors associated with prolonged survival included typical adenoma, younger age, and smaller tumor size. Whereas, black and male patients had worse overall survival. Our study provides a reliable estimate on the incidence of pituitary adenoma and confirms that the annual standardized incidence rate is increasing. Pituitary adenomas have a satisfactory long-term prognosis and age, tumor size, and tumor subtypes are related to overall survival. Though statistically significant, our inferential findings should be constrained within the limitations of SEER database.
Collapse
Affiliation(s)
- Cheng Chen
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Yu Hu
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Liang Lyu
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China.,State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Senlin Yin
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Yang Yu
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Shu Jiang
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China.,Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Peizhi Zhou
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China. .,Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
| |
Collapse
|
25
|
De Ravin E, Phan HAT, Harmsen S, Cho SS, Teng CW, Petersson EJ, White C, Galban EM, Hess R, Lee JYK. Somatostatin Receptor as a Molecular Imaging Target in Human and Canine Cushing Disease. World Neurosurg 2021; 149:94-102. [PMID: 33601082 DOI: 10.1016/j.wneu.2021.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fluorescence-guided surgery may improve completeness of resection in transsphenoidal surgery for Cushing disease (CD) by enabling visualization of residual tumor tissue at the margins. In this review we discuss somatostatin receptors (SSTRs) as targets for fluorescence-guided surgery and overview existing SSTR-specific imaging agents. We also compare SSTR expression in normal pituitary and corticotrophinoma tissues from human and canine CD patients to assess canines as a translational model for CD. METHODS A PubMed literature search was conducted for publications containing the terms canine, somatostatin receptor, Cushing's disease, and corticotroph adenoma. SSTR expression data from each study was documented as the presence or absence of expression or, when possible, the number of tumors expressing a given SSTR subtype within a group of tumors being studied. Studies that used reverse transcription polymerase chain reaction to quantify SSTR expression were selected for additional comparative analysis. RESULTS SSTR5 is strongly expressed in human corticotroph adenomas and weakly expressed in surrounding pituitary parenchyma, a pattern not conclusively observed in canine patients. SSTR2 mRNA expression is similar in human normal pituitary and corticotrophinoma cells but may be significantly higher in canine normal pituitary tissue than in corticotroph tumoral tissue. Limited data were available on SSTR subtypes 1, 3, and 4. CONCLUSIONS Further studies must fill the knowledge gaps related to species-specific SSTR expression, so using canine CD as a translational model may be premature. We do conclude that the expression profile of SSTR5 (i.e., high local expression in pituitary adenomas relative to normal surrounding tissues) makes SSTR5 a promising molecular target for FGS.
Collapse
Affiliation(s)
- Emma De Ravin
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hoang Anh T Phan
- Department of Chemistry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stefan Harmsen
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steve S Cho
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clare W Teng
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - E James Petersson
- Department of Chemistry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caitlin White
- Department of Endocrinology at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Evelyn M Galban
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecka Hess
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
26
|
Zhang W, Sun M, Fan Y, Wang H, Feng M, Zhou S, Wang R. Machine Learning in Preoperative Prediction of Postoperative Immediate Remission of Histology-Positive Cushing's Disease. Front Endocrinol (Lausanne) 2021; 12:635795. [PMID: 33737912 PMCID: PMC7961560 DOI: 10.3389/fendo.2021.635795] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/25/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There are no established accurate models that use machine learning (ML) methods to preoperatively predict immediate remission after transsphenoidal surgery (TSS) in patients diagnosed with histology-positive Cushing's disease (CD). PURPOSE Our current study aims to devise and assess an ML-based model to preoperatively predict immediate remission after TSS in patients with CD. METHODS A total of 1,045 participants with CD who received TSS at Peking Union Medical College Hospital in a 20-year period (between February 2000 and September 2019) were enrolled in the present study. In total nine ML classifiers were applied to construct models for the preoperative prediction of immediate remission with preoperative factors. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the performance of the models. The performance of each ML-based model was evaluated in terms of AUC. RESULTS The overall immediate remission rate was 73.3% (766/1045). First operation (p<0.001), cavernous sinus invasion on preoperative MRI(p<0.001), tumour size (p<0.001), preoperative ACTH (p=0.008), and disease duration (p=0.010) were significantly related to immediate remission on logistic univariate analysis. The AUCs of the models ranged between 0.664 and 0.743. The highest AUC, i.e., the best performance, was 0.743, which was achieved by stacking ensemble method with four factors: first operation, cavernous sinus invasion on preoperative MRI, tumour size and preoperative ACTH. CONCLUSION We developed a readily available ML-based model for the preoperative prediction of immediate remission in patients with CD.
