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Andereggen L, Gralla J, Christ E. The diagnostic yield of inferior petrosal sinus sampling in Cushing syndrome in the era of ovine CRH shortage. Acta Neurochir (Wien) 2024; 166:167. [PMID: 38565838 PMCID: PMC10987334 DOI: 10.1007/s00701-024-06058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE The ovine corticotropin-releasing hormone (oCRH) stimulation test has been routinely used in the diagnostic work-up of ACTH-dependent Cushing syndrome (CS). With oCRH currently being out-of-stock in Europe, we aimed at evaluating the diagnostic performance of inferior petrosal sinus sampling (IPSS) without oCRH stimulation. METHODS We compared the values of 40 patients with ACTH-dependent CS and negative MRI findings in whom ACTH was measured before and after oCRH stimulation. RESULTS The ratio of central-to-peripheral ACTH measurement (IPS:P) before the combined 3, 5, and 10 min of oCRH stimulation yielded diminished sensitivity (85% vs. 97%), alongside markedly decreased specificity (57% vs. 71%), as well as reduced positive and negative predictive values (90% vs. 94% and 44% vs. 83%), respectively. CONCLUSIONS With the current drug shortages in Europe, ACTH measurements without oCRH stimulation in IPSS cannot be recommended. Thus, we call for desmopressin or the commercially available human CRH as a potential alternative in the confirmation of ACTH excess by IPSS in equivocal MRI findings.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
- Faculty of Medicine, University of Bern, Bern, Switzerland.
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital Bern, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Emanuel Christ
- Department of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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2
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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.
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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.
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3
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Maddy K, Luther E, Berry K, Lu VM, Shah A, Ivan ME, Komotar RJ. Rathke's cleft cysts causing Cushing's disease: Two unique cases and review of the literature. Surg Neurol Int 2023; 14:402. [PMID: 38053717 PMCID: PMC10695451 DOI: 10.25259/sni_616_2023] [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: 07/23/2023] [Accepted: 10/19/2023] [Indexed: 12/07/2023] Open
Abstract
Background The presentation of isolated Rathke's cleft cysts (RCC) without any associated pituitary adenoma in patients with symptoms consistent with Cushing's disease (CD) remains exceedingly rare. As such, we aim to present two cases of RCC presenting with CD with a resultant resolution of their CD following surgical resection. Case Description Here, we present two cases of RCCs presenting with symptoms suggestive of CD. A functional pituitary microadenoma was the presumed diagnosis based on initial clinical presentation and diagnostic imaging suggesting a pituitary lesion. However, pathology results demonstrated no evidence of adenoma but cysts lined with columnar epithelia consistent with RCC. Complete surgical resection was achieved in both patients through endoscopic endonasal pituitary resection with postoperative symptomatic resolution and normalization of cortisol levels. In addition, we discuss the literature on this rare presentation and suggest a pathological mechanism for this unique presentation of RCC-causing CD. Conclusion Surgical resection of RCC may provide a "biochemical cure" for patients presenting with CD, as demonstrated by these two unique cases. The clinical features, histological findings, and possible pathological mechanisms for this unique presentation of RCC causing CD discussed lay the groundwork for future studies into the pathophysiology of RCC and CD.
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Affiliation(s)
- Krisna Maddy
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Evan Luther
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Katherine Berry
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Victor M. Lu
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Ashish Shah
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Michael E. Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Ricardo J. Komotar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
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4
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Stratakis CA. An update on, and genetics of refractory adenomas of childhood. Pituitary 2023:10.1007/s11102-023-01327-2. [PMID: 37318708 DOI: 10.1007/s11102-023-01327-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/16/2023]
Abstract
Pituitary adenomas in childhood tend to be more frequently due to germline genetic changes and are often diagnosed at late stages due to delayed recognition by pediatricians and other caretakers who are not familiar with this rare disease in childhood. As a result, often, pediatric pituitary adenomas are aggressive or remain refractory to treatment. In this review, we discuss germline genetic defects that account for the most common pediatric pituitary adenomas that are refractory to treatment. We also discuss some somatic genetic events, such as chromosomal copy number changes that characterize some of the most aggressive pituitary adenomas in childhood that end up being refractory to treatment.