Collapse
Affiliation(s)
- Wentai Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengke Sun
- Medical Imaging, Robotics, Analytic Computing Laboratory/Engineering (MIRACLE), Key Laboratory of Intelligent Information Processing of Chinese Academy of Sciences (CAS), Institute of Computing Technology, CAS, Beijing, China
| | - Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - He Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Ming Feng, ; Shaohua Zhou, ; Renzhi Wang,
| | - Shaohua Zhou
- Medical Imaging, Robotics, Analytic Computing Laboratory/Engineering (MIRACLE), Key Laboratory of Intelligent Information Processing of Chinese Academy of Sciences (CAS), Institute of Computing Technology, CAS, Beijing, China
- *Correspondence: Ming Feng, ; Shaohua Zhou, ; Renzhi Wang,
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Ming Feng, ; Shaohua Zhou, ; Renzhi Wang,
| |
Collapse
|
27
|
Jurek A, Krzesiński P, Gielerak G, Witek P, Zieliński G, Kazimierczak A, Wierzbowski R, Banak M, Uziębło-Życzkowska B. Cushing's Disease: Assessment of Early Cardiovascular Hemodynamic Dysfunction With Impedance Cardiography. Front Endocrinol (Lausanne) 2021; 12:751743. [PMID: 34659130 PMCID: PMC8517395 DOI: 10.3389/fendo.2021.751743] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cushing's disease is a rare condition associated with a high cardiovascular risk and hypercortisolemia-related hemodynamic dysfunction, the extent of which can be assessed with a noninvasive method, called impedance cardiography. The standard methods for hemodynamic assessment, such as echocardiography or ambulatory blood pressure monitoring may be insufficient to fully evaluate patients with Cushing's disease; therefore, impedance cardiography is being currently considered a new modality for assessing early hemodynamic dysfunction in this patient population. The use of impedance cardiography for diagnosis and treatment of Cushing's disease may serve as personalized noninvasive hemodynamic status assessment and provide a better insight into the pathophysiology of Cushing's disease. The purpose of this study was to assess the hemodynamic profile of Cushing's disease patients and compare it with that in the control group. MATERIAL AND METHODS This observational prospective clinical study aimed to compare 54 patients with Cushing's disease (mean age 41 years; with 64.8% of this population affected with arterial hypertension) and a matched 54-person control group (mean age 45 years; with 74.1% of this population affected with arterial hypertension). The hemodynamic parameters assessed with impedance cardiography included the stroke index (SI), cardiac index (CI), systemic vascular resistance index (SVRI), velocity index (VI), (ACI), Heather index (HI), and thoracic fluid content (TFC). RESULTS The Cushing's disease group was characterized by a higher diastolic blood pressure and a younger age than the control group (82.9 vs. 79.1 mmHg, p=0.045; and 41.1 vs. 44.9 years, p=0.035, respectively). Impedance cardiography parameters in the Cushing's disease group showed: lower values of SI (42.1 vs. 52.8 ml/m2; p ≤ 0.0001), CI (2.99 vs. 3.64 l/min/m2; p ≤ 0,0001), VI (42.9 vs. 52.1 1/1000/s; p=0.001), ACI (68.7 vs. 80.5 1/100/s2; p=0,037), HI (13.1 vs. 15.2 Ohm/s2; p=0.033), and TFC (25.5 vs. 27.7 1/kOhm; p=0.006) and a higher SVRI (2,515 vs. 1,893 dyn*s*cm-5*m2; p ≤ 0.0001) than those in the control group. CONCLUSIONS Cushing's disease is associated with significantly greater vasoconstriction and left ventricular systolic dysfunction. An individual assessment with impedance cardiography may be useful in Cushing's disease patients in order to identify subclinical cardiovascular complications of chronic hypercortisolemia as potential therapeutic targets.
Collapse
Affiliation(s)
- Agnieszka Jurek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
- *Correspondence: Agnieszka Jurek,
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Grzegorz Gielerak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
| | - Anna Kazimierczak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Robert Wierzbowski
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Małgorzata Banak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | | |
Collapse
|
28
|
Dai C, Fan Y, Liu X, Bao X, Yao Y, Wang R, Feng M. Predictors of Immediate Remission after Surgery in Cushing's Disease Patients: A Large Retrospective Study from a Single Center. Neuroendocrinology 2021; 111:1141-1150. [PMID: 32512562 DOI: 10.1159/000509221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is the first-line treatment of patients with Cushing's disease (CD). However, biochemical remission rates after TSS for CD vary from 59 to 95%, and the predictors of surgical outcomes remain unclear. The aim of this study was to identify the predictors of early outcomes in patients with CD treated with TSS. METHODS The clinical features and outcomes of CD patients who underwent TSS between February 2000 and September 2019 at the Peking Union Medical College Hospital were collected from medical records and analyzed. Uni- and multivariate odds ratio (OR) analyses were performed to identify the predictors of early outcomes in patients with CD. RESULTS A total of 1,045 patients were included. The median age at TSS was 34.0 years (IQR 26.0-45.0), with a female:male ratio of 4.2:1 (844/201). The median duration of symptoms was 46.0 months (IQR 24.0-72.0). After surgery, the overall postoperative immediate remission rate was 73.3%, and 26.7% of patients had persistent hypercortisolism. Univariate analysis demonstrated that the number of operations was correlated with a lower immediate remission rate (OR 0.393, 95% CI 0.266-0.580, p = 0.000), as was tumor size (OR 0.462, 95% CI 0.334-0.639, p = 0.000), the duration of disease (OR 0.996, 95% CI 0.993-0.999, p = 0.003), and preoperative ACTH concentration (0.998, 95% CI 0.996-0.999, p = 0.003). Cavernous sinus invasion has also been identified as an important factor associated with a lower immediate remission rate (OR 0.275, 95% CI 0.166-0.456, p = 0.000). No correlations were detected between the immediate outcomes and age, gender, BMI, the combination of a low- and high-dose dexamethasone suppression test, preoperative morning serum cortisol level, or 24-h urinary free cortisol level (all p > 0.05). The results of multivariate analysis were similar to those of univariate analysis. Preoperative ACTH ≤67.35 ng/L predicted remission with 60.9% sensitivity and 49.5% specificity (AUC 0.553; p = 0.008). A cutoff of ≤64.5 months for disease duration predicted immediate remission with 40.5% sensitivity and 71.0% specificity (AUC 0.552; p = 0.01). CONCLUSION Early outcomes of TSS in CD patients can be predicted by factors including the number of operations, duration of disease, tumor invasion, tumor size, and preoperative ACTH concentration. These predictors can be used to improve the perioperative management of CD patients.
Collapse
Affiliation(s)
- Congxin Dai
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,
| |
Collapse
|
29
|
Roldán-Sarmiento P, Lam-Chung CE, Hinojosa-Amaya JM, Morales-García M, Guillén-Placencia MF, Pérez-Flores GE, León-Suárez A, León-Domínguez J, Balbuena-Álvarez S, Nava de la Vega A, Pérez-Guzmán CM, Gómez-Sámano MÁ, Enríquez-Estrada V, Gómez-Pérez FJ, Cuevas-Ramos D. Diabetes, Active Disease, and Afternoon Serum Cortisol Levels Predict Cushing's Disease Mortality: A Cohort Study. J Clin Endocrinol Metab 2021; 106:e103-e111. [PMID: 33108798 DOI: 10.1210/clinem/dgaa774] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Indexed: 01/15/2023]
Abstract
CONTEXT Cushing's disease (CD) is a life-threating disease, with increased mortality in comparison with the general population. OBJECTIVE This study aimed to evaluate standardized mortality ratios (SMRs) in CD patients. We also analyzed independent risk factors related to increased mortality. DESIGN We conducted a longitudinal cohort study in a 3rd level specialty center, from 1979 to 2018, in patients with CD. RESULTS From 1375 cases with a pathology diagnosis of pituitary adenoma, 191 cases had the confirmed diagnosis of CD (14%). A total of 172 patients completed follow-up, with a mean age at diagnosis of 33 ± 11 years, female predominance (n = 154, 89.5%), majority of them with microadenoma (n = 136, 79%), and a median follow-up of 7.5 years (2.4-15). Eighteen patients (10.5%) died, 8 of them (44%) were with active CD, 8 (44%) were under remission, and 2 (11%) were under disease control. Estimated all-cause SMR = 3.1, 95% confidence interval (CI) 1.9-4.8, P < 0.001. Cardiovascular disease was the main cause of death (SMR = 4.2, 1.5-9.3, P = 0.01). Multivariate Cox regression models adjusted for potential cofounders showed that diabetes (HR = 5.2, IC 95% 1.8-15.4, P = 0.002), high cortisol levels after 1600 hours at diagnosis (3.4, 2.3-7.0, P = 0.02), and active CD (7.5, 3.8-17.3, P = 0.003) significantly increased the risk of mortality. CONCLUSIONS Main cause of CD mortality was cardiovascular disease. Main risk factors for mortality were uncontrolled diabetes, persistently high cortisol levels after 1600 hours at diagnosis, and active disease at last follow-up.
Collapse
Affiliation(s)
- Paola Roldán-Sarmiento
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - César Ernesto Lam-Chung
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - José Miguel Hinojosa-Amaya
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Mariana Morales-García
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - María Fernanda Guillén-Placencia
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Greta E Pérez-Flores
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Andrés León-Suárez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Jefsi León-Domínguez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Salvador Balbuena-Álvarez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Alfredo Nava de la Vega
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Citlalli Mireya Pérez-Guzmán
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Miguel Ángel Gómez-Sámano
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Víctor Enríquez-Estrada
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Francisco J Gómez-Pérez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico
| |
Collapse
|
30
|
Kumari M, Kumar T, Rai S, Rai A, Sultana R, Priya L. Evaluation of Dental Health in Terminally Ill Patients. J Med Life 2020; 13:321-328. [PMID: 33072203 PMCID: PMC7550152 DOI: 10.25122/jml-2020-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Dental health plays an imperative role in the general health and well-being of an individual. Terminally ill patients due to a compromised immune response are susceptible to a wide array of oral complications, which may affect their ability to speak and chew, leading to malnutrition. The present study was conducted to evaluate dental health and various oral manifestations in terminally ill patients. One hundred twenty terminally ill patients hospitalized with diseases of the respiratory tract, gastrointestinal tract, circulatory system, liver, and endocrinal disorders were included in the study. The evaluation of oral manifestations and their prevalence was done by a single examiner. The oral health was evaluated according to symptoms exhibited by the patients and clinical presentation. Of the patients included in the study, 78 were male, and 42 were female. All the individuals were adults between 25 to 55 years of age. Out of 120 admitted terminally ill patients, 27 subjects had respiratory diseases, 17 had gastrointestinal disorders, 5 had disorders of the circulatory system, 39 had liver disorders, and 32 had endocrine disorders. A need for added comprehension is mandatory to link the inter-relationships between dentistry and medicine to further perk up the management of the overall health of patients, which will further reinforce the partnership between dental and medical communities.
Collapse
Affiliation(s)
- Minti Kumari
- Department of Public Health Dentistry, Patna Dental College and Hospital, Patna, India
| | - Tanoj Kumar
- Department of Oral Pathology and Microbiology, Patna Dental College and Hospital, Patna, India
| | - Shweta Rai
- Department of Oral and Maxillofacial Surgery, Buddha Institute of Dental Sciences and Hospital, Kankarbagh, Patna, India
| | - Anurag Rai
- Department of Orthodontics, Patna Dental College and Hospital, Bankipore, Patna, India
| | | | - Leena Priya
- Department of Oral Medicine And Radiology, Buddha Institute of Dental Science and Hospital, Patna, India
| |
Collapse
|
31
|
Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
Collapse
Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
| |
Collapse
|
32
|
Fan Y, Li D, Liu Y, Feng M, Chen Q, Wang R. Toward better prediction of recurrence for Cushing’s disease: a factorization-machine based neural approach. INT J MACH LEARN CYB 2020. [DOI: 10.1007/s13042-020-01192-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
33
|
Neuropsychological and Emotional Functioning in Patients with Cushing's Syndrome. Behav Neurol 2020; 2020:4064370. [PMID: 32831970 PMCID: PMC7428886 DOI: 10.1155/2020/4064370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/30/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022] Open
Abstract
Patients with Cushing's syndrome (CS) frequently report impairments in cognitive and emotional functioning. Given neuroimaging research that implicates alterations in structure and function in the brain in this population, goals of this study were to investigate neuropsychological and emotional functioning, with particular emphasis on complex attention and memory. In a clinical sample of 18 adults with CS referred for neuropsychological evaluation (age 41.6 ± 10.6, 72% Caucasian), patients' most common subjective complaints were in attention and increased irritability. On objective testing, patients exhibited significant declines in the consistency of their sustained attention and visual-spatial functioning compared to normative peers. Patients exhibited on average significantly reduced initial learning following first exposure to visual and verbal stimuli but intact retention of information learned. Patients with CS endorsed highly elevated levels of somatization, depression, and anxiety, and 59% of them scored in the clinically elevated range for somatization and depressive symptomatology. Exploratory analyses suggested that the 11 patients with active Cushing's exhibited lower processing speed, poorer sustained attention, naming, and cognitive flexibility compared to the 7 patients who achieved biochemical remission. Patients with active Cushing's also reported higher levels of somatization and anxiety compared to patients in biochemical remission. Overall, this study provides new insights into complex attention and memory deficits in patients with CS and concern regarding cognitive and emotional issues despite resolution of hypercortisolism. Our study opens several avenues for further exploration.
Collapse
|
34
|
Albani A, Theodoropoulou M. Persistent Cushing's Disease after Transsphenoidal Surgery: Challenges and Solutions. Exp Clin Endocrinol Diabetes 2020; 129:208-215. [PMID: 32838436 DOI: 10.1055/a-1220-6056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Transsphenoidal surgery remains the primary treatment for Cushing's disease (CD). However, despite the vast improvements in pituitary surgery, successful treatment of CD remains a great challenge. Although selective transsphenoidal removal of the pituitary tumor is a safe and effective procedure, the disease persists in around 22% of CD patients due to incomplete tumor resection. The persistence of hypercortisolism after pituitary surgery may also be the consequence of a misdiagnosis, as can occur in case of ectopic ACTH secretion or pseudo-Cushing. Considering the elevated mortality and morbidity characterizing the disease, a multidisciplinary approach is needed to minimize potential pitfalls occurring during the diagnosis, avoid surgical failure and provide the best care in those patients who have undergone unsuccessful surgery. In this review, we analyze the factors that could predict remission or persistence of CD after pituitary surgery and revise the therapeutic options in case of surgical failure.