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Affiliation(s)
- Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 20892, Bethesda, MD, USA.
- Human Genetics & Precision Medicine, IMMB, FORTH, Heraklion, Greece.
- ELPEN Research Institute, Athens, Greece.
- Medical Genetics, H. Dunant Hospital, Athens, Greece.
- Faculty of Medicine, European University of Cyprus, Nicosia, Cyprus.
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5
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Asuzu DT, Alvarez R, Fletcher PA, Mandal D, Johnson K, Wu W, Elkahloun A, Clavijo P, Allen C, Maric D, Ray-Chaudhury A, Rajan S, Abdullaev Z, Nwokoye D, Aldape K, Nieman LK, Stratakis C, Stojilkovic SS, Chittiboina P. Pituitary adenomas evade apoptosis via noxa deregulation in Cushing's disease. Cell Rep 2022; 40:111223. [PMID: 36001971 PMCID: PMC9527711 DOI: 10.1016/j.celrep.2022.111223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 06/03/2022] [Accepted: 07/26/2022] [Indexed: 12/13/2022] Open
Abstract
Sporadic pituitary adenomas occur in over 10% of the population. Hormone-secreting adenomas, including those causing Cushing’s disease (CD), cause severe morbidity and early mortality. Mechanistic studies of CD are hindered by a lack of in vitro models and control normal human pituitary glands. Here, we surgically annotate adenomas and adjacent normal glands in 25 of 34 patients. Using single-cell RNA sequencing (RNA-seq) analysis of 27594 cells, we identify CD adenoma transcriptomic signatures compared with adjacent normal cells, with validation by bulk RNA-seq, DNA methylation, qRT-PCR, and immunohistochemistry. CD adenoma cells include a subpopulation of proliferating, terminally differentiated corticotrophs. In CD adenomas, we find recurrent promoter hypomethylation and transcriptional upregulation of PMAIP1 (encoding pro-apoptotic BH3-only bcl-2 protein noxa) but paradoxical noxa downregulation. Using primary CD adenoma cell cultures and a corticotroph-enriched mouse cell line, we find that selective proteasomal inhibition with bortezomib stabilizes noxa and induces apoptosis, indicating its utility as an anti-tumor agent. Asuzu et al. perform single-cell transcriptomic profiling in Cushing’s disease (CD) adenomas and find overexpression and DNA hypomethylation of PMAIP1, which encodes the pro-apoptotic protein noxa. Noxa is degraded by the proteasome. Proteasomal inhibition rescues noxa and induces apoptosis in CD.
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Affiliation(s)
- David T Asuzu
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, Bethesda, MD 20892, USA; Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Reinier Alvarez
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, Bethesda, MD 20892, USA; Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Patrick A Fletcher
- Laboratory of Biological Modeling, National Institute of Diabetes, Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Debjani Mandal
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, Bethesda, MD 20892, USA
| | - Kory Johnson
- DIR Bioinformatics Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Weiwei Wu
- Cancer Genetics and Comparative Genomics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Abdel Elkahloun
- Cancer Genetics and Comparative Genomics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Paul Clavijo
- Translational Tumor Immunology Program, National Institute on Deafness and Other Communication Disorders, Bethesda, MD, USA
| | - Clint Allen
- Translational Tumor Immunology Program, National Institute on Deafness and Other Communication Disorders, Bethesda, MD, USA
| | - Dragan Maric
- Flow and Imaging Cytometry Core Facility, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Abhik Ray-Chaudhury
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Sharika Rajan
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Zied Abdullaev
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Diana Nwokoye
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, Bethesda, MD 20892, USA
| | - Kenneth Aldape
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Lynnette K Nieman
- Section on Translational Endocrinology, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Constantine Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Stanko S Stojilkovic
- Section on Cellular Signaling, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Prashant Chittiboina
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, Bethesda, MD 20892, USA; Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA.