Collapse
Affiliation(s)
- Adriana Albani
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| | | |
Collapse
|
35
|
Ntali G, Hakami O, Wattegama M, Ahmed S, Karavitaki N. Mortality of Patients with Cushing's Disease. Exp Clin Endocrinol Diabetes 2020; 129:203-207. [PMID: 32645721 DOI: 10.1055/a-1197-6380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cushing's disease is a rare condition of cortisol excess attributed to a pituitary adenoma with an annual incidence of 1.2-2.4 cases per million population. It is associated with several co-morbidities leading to increased mortality predominantly due to cardiovascular disease. Despite the advances in its diagnosis and management, survival can be compromised even after apparent successful treatment. Minimizing the duration and extent of exposure to hypercortisolaemia by early diagnosis and rapid, effective therapeutic interventions, as well as close monitoring and aggressive control of cardiovascular risk factors are vital for improving outcomes of the patients.
Collapse
Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Osamah Hakami
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom of Great Britain and Northern Ireland.,Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Milanka Wattegama
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom of Great Britain and Northern Ireland.,Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Shahzada Ahmed
- Department of Ear, Nose & Throat, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom of Great Britain and Northern Ireland.,Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
36
|
Schey C, Postma M, Krabbe P, Medic G, Connolly M. The application of multi-criteria decision analysis to inform in resource allocation. F1000Res 2020. [DOI: 10.12688/f1000research.21728.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: There is a perception held by payers that orphan products are expensive. As a result, the current health technology assessment systems might be too restrictive for orphan drugs, therefore potentially denying patients access to life-saving medicines. While price is important, it should be considered in relation to a broader range of disease-related product attributes that are not necessarily considered by many health technology assessment agencies. To overcome these challenges, multi-criteria decision analysis has been proposed as an alternative to evaluate technologies. Methods: A targeted literature review was conducted to identify the most frequently cited attributes in multi-criteria decision analysis (MCDA) in rare diseases. From the leading attributes identified, we developed a multi-criteria decision analysis framework with which to aggregate the orphan drug values. We subsequently reviewed and plotted the relationship between single attributes and the average annual treatment costs for 8 drugs used in the treatment of rare endocrine diseases. The annual treatment costs were based on UK list prices for the average daily dose per patient. Results: The five most frequently mentioned attributes in the literature were as follows: Disease severity, Unmet need (or availability of therapeutic alternatives), Comparative effectiveness or efficacy, Quality of evidence and Safety & tolerability. Results from the multi-criteria decision analysis framework indicate a wide range of average annual per-patients costs for drugs intended for the same diseases, and likewise for diseases with a similar level of Disease severity. Conclusions: Multi-criteria decision analysis may offer a viable alternative to support discussion in reimbursement decisions for orphan drugs. The analyses can be used to inform investigations on the application of MCDAs in rare diseases.
Collapse
|
37
|
Fountas A, Lim ES, Drake WM, Powlson AS, Gurnell M, Martin NM, Seejore K, Murray RD, MacFarlane J, Ahluwalia R, Swords F, Ashraf M, Pal A, Chong Z, Freel M, Balafshan T, Purewal TS, Speak RG, Newell-Price J, Higham CE, Hussein Z, Baldeweg SE, Dales J, Reddy N, Levy MJ, Karavitaki N. Outcomes of Patients with Nelson's Syndrome after Primary Treatment: A Multicenter Study from 13 UK Pituitary Centers. J Clin Endocrinol Metab 2020; 105:5628028. [PMID: 31735971 DOI: 10.1210/clinem/dgz200] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023]
Abstract
CONTEXT Long-term outcomes of patients with Nelson's syndrome (NS) have been poorly explored, especially in the modern era. OBJECTIVE To elucidate tumor control rates, effectiveness of various treatments, and markers of prognostic relevance in patients with NS. PATIENTS, DESIGN, AND SETTING Retrospective cohort study of 68 patients from 13 UK pituitary centers with median imaging follow-up of 13 years (range 1-45) since NS diagnosis. RESULTS Management of Cushing's disease (CD) prior to NS diagnosis included surgery+adrenalectomy (n = 30; eight patients had 2 and one had 3 pituitary operations), surgery+radiotherapy+adrenalectomy (n = 17; two received >1 courses of irradiation, two had ≥2 pituitary surgeries), radiotherapy+adrenalectomy (n = 2), and adrenalectomy (n = 19). Primary management of NS mainly included surgery, radiotherapy, surgery+radiotherapy, and observation; 10-year tumor progression-free survival was 62% (surgery 80%, radiotherapy 52%, surgery+radiotherapy 81%, observation 51%). Sex, age at CD or NS diagnosis, size of adenoma (micro-/macroadenoma) at CD diagnosis, presence of pituitary tumor on imaging prior adrenalectomy, and mode of NS primary management were not predictors of tumor progression. Mode of management of CD before NS diagnosis was a significant factor predicting progression, with the group treated by surgery+radiotherapy+adrenalectomy for their CD showing the highest risk (hazard ratio 4.6; 95% confidence interval, 1.6-13.5). During follow-up, 3% of patients had malignant transformation with spinal metastases and 4% died of aggressively enlarging tumor. CONCLUSIONS At 10 years follow-up, 38% of the patients diagnosed with NS showed progression of their corticotroph tumor. Complexity of treatments for the CD prior to NS diagnosis, possibly reflecting corticotroph adenoma aggressiveness, predicts long-term tumor prognosis.