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6
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Wahba NS, Saliem AO, Abd Allah EG, Mohammed MZ. Therapeutic efficacy of adipose-derived mesenchymal stem cells after chronic fluoxetine treatment on pars distalis in adult male albino rats. Tissue Cell 2022; 76:101770. [DOI: 10.1016/j.tice.2022.101770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 10/19/2022]
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Abstract
Cushing disease is a disorder of hypercortisolemia caused by hypersecretion of adrenocorticotropic hormone by a pituitary adenoma and is a rare diagnosis. Cushing disease presents with characteristic clinical signs and symptoms associated with excess cortisol, but diagnosis is difficult and often relies on repeated and varied endocrinologic assays and neuroradiologic investigations. Gold standard treatment is surgical resection of adrenocorticotropic hormone-secreting pituitary adenoma, which is curative. Patients require close endocrinologic follow-up for maintenance of associated neuroendocrine deficiencies and surveillance for potential recurrence. Medications, radiation therapy, and bilateral adrenalectomy are alternative treatments for residual or recurrent disease.
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8
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Mallari RJ, Thakur JD, Barkhoudarian G, Eisenberg A, Rodriguez A, Rettinger S, Cohan P, Nieman L, Kelly DF. Diagnostic Pitfalls in Cushing Disease: Surgical Remission Rates, Test Thresholds, and Lessons Learned in 105 Patients. J Clin Endocrinol Metab 2022; 107:205-218. [PMID: 34478542 PMCID: PMC8684536 DOI: 10.1210/clinem/dgab659] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Confirming a diagnosis of Cushing disease (CD) remains challenging, yet is critically important before recommending transsphenoidal surgery for adenoma resection. OBJECTIVE To describe predictive performance of preoperative biochemical and imaging data relative to post-operative remission and clinical characteristics in patients with presumed CD. DESIGN, SETTING, PATIENTS, INTERVENTIONS Patients (n = 105; 86% female) who underwent surgery from 2007 through 2020 were classified into 3 groups: group A (n = 84) pathology-proven ACTH adenoma; group B (n = 6) pathology-unproven but with postoperative hypocortisolemia consistent with CD; and group C (n = 15) pathology-unproven, without postoperative hypocortisolemia. Group A + B were combined as confirmed CD and group C as unconfirmed CD. MAIN OUTCOMES Group A + B was compared with group C regarding predictive performance of preoperative 24-hour urinary free cortisol (UFC), late night salivary cortisol (LNSC), 1-mg dexamethasone suppression test (DST), plasma ACTH, and pituitary magnetic resonance imaging (MRI). RESULTS All groups had a similar clinical phenotype. Compared with group C, group A + B had higher mean UFC (P < 0.001), LNSC (P = 0.003), DST (P = 0.06), and ACTH (P = 0.03) and larger MRI-defined lesions (P < 0.001). The highest accuracy thresholds were: UFC 72 µg/24 hours; LNSC 0.122 µg/dL, DST 2.70 µg/dL, and ACTH 39.1 pg/mL. Early (3-month) biochemical remission was achieved in 76/105 (72%) patients: 76/90(84%) and 0/15(0%) of group A + B vs group C, respectively, P < 0.0001. In group A + B, nonremission was strongly associated with adenoma cavernous sinus invasion. CONCLUSIONS Use of strict biochemical thresholds may help avoid offering transsphenoidal surgery to presumed CD patients with equivocal data and improve surgical remission rates. Patients with Cushingoid phenotype but equivocal biochemical data warrant additional rigorous testing.