Collapse
Affiliation(s)
- Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Eugenie S Lim
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - William M Drake
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Andrew S Powlson
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Niamh M Martin
- Section of Endocrinology and Investigative Medicine, Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Khyatisha Seejore
- Department of Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Robert D Murray
- Department of Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James MacFarlane
- Department of Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Rupa Ahluwalia
- Department of Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Francesca Swords
- Department of Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Muhammad Ashraf
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Aparna Pal
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Zhuomin Chong
- Department of Endocrinology, Queen Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Marie Freel
- Department of Endocrinology, Queen Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Tala Balafshan
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Tejpal S Purewal
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Rowena G Speak
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ziad Hussein
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephanie E Baldeweg
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jolyon Dales
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Narendra Reddy
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Miles J Levy
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
38
|
Burke WT, Penn DL, Repetti CS, Iuliano S, Laws ER. Outcomes After Repeat Transsphenoidal Surgery for Recurrent Cushing Disease: Updated. Neurosurgery 2020; 85:E1030-E1036. [PMID: 31140553 DOI: 10.1093/neuros/nyz193] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 02/24/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Transspheniodal surgery (TSS) for Cushing disease (CD) is considered the first-line treatment; however, reported recurrence rates are high. OBJECTIVE To systemically review indications and outcomes for repeat TSS in recurrent CD. METHODS Retrospective review of patients undergoing TSS from 2008 to 2018 was performed. Patients undergoing repeat TSS for clinical and/or biochemically recurrent CD with follow-up at least 12 mo postoperatively were included. These data were analyzed in our "current cohort" and combined with our previously published data in a "combined cohort." RESULTS The current cohort of patients undergoing operations from 2008 to 2018 with repeat surgery following a prior operation included 15 patients. Pathology at the time of first operation was positive for adrenocortiotrophic hormone (ACTH) adenoma in 13/15 (86.7%) and 9/15 (60%) had evidence of recurrence after a previous surgical procedure on preoperative magnetic resonance imaging (MRI). Remission was achieved immediately postoperatively in 13/15 (86.7%). Over an average follow-up of 34.7 mo (range: 12-116), 11/15 (68.8%) achieved persistent remission. When combined with the historical cohort that underwent an operation during 1992-2006, 44/51 (86.3%) patients had a prior operation demonstrating ACTH adenoma and 35/51 (68.6%) had evidence of recurrent disease on preoperative MRI. Thirty-five (68.6%) patients went into remission immediately postoperatively. Thirty one (60.8%) had continued remission at most recent reported follow-up. CONCLUSION Recurrent CD can be a therapeutic challenge; however, these data demonstrate that in many patients repeat surgery can be an effective and safe next step prior to radiation or medical therapy.
Collapse
Affiliation(s)
- William T Burke
- University of Louisville School of Medicine, University of Louisville, Louisville, Kentucky
| | - David L Penn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Caroline S Repetti
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sherry Iuliano
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
39
|
Tonari M, Nishikawa Y, Matsuo J, Mimura M, Oku H, Sugasawa J, Ikeda N, Kurisu Y, Ikeda T. A Case of Giant Pituitary Adenoma Associated with a Postoperative Mental Disorder That Ultimately Resulted in Bilateral Blindness. Case Rep Ophthalmol 2020; 11:92-99. [PMID: 32308609 PMCID: PMC7154240 DOI: 10.1159/000506392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 02/09/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To report the case of a patient with adrenocorticotropic hormone (ACTH)-producing pituitary adenoma who developed a mental disorder after initial surgery that kept him from undergoing scheduled follow-up visits and who ultimately had a giant recurrent tumor that resulted in blindness. Case Report A 37-year-old male presented with the primary complaint of decreased visual acuity (VA) in both eyes and visual field defects. Visual field examination revealed bitemporal hemianopia. Magnetic resonance imaging (MRI) showed a pituitary tumor of approximately 4 cm in diameter extending from the intrasellar region to the sphenoid sinus and the suprasellar region. Transnasal transsphenoidal surgery was performed. Immunostaining of tumor tissue collected intraoperatively showed ACTH-positive cells, thus leading to the diagnosis of ACTH-producing pituitary adenoma. Postoperatively, the patient reportedly developed mental disorder that possibly interfered with scheduled appointments or continuous follow-up visits for many years, so we had no postoperative data about the vision/visual filed. Seven years later, he presented with markedly decreased VA (i.e., no light perception) in both eyes. Fundus examination showed bilateral marked optic disc atrophy. MRI showed a larger than 8-cm diameter giant recurrent pituitary adenoma in the suprasellar region, for which craniotomy was performed for partial tumor resection. Preoperatively, his blood cortisol level was low, and the lesion was deemed a nonfunctioning pituitary adenoma. Postoperatively, no significant complications occurred, yet his VA was no light perception OD and light perception OS. Conclusions Clinicians should be aware that patients with ACTH-producing pituitary adenomas may develop a mental disorder following surgery and possibly be unable to undergo scheduled follow-up, thus illustrating the importance of establishing an adequate patient follow-up system.
Collapse
Affiliation(s)
- Masahiro Tonari
- Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Japan
| | - Yuko Nishikawa
- Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Japan
| | - Junko Matsuo
- Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Japan
| | - Masashi Mimura
- Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Japan
| | - Hidehiro Oku
- Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Japan
| | - Jun Sugasawa
- Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Japan
| | - Naokado Ikeda
- Department of Neurosurgery, Osaka Medical College, Takatsuki-City, Japan
| | - Yoshitaka Kurisu
- Department of Pathology, Osaka Medical College, Takatsuki-City, Japan
| | - Tsunehiko Ikeda
- Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Japan
| |
Collapse
|
40
|
Abstract
Overt Cushing's syndrome is a severe condition responsible for multiple comorbidities and increased mortality. Effective treatment is essential to reduce mortality, improve comorbidities and long-term quality of life. Surgical resection of the causal lesion(s) is generally the first-line and most effective treatment to normalize cortisol secretion. Adjunctive symptomatic treatments of co-morbidities are often necessary both during the active phase of the disease and for persisting co-morbidities after cessation of hypercortisolism. Second-line treatments include various pharmacological treatments, bilateral adrenalectomy, and radiotherapy of corticotroph tumors. The choice of these treatments is complex, must be performed in a multidisciplinary expert team to be individualized for each patient, and use a shared decision-making approach.
Collapse
Affiliation(s)
- Amandine Ferriere
- Service d'endocrinologie, Diabétologie et maladies métaboliques, CHU de bordeaux, Avenue Magellan 33600, Pessac, France.
| | - Antoine Tabarin
- Service d'endocrinologie, Diabétologie et maladies métaboliques, CHU de bordeaux, Avenue Magellan 33600, Pessac, France; INSERM and University of Bordeaux, Neurocentre Magendie, U1215, France.
| |
Collapse
|
41
|
Ragnarsson O. Cushing's syndrome - Disease monitoring: Recurrence, surveillance with biomarkers or imaging studies. Best Pract Res Clin Endocrinol Metab 2020; 34:101382. [PMID: 32139169 DOI: 10.1016/j.beem.2020.101382] [Citation(s) in RCA: 8] [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] [Indexed: 12/18/2022]
Abstract
Pituitary surgery is the first-line treatment for patients with Cushing's disease. For patients who are not considered candidates for pituitary surgery, pituitary radiation and bilateral adrenalectomy are further treatment alternatives. Not all patients are cured with pituitary surgery, and a substantial number of patients develop recurrence, sometimes many years after an apparently successful treatment. The same applies to patients treated with radiotherapy. Far from all patients are cured, and in many cases the disease recurs. Bilateral adrenalectomy, although always curative, causes chronic adrenal insufficiency and the remaining pituitary tumour can continue to grow and cause symptoms due to pressure on adjacent tissues, a phenomenon called Nelson's syndrome. In this paper the rate of recurrence of hypercortisolism, as well as the rate of development of Nelson's syndrome, following treatment of patients with Cushing's syndrome, will be reviewed. The aim of the paper is also to summarize clinical and biochemical factors that are associated with recurrence of hypercortisolism and how the patients should be monitored following treatment.
Collapse
Affiliation(s)
- Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, SE-41302, Sweden.
| |
Collapse
|
42
|
Barbot M, Zilio M, Scaroni C. Cushing's syndrome: Overview of clinical presentation, diagnostic tools and complications. Best Pract Res Clin Endocrinol Metab 2020; 34:101380. [PMID: 32165101 DOI: 10.1016/j.beem.2020.101380] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cushing's syndrome (CS) is a severe condition that results from chronic exposure to elevated circulating cortisol levels; it is a rare but potentially life-threating condition, especially when not timely diagnosed and treated. Even though the diagnosis can be straightforward in florid cases due to their typical phenotype, milder forms can be missed. Despite the availability of different screening tests, the diagnosis remains challenging as none of the available tools proved to be fully accurate. Due to the ubiquitous effect of cortisol, it is easy understandable that its excess leads to a variety of systemic complications including hypertension, metabolic syndrome, bone damages and neurocognitive impairment. This article discusses clinical presentation of CS with an eye on the most frequent cortisol-related comorbidities and discuss the main pitfalls of first- and second-line tests in endogenous hypercortisolism diagnostic workup.
Collapse
Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy.
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy
| |
Collapse
|
43
|
Bunevicius A, Kano H, Lee CC, Krsek M, Nabeel AM, El-Shehaby A, Abdel Karim K, Martinez-Moreno N, Mathieu D, Lee JYK, Grills I, Kondziolka D, Martinez-Alvarez R, Reda WA, Liscak R, Su YH, Lunsford LD, Lee Vance M, Sheehan JP. Early versus late Gamma Knife radiosurgery for Cushing's disease after prior resection: results of an international, multicenter study. J Neurosurg 2020; 134:807-815. [PMID: 32084634 DOI: 10.3171/2019.12.jns192836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The optimal time to perform stereotactic radiosurgery after incomplete resection of adrenocorticotropic hormone (ACTH)-producing pituitary adenoma in patients with Cushing's disease (CD) remains unclear. In patients with persistent CD after resection of ACTH-producing pituitary adenoma, the authors evaluated the association of the interval between resection and Gamma Knife radiosurgery (GKRS) with outcomes. METHODS Pooled data from 10 institutions participating in the International Radiosurgery Research Foundation were used in this study. RESULTS Data from 255 patients with a mean follow-up of 65.59 ± 49.01 months (mean ± SD) were analyzed. Seventy-seven patients (30%) underwent GKRS within 3 months; 46 (18%) from 4 to 6 months; 34 (13%) from 7 to 12 months; and 98 (38%) at > 12 months after the resection. Actuarial endocrine remission rates were higher in patients who underwent GKRS ≤ 3 months than when treatment was > 3 months after the resection (78% and 65%, respectively; p = 0.017). Endocrine remission rates were lower in patients who underwent GKRS at > 12 months versus ≤ 12 months after the resection (57% vs 76%, respectively; p = 0.006). In multivariate Cox regression analyses adjusted for clinical and treatment characteristics, early GKRS was associated with increased probability of endocrine remission (hazard ratio [HR] 1.518, 95% CI 1.039-2.218; p = 0.031), whereas late GKRS (HR 0.641, 95% CI 0.448-0.919; p = 0.015) was associated with reduced probability of endocrine remission. The incidence of some degree of new pituitary deficiency (p = 0.922), new visual deficits (p = 0.740), and other cranial nerve deficits (p = 0.610) was not significantly related to time from resection to GKRS. CONCLUSIONS Early GKRS is associated with an improved endocrine remission rate, whereas later GKRS is associated with a lower rate of endocrine remission after pituitary adenoma resection. Early GKRS should be considered for patients with CD after incomplete pituitary adenoma resection.
Collapse
Affiliation(s)
- Adomas Bunevicius
- 1Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cheng-Chia Lee
- 3Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Michal Krsek
- 4Third Department of Internal Medicine, First Faculty of Medicine of the Charles University and General Teaching Hospital, Prague, Czech Republic
| | - Ahmed M Nabeel
- 5Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Benha University, Benha, Egypt
| | - Amr El-Shehaby
- 6Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt
| | - Khaled Abdel Karim
- 7Clinical Oncology Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt
| | - Nuria Martinez-Moreno
- 8Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - David Mathieu
- 9Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - John Y K Lee
- 10Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Inga Grills
- 11Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Douglas Kondziolka
- 12Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Roberto Martinez-Alvarez
- 8Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Wael A Reda
- 6Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt
| | - Roman Liscak
- 13Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic; and
| | - Yan-Hua Su
- 3Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - L Dade Lunsford
- 2Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Lee Vance
- 1Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia.,14Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
44
|
Li D, El Kawkgi OM, Henriquez AF, Bancos I. Cardiovascular risk and mortality in patients with active and treated hypercortisolism. Gland Surg 2020; 9:43-58. [PMID: 32206598 DOI: 10.21037/gs.2019.11.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with hypercortisolism demonstrate high cardiovascular morbidity and mortality, especially if diagnosis is delayed. Hypercortisolism-induced cardiovascular and metabolic comorbidities include hypertension, impaired glucose metabolism, dyslipidemia, and obesity. High prevalence of cardiovascular risk factors leads to increased rate of cardiovascular events and mortality. This risk is reduced, albeit not reversed even after successful treatment of hypercortisolism. In this review we will describe prevalence and mechanisms of cardiovascular comorbidities in patients with hypercortisolism. In addition, we will summarize the effect of therapy on cardiovascular risk factors, events, as well as mortality.