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Affiliation(s)
- Regin Jay Mallari
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Jai Deep Thakur
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
- University of South Alabama, Mobile, AL 36604, USA
| | - Garni Barkhoudarian
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
- Saint John’s Cancer Institute at Saint John’s Health Center, Santa Monica, CA 90404, USA
| | - Amy Eisenberg
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Amanda Rodriguez
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Sarah Rettinger
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Pejman Cohan
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Lynnette Nieman
- Diabetes, Endocrine and Obesity Branch, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD 20814, USA
| | - Daniel F Kelly
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
- Saint John’s Cancer Institute at Saint John’s Health Center, Santa Monica, CA 90404, USA
- Correspondence: Daniel F. Kelly, MD, Pacific Neuroscience Institute, Saint John’s Cancer Institute, Providence Saint John’s Health Center, 2125 Arizona Ave., Santa Monica, CA 90404, USA.
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9
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Zhu D, Wang Z, Tian T, Wu X, He D, Zhu Y, Liu D, Wang H. Prevalence and clinical characteristics of Crooke's cell adenomas in 101 patients with T-PIT-positive pituitary adenomas: Case series and literature review. Front Endocrinol (Lausanne) 2022; 13:947085. [PMID: 36060980 PMCID: PMC9437488 DOI: 10.3389/fendo.2022.947085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE We aimed to perform a retrospective analysis of a rare subtype of corticotroph adenoma, Crooke's cell adenoma, to better understand its clinical features. METHODS We collected T-PIT-positive pituitary adenomas and screened Crooke's cell adenomas from January 2020 to December 2021 in our center. Case reports of such tumors were also collected through a literature search. Clinical data such as biochemical tests, imaging examinations, and pathological data of the above cases were analyzed. RESULTS A total of 101 T-PIT-positive patients were treated in our center in the last 2 years, and 4 were finally pathologically diagnosed with Crooke's cell adenomas. All of these patients were male with elevated adrenocorticotropic hormone levels, and 50.0% presented with hypercortisolemia, Cushing's syndrome, visual impairment, and headache. The tumor diameter was significantly larger in these 4 patients (37.0 mm) than in the other patients (26.0 mm), and their tumor invasive behavior was more pronounced. Cases reported in the literature were mainly female (72.8%), and the clinical presentation was also dominated by Cushing's syndrome (65.1%) and hormonal dysfunction. Tumors were more common as macroadenomas (33.2 mm) and suprasellar growths (63.8%). The tumor recurrence rate was as high as 55.6%, with 6 cases progressing to pituitary carcinomas and 7.7% of tumor-related deaths. Our further integrated analysis of our center and reported cases revealed that gender, Cushing's syndrome, visual dysfunction, hormonal disorders, and tumor growth characteristics were statistically different in different tumor categories. CONCLUSION Crooke's cell adenoma is a tumor subtype with obvious clinical aggressive behavior, and an in-depth analysis of its clinical characteristics may assist in developing a comprehensive treatment plan.
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Affiliation(s)
- Dimin Zhu
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zongming Wang
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tian Tian
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xinyi Wu
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dongsheng He
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yonghong Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Dawei Liu
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Dawei Liu, ; Haijun Wang,
| | - Haijun Wang
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Dawei Liu, ; Haijun Wang,
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10
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Andereggen L, Mariani L, Beck J, Andres RH, Gralla J, Luedi MM, Weis J, Christ E. Lateral one-third gland resection in Cushing patients with failed adenoma identification leads to low remission rates: long-term observations from a small, single-center cohort. Acta Neurochir (Wien) 2021; 163:3161-3169. [PMID: 33811521 PMCID: PMC8520517 DOI: 10.1007/s00701-021-04830-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Currently, there are no guidelines for neurosurgeons treating patients with Cushing's disease (CD) when intraoperative adenoma identification is negative. Under these circumstances, a total hypophysectomy or hemi-hypophysectomy on the side indicated by inferior petrosal sinus sampling (IPSS) is the approach being used, although there is a subsequent risk of hypopituitarism. Data on whether one-third lateral pituitary gland resection results in cure of hypercortisolism and low rates of hypopituitarism remain inconclusive. METHODS Retrospective single-center study of CD patients with failed intraoperative adenoma identification and subsequent resection of the lateral one-third of the pituitary gland as predicted by IPSS. We assessed (i) histopathological findings, (ii) early and long-term remission rates, and (iii) rates of additional pituitary hormone insufficiency. RESULTS Ten women and three men met the inclusion criteria. At 3 months, remission was noted in six (46%) patients: three (23%) had histologically confirmed adenomas, two (15%) had ACTH hyperplasia, and one patient (8%) was positive for Crooke's hyaline degeneration. New pituitary hormone deficits were noted in two patients (15%). After a median (±SD) follow-up of 14±4 years, recurrence was noted in two (15%) patients. Long-term control of hypercortisolism was attained by 10 patients (77%), with additional therapies required in nine (69%) of them. CONCLUSIONS In CD patients with failed intraoperative adenoma visualization, lateral one-third gland resection resulted in low morbidity and long-term remission in 31% of patients without the need for additional therapies. Bearing in mind the sample size of this audit, the indication for lateral one-third-gland resection has to be critically appraised and discussed with the patients before surgery.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Robert H Andres
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joachim Weis
- Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany
| | - Emanuel Christ
- Department of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
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11
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Detomas M, Altieri B, Schlötelburg W, Appenzeller S, Schlaffer S, Coras R, Schirbel A, Wild V, Kroiss M, Sbiera S, Fassnacht M, Deutschbein T. Case Report: Consecutive Adrenal Cushing's Syndrome and Cushing's Disease in a Patient With Somatic CTNNB1, USP8, and NR3C1 Mutations. Front Endocrinol (Lausanne) 2021; 12:731579. [PMID: 34489873 PMCID: PMC8417750 DOI: 10.3389/fendo.2021.731579] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/29/2021] [Indexed: 11/23/2022] Open
Abstract
The occurrence of different subtypes of endogenous Cushing's syndrome (CS) in single individuals is extremely rare. We here present the case of a female patient who was successfully cured from adrenal CS 4 years before being diagnosed with Cushing's disease (CD). The patient was diagnosed at the age of 50 with ACTH-independent CS and a left-sided adrenal adenoma, in January 2015. After adrenalectomy and histopathological confirmation of a cortisol-producing adrenocortical adenoma, biochemical hypercortisolism and clinical symptoms significantly improved. However, starting from 2018, the patient again developed signs and symptoms of recurrent CS. Subsequent biochemical and radiological workup suggested the presence of ACTH-dependent CS along with a pituitary microadenoma. The patient underwent successful transsphenoidal adenomectomy, and both postoperative adrenal insufficiency and histopathological workup confirmed the diagnosis of CD. Exome sequencing excluded a causative germline mutation but showed somatic mutations of the β-catenin protein gene (CTNNB1) in the adrenal adenoma, and of both the ubiquitin specific peptidase 8 (USP8) and the glucocorticoid receptor (NR3C1) genes in the pituitary adenoma. In conclusion, our case illustrates that both ACTH-independent and ACTH-dependent CS may develop in a single individual even without evidence for a common genetic background.