Collapse
Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Omar M El Kawkgi
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Andres F Henriquez
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
45
|
Bunevicius A, Sheehan D, Lee Vance M, Schlesinger D, Sheehan JP. Outcomes of Cushing's disease following Gamma Knife radiosurgery: effect of a center's growing experience and era of treatment. J Neurosurg 2020; 134:547-554. [PMID: 32005023 DOI: 10.3171/2019.12.jns192743] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is used for the management of residual or recurrent Cushing's disease (CD). Increasing experience and technological advancements of Gamma Knife radiosurgery (GKRS) systems can impact the outcomes of CD patients. The authors evaluated the association of their center's growing experience and the era in which GKRS was performed with treatment success and adverse events in patients with CD. METHODS The authors studied consecutive patients with CD treated with GKRS at the University of Virginia since installation of the first Gamma Knife system in March 1989 through August 2019. They compared endocrine remission and complication rates between patients treated before 2000 (early cohort) and those who were treated in 2000 and later (contemporary cohort). RESULTS One hundred thirty-four patients with CD underwent GKRS during the study period: 55 patients (41%) comprised the early cohort, and 79 patients (59%) comprised the contemporary cohort. The contemporary cohort, compared with the early cohort, had a significantly greater treatment volume, radiation prescription dose, maximal dose to the optic chiasm, and number of isocenters, and they more often had cavernous sinus involvement. Endocrine remission rates were higher in the contemporary cohort when compared with the early cohort (82% vs 66%, respectively; p = 0.01). In a Cox regression analysis adjusted for demographic, clinical, and SRS characteristics, the contemporary GKRS cohort had a higher probability of endocrine remission than the early cohort (HR 1.987, 95% CI 1.234-3.199; p = 0.005). The tumor control rate, incidence of cranial nerve neuropathy, and new anterior pituitary deficiency were similar between the two groups. CONCLUSIONS Technological advancements over the years and growing center experience were important factors for improved endocrine remission rates in patients with CD. Technological aspects and results of contemporary Gamma Knife systems should be considered when counseling patients, planning treatment, and reporting treatment results. Studies exploring the learning curve for GKRS are warranted.
Collapse
Affiliation(s)
| | | | - Mary Lee Vance
- Departments of1Neurological Surgery and
- 2Medicine, University of Virginia Health System, Charlottesville, Virginia
| | | | | |
Collapse
|
46
|
Suarez MG, Stack M, Hinojosa-Amaya JM, Mitchell MD, Varlamov EV, Yedinak CG, Cetas JS, Sheppard B, Fleseriu M. Hypercoagulability in Cushing Syndrome, Prevalence of Thrombotic Events: A Large, Single-Center, Retrospective Study. J Endocr Soc 2019; 4:bvz033. [PMID: 32064411 PMCID: PMC7009121 DOI: 10.1210/jendso/bvz033] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background The risk of Cushing syndrome (CS) patients experiencing a thrombotic event (TE) is significantly higher (odds ratio; OR 18%) than that of the general population. However, there are currently no anticoagulation guidelines. Methods A retrospective, single-center, longitudinal study of patients undergoing all types of treatment—surgical (pituitary, unilateral, and bilateral adrenalectomy) and medical treatment—was undertaken. TEs were recorded at any point up until last patient follow-up; myocardial infarction (MI), deep venous thrombosis (DVT), and pulmonary embolism (PE) or stroke. Patients’ doses and complications of anticoagulation were recorded. Results Included were 208 patients; a total of 165 (79.3%) were women, and mean age at presentation was 44 ± 14.7 years. Thirty-nine (18.2%) patients had a TE; extremity DVT (38%), cerebrovascular accident (27%), MI (21%), and PE (14%). Of 56 TEs, 27 (48%) were arterial and 29 (52%) were venous. Patients who underwent bilateral adrenalectomy (BLA) had an odds ratio of 3.74 (95% CI 1.69-8.27) of developing a TE. Of patients with TEs, 40.5% experienced the event within the first 60 days after surgery. Baseline 24-hour urinary free cortisol levels did not differ in patients with or without TE after BLA. Of 197 patients who underwent surgery, 50 (25.38%) received anticoagulation after surgery, with 2% having bleeding complications. Conclusions The risk of TEs in patients with CS was approximately 20%. Many patients had more than 1 event, with higher risk 30 to 60 days postoperatively. The optimal prophylactic anticoagulation duration is unknown, but most likely needs to continue up to 60 days postoperatively, particularly after BLA.
Collapse
Affiliation(s)
- Maria Gabriela Suarez
- Department of Medicine (Endocrinology), Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Madeleine Stack
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jose Miguel Hinojosa-Amaya
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA.,Endocrinology Division, Department of Medicine, Hospital Universitario "Dr. Jose E. Gonzalez", Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | | | - Elena V Varlamov
- Department of Medicine (Endocrinology), Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Chris G Yedinak
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA.,Operative Care Division, Portland Veterans Administration Hospital, Portland, Oregon, USA
| | - Brett Sheppard
- Department of General Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Department of Medicine (Endocrinology), Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
47
|
Nadezhdina EY, Rebrova OY, Grigoriev AY, Ivaschenko OV, Azizyan VN, Melnichenko GA, Dedov II. Prediction of recurrence and remission within 3 years in patients with Cushing disease after successful transnasal adenomectomy. Pituitary 2019; 22:574-580. [PMID: 31506907 DOI: 10.1007/s11102-019-00985-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Some laboratory and clinical features are associated with a probability of recurrence after transnasal adenomectomy for Cushing disease (CD). However, there is no consensus on a set of predictors. Rules for prediction of recurrence were not proposed earlier. AIM To develop prediction model of recurrence/remission after successful neurosurgical treatment for CD. METHODS Retrospective single-site comparative study included 349 patients (52 men and 297 women) with a verified diagnosis of CD who underwent effective endoscopic transsphenoidal adenomectomy between 2007 and 2014. Clinical and laboratory parameters were evaluated. Laboratory tests were performed using immunochemiluminescent method. Time-to-event analysis and ROC-analysis were applied. Multivariate models were developed using logistic regression and artificial neural network (ANN). RESULTS Postoperative cortisol and ACTH levels and their combinations cannot be used for prediction of recurrence. ANN for prediction of recurrence within 3 years after successful surgery was developed. Input variables are age, duration of the disease, MRI data on adenoma, morning postoperative levels of ACTH and cortisol, output variable is binary (recurrence/remission). Predictive value for remission is 93%, 95% CI [89%; 96%], and predictive value for recurrence is 85%, 95% CI [71%; 94%]. Web-calculator based on the model is developed and free for use. CONCLUSION Effective method for prediction of recurrence and long-term remission within 3 years after successful endoscopic transsphenoidal adenomectomy is proposed.