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Affiliation(s)
- Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- *Correspondence: Mario Detomas,
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Wiebke Schlötelburg
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Department of Nuclear Medicine, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Silke Appenzeller
- Core Unit Bioinformatics, Comprehensive Cancer Center Mainfranken, University Hospital of Würzburg, University of Würzburg, Würzburg, Germany
| | - Sven Schlaffer
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Roland Coras
- Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Vanessa Wild
- Institute of Pathology, University of Würzburg, Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine IV, University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Silviu Sbiera
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
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12
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Yamamoto M, Nakao T, Ogawa W, Fukuoka H. Aggressive Cushing's Disease: Molecular Pathology and Its Therapeutic Approach. Front Endocrinol (Lausanne) 2021; 12:650791. [PMID: 34220707 PMCID: PMC8242934 DOI: 10.3389/fendo.2021.650791] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022] Open
Abstract
Cushing's disease is a syndromic pathological condition caused by adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas (ACTHomas) mediated by hypercortisolemia. It may have a severe clinical course, including infection, psychiatric disorders, hypercoagulability, and metabolic abnormalities, despite the generally small, nonaggressive nature of the tumors. Up to 20% of ACTHomas show aggressive behavior, which is related to poor surgical outcomes, postsurgical recurrence, serious clinical course, and high mortality. Although several gene variants have been identified in both germline and somatic changes in Cushing's disease, the pathophysiology of aggressive ACTHomas is poorly understood. In this review, we focused on the aggressiveness of ACTHomas, its pathology, the current status of medical therapy, and future prospects. Crooke's cell adenoma (CCA), Nelson syndrome, and corticotroph pituitary carcinoma are representative refractory pituitary tumors that secrete superphysiological ACTH. Although clinically asymptomatic, silent corticotroph adenoma is an aggressive ACTH-producing pituitary adenoma. In this review, we summarize the current understanding of the pathophysiology of aggressive ACTHomas, including these tumors, from a molecular point of view based on genetic, pathological, and experimental evidence. The treatment of aggressive ACTHomas is clinically challenging and usually resistant to standard treatment, including surgery, radiotherapy, and established medical therapy (e.g., pasireotide and cabergoline). Temozolomide is the most prescribed pharmaceutical treatment for these tumors. Reports have shown that several treatments for patients with refractory ACTHomas include chemotherapy, such as cyclohexyl-chloroethyl-nitrosourea combined with 5-fluorouracil, or targeted therapies against several molecules including vascular endothelial growth factor receptor, cytotoxic T lymphocyte antigen 4, programmed cell death protein 1 (PD-1), and ligand for PD-1. Genetic and experimental evidence indicates that some possible therapeutic candidates are expected, such as epidermal growth factor receptor tyrosine kinase inhibitor, cyclin-dependent kinase inhibitor, and BRAF inhibitor. The development of novel treatment options for aggressive ACTHomas is an emerging task.
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Affiliation(s)
- Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | | | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
- *Correspondence: Hidenori Fukuoka,
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13
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Hinojosa-Amaya JM, Lam-Chung CE, Cuevas-Ramos D. Recent Understanding and Future Directions of Recurrent Corticotroph Tumors. Front Endocrinol (Lausanne) 2021; 12:657382. [PMID: 33986726 PMCID: PMC8111286 DOI: 10.3389/fendo.2021.657382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Corticotroph tumors (CTs) are pituitary neoplasms arising from the Tpit lineage, which may or not express adrenocorticotrophic hormone (ACTH). Functioning CTs cause Cushing's disease (CD), which has high morbidity and mortality due to hypercortisolemia. "Non-functioning" or silent CTs (SCT) and the Crooke's cell subtypes do not cause CD and may be asymptomatic until manifested by compressive symptoms and are more frequently found as macroadenoma. Both tend toward more aggressive behavior, recurrence, and a higher rate of malignant transformation to pituitary carcinoma. Tumorigenesis involves genetic, epigenetic, and post-transcriptional disruption of cell-cycle regulators, which increase cell proliferation, POMC overexpression, ACTH transcription, and/or hypersecretion. Furthermore, functioning CTs develop resistance to glucocorticoid-mediated negative feedback on ACTH secretion, through increased expression of testicular orphan nuclear receptor 4 (TR4), heat-shock protein 90 (HSP90), and loss-of-function mutation of CDK5 and ABL enzyme substrate 1 (CABLES1) gene. Overt autonomous hypercortisolemia is difficult to control, and multiple diagnostic studies and therapeutic modalities are commonly required. Cell-cycle regulation depends mainly on p27, cyclin E, cyclin-dependent kinases (CDKs), and the retinoblastoma protein (Rb)/E2F1 transcription factor complex. Gain-of-function mutations of ubiquitin-specific protease (USP) 8, USP48, and BRAF genes may subsequently cause overexpression of epithelial growth factor receptor (EGFR), and enhance POMC transcription, cell proliferation, and tumor growth. Epigenetic changes through micro RNAs and decreased DNA deacetylation by histone deacetylase type 2 (HDAC2), may also affect tumor growth. All the former mechanisms may become interesting therapeutic targets for CTs, aside from temozolomide, currently used for aggressive tumors. Potential therapeutic agents are EGFR inhibitors such as gefitinib and lapatinib, the purine analog R-roscovitine by dissociation of CDK2/Cyclin E complex, the HSP90 inhibitor silibinin (novobiocin), to reduce resistance to glucocorticoid-mediated negative feedback, and BRAF inhibitors vemurafenib and dabrafenib in BRAF V600E positive tumors. This review summarizes the molecular mechanisms related to CTs tumorigenesis, their diagnostic approach, and provides an update of the potential novel therapies, from the lab bench to the clinical translation.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Pituitary Clinic, Endocrinology Division, Department of Medicine, Hospital Universitario “Dr. José E. González” UANL, Monterrey, Mexico
| | - César Ernesto Lam-Chung
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- *Correspondence: Daniel Cuevas-Ramos,
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14
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Akirov A, Larouche V, Shimon I, Asa SL, Mete O, Sawka AM, Gentili F, Ezzat S. Significance of Crooke's Hyaline Change in Nontumorous Corticotrophs of Patients With Cushing Disease. Front Endocrinol (Lausanne) 2021; 12:620005. [PMID: 33815279 PMCID: PMC8013723 DOI: 10.3389/fendo.2021.620005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Glucocorticoid excess in Cushing disease (CD) leads to negative feedback suppression, resulting in Crooke's hyaline change (CC) of nontumorous pituitary corticotrophs. We aimed to determine the predictive value of CC of nontumorous corticotrophs in CD. METHODS The retrospective chart review study included patients with clinical, biochemical, radiologic and outcome data and evaluable histopathology specimens from pituitary surgery for CD. The main outcome was remission of CD, defined by clinical features, biochemical testing, and corticosteroid dependency. RESULTS Of 144 CD patients, 60 (50 women, mean age 43.6±14) had clinical follow-up, biochemical data and histopathology specimens that included evaluable nontumorous adenohypophysis. Specimens from 50 patients (83.3%) demonstrated CC in nontumorous corticotrophs, and 10 (16.7%) had no CC (including 3 with corticotroph hyperplasia). One patient with CC was lost to follow-up and one without CC had equivocal outcome results. During a mean (SD) follow-up period of 74.9 months (61.0), recurrent or persistent disease was documented in 18 patients (31.0%), while 40 (69.0%) were in remission. In patients with CC, the remission rate was 73.5% (95% CI, 59.7%-83.7%) (36/49), whereas it was 44.4% (95% CI, 18.9%-73.3%) (4/9) in patients with no CC. The combination of serum cortisol >138 nmol/L within a week of surgery coupled with absence of nontumorous CC greatly improved the prediction of recurrent or persistent disease. CONCLUSIONS CC of nontumorous corticotrophs was observed in 83% of patients with CD, and most patients with CC experienced remission. Absence of CC in nontumorous corticotrophs may serve as a predictor of reduced remission in patients with CD.