Collapse
Affiliation(s)
- Elena Y Nadezhdina
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia.
| | - Olga Yu Rebrova
- National Research University Higher School of Economics, 20 Myasnitskaya Ul., 101000, Moscow, Russia
- Pirogov Russian National Research Medical University, 1 Ostrovitianov str., 117997, Moscow, Russia
| | - Andrey Y Grigoriev
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
| | | | - Vilen N Azizyan
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
| | | | - Ivan I Dedov
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
| |
Collapse
|
48
|
Cesana-Nigro N, Keshvari S, Barclay JL, Sorbello J, Upham JW, Benham H, Anderson ST, Steiger N, Prins JB, Inder WJ. The effect of glucocorticoids on Thrombospondin-1, Osteocalcin and the Thrombospondin-1:Osteocalcin ratio in humans. Clin Endocrinol (Oxf) 2019; 91:728-736. [PMID: 31612515 DOI: 10.1111/cen.14108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/10/2019] [Accepted: 10/13/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Thrombospondin-1 (TSP1), a matricellular protein, and Osteocalcin (OCN), a noncollagenous protein secreted by osteoblasts, are known to be up- and down-regulated, respectively, by glucocorticoids. The aim of this study was to determine whether a ratio between TSP1:OCN was altered by changes in glucocorticoid activity in humans. DESIGN Prospective observational study. SETTING Tertiary university hospital in Queensland, Australia. PATIENTS AND MEASUREMENTS Patients with Cushing's syndrome (CS, n = 19), asthma or giant cell arteritis on chronic prednisolone treatment (PRED, n = 13), adrenal insufficiency (AI, n = 16) and healthy volunteers (HV, n = 20). Plasma TSP1 and serum total OCN were measured by immunoassay at 0800h, 1200h and 1600h in patients with CS, patients with AI taking replacement glucocorticoids, HV before and after 4 mg dexamethasone and PRED patients predose at 800 and 4 hours post-dose at 1200 hours. RESULTS Plasma TSP1 in CS was higher (P < .0001), and serum OCN was lower (P < .0001) than HV. The TSP1:OCN ratio in HV increased significantly after 4 mg dexamethasone (P < .0001) and in AI after taking their hydrocortisone replacement therapy (P < .001). PRED patients had a higher TSP1:OCN ratio compared with HV at both 800 and 1200 hours (both P < .001), but no significant change occurred from pre- to post-dose. A TSP1:OCN ratio of >73 at 800 hours differentiated CS from HV with a sensitivity of 95% and a specificity of 100%. CONCLUSIONS The TSP1:OCN ratio is elevated in patients on prednisolone and in patients with CS compared with healthy volunteers. It may be a useful biomarker of total body glucocorticoid activity in humans.
Collapse
Affiliation(s)
- Nicole Cesana-Nigro
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Qld., Australia
| | - Sahar Keshvari
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Johanna L Barclay
- Mater Research Institute, University of Queensland, Brisbane, Qld, Australia
| | - Jane Sorbello
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Qld., Australia
| | - John W Upham
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
- Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Helen Benham
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
- Department of Rheumatology, Princess Alexandra Hospital, Brisbane, Qld, Australia
| | | | - Natasha Steiger
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Johannes B Prins
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Qld., Australia
- Mater Research Institute, University of Queensland, Brisbane, Qld, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Qld., Australia
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| |
Collapse
|
49
|
Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
Collapse
Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
| |
Collapse
|
50
|
Sbiera S, Kunz M, Weigand I, Deutschbein T, Dandekar T, Fassnacht M. The New Genetic Landscape of Cushing's Disease: Deubiquitinases in the Spotlight. Cancers (Basel) 2019; 11:cancers11111761. [PMID: 31717455 PMCID: PMC6895825 DOI: 10.3390/cancers11111761] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022] Open
Abstract
Cushing’s disease (CD) is a rare condition caused by adrenocorticotropic hormone (ACTH)-producing adenomas of the pituitary, which lead to hypercortisolism that is associated with high morbidity and mortality. Treatment options in case of persistent or recurrent disease are limited, but new insights into the pathogenesis of CD are raising hope for new therapeutic avenues. Here, we have performed a meta-analysis of the available sequencing data in CD to create a comprehensive picture of CD’s genetics. Our analyses clearly indicate that somatic mutations in the deubiquitinases are the key drivers in CD, namely USP8 (36.5%) and USP48 (13.3%). While in USP48 only Met415 is affected by mutations, in USP8 there are 26 different mutations described. However, these different mutations are clustering in the same hotspot region (affecting in 94.5% of cases Ser718 and Pro720). In contrast, pathogenic variants classically associated with tumorigenesis in genes like TP53 and BRAF are also present in CD but with low incidence (12.5% and 7%). Importantly, several of these mutations might have therapeutic potential as there are drugs already investigated in preclinical and clinical setting for other diseases. Furthermore, network and pathway analyses of all somatic mutations in CD suggest a rather unified picture hinting towards converging oncogenic pathways.
Collapse
Affiliation(s)
- Silviu Sbiera
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, D-97080 Würzburg, Germany; (I.W.); (T.D.); (M.F.)
- Comprehensive Cancer Center Mainfranken, University of Würzburg, D-97080 Würzburg, Germany
- Correspondence:
| | - Meik Kunz
- Chair of Medical Informatics, Friedrich-Alexander University of Erlangen-Nürnberg, D-91058 Erlangen, Germany;
| | - Isabel Weigand
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, D-97080 Würzburg, Germany; (I.W.); (T.D.); (M.F.)
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, D-97080 Würzburg, Germany; (I.W.); (T.D.); (M.F.)
| | - Thomas Dandekar
- Department of Bioinformatics, Biocenter, University of Würzburg, D-97074 Würzburg, Germany;
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, D-97080 Würzburg, Germany; (I.W.); (T.D.); (M.F.)
- Comprehensive Cancer Center Mainfranken, University of Würzburg, D-97080 Würzburg, Germany
| |
Collapse
|