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Affiliation(s)
- Amit Akirov
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Amit Akirov,
| | - Vincent Larouche
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sylvia L. Asa
- Department of Pathology, University Hospitals, Cleveland, Case Western Reserve University, Cleveland, OH, United States
| | - Ozgur Mete
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shereen Ezzat
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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15
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Catalino MP, Meredith DM, De Girolami U, Tavakol S, Min L, Laws ER. Corticotroph hyperplasia and Cushing disease: diagnostic features and surgical management. J Neurosurg 2020; 135:152-163. [PMID: 32886921 DOI: 10.3171/2020.5.jns201514] [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: 04/28/2020] [Accepted: 05/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study was done to compare corticotroph hyperplasia and histopathologically proven adenomas in patients with Cushing disease by analyzing diagnostic features, surgical management, and clinical outcomes. METHODS Patients with suspected pituitary Cushing disease were included in a retrospective cohort study and were excluded if results of pathological analysis of the surgical specimen were nondiagnostic or normal. Cases were reviewed by two experienced neuropathologists. Total lesion removal was used as a dichotomized surgical variable; it was defined as an extracapsular resection (including a rim of normal gland) in patients with an adenoma, and for hyperplasia patients it was defined as removal of the presumed lesion plus a rim of surrounding normal gland. Bivariate and multivariate analyses were performed. Recurrence-free survival was compared between the two groups. RESULTS The final cohort consisted of 63 patients (15 with hyperplasia and 48 with adenoma). Normal pituitary acinar architecture was highly variable. Corticotroph hyperplasia was diagnosed based on the presence of expanded acini showing retained reticulin architecture and predominant staining for adrenocorticotropic hormone. Crooke's hyaline change was seen in 46.7% of specimens, and its frequency was equal in nonlesional tissue of both groups. The two groups differed only by MRI findings (equivocal/diffuse lesion in 46% of hyperplasia and 17% of adenoma; p = 0.03). Diagnostic uncertainty in the hyperplasia group resulted in additional confirmatory testing by 24-hour urinary free cortisol. Total lesion removal was infrequent in patients with hyperplasia compared to those with adenoma (33% vs 65%; p = 0.03). Initial biochemical remission was similar (67% in hyperplasia and 85% in adenoma; p = 0.11). There was no difference in hypothalamic-pituitary-adrenal axis recovery or disease recurrence. The median follow-up was 1.9 years (IQR 0.7-7.6 years) for the hyperplasia group and 1.2 years (IQR 0.4-2.4 years) for the adenoma group. Lack of a discrete lesion and diagnostic uncertainty were the only significant predictors of hyperplasia (sensitivity 53.3%, specificity 97.7%, positive predictive value 88.9%, negative predictive value 85.7%). An adjusted Cox proportional hazards model showed similar recurrence-free survival in the two groups. CONCLUSIONS This study suggests an association between biochemically proven Cushing disease and histopathologically proven corticotroph hyperplasia. Imaging and operative findings can be ambiguous, and, compared to typical adenomas with a pseudocapsule, the surgical approach is more nuanced. Nevertheless, if treated appropriately, biochemical outcomes may be similar.
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Affiliation(s)
- Michael P Catalino
- 1Department of Neurosurgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
- 2Department of Neurosurgery, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - David M Meredith
- 3Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston
- 4Dana Farber Cancer Institute, Boston
| | - Umberto De Girolami
- 3Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston
- 4Dana Farber Cancer Institute, Boston
| | - Sherwin Tavakol
- 1Department of Neurosurgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
- 5Harvard TH Chan School of Public Health, Boston; and
| | - Le Min
- 6Division of Endocrinology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Edward R Laws
- 1Department of Neurosurgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
- 4Dana Farber Cancer Institute, Boston
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16
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Abstract
Aggressive pituitary tumors (APTs) represent rare pituitary adenomas (PAs) with local invasion of surrounding tissues, increased risk for multiple recurrence, rapid tumor growth, or resistance to standard therapies. The most common APTs in children and adolescents are giant prolactinomas and somatotropinomas. Few cases of Crooke's cell adenomas, silent corticotroph adenomas and pituitary carcinomas have also been reported in the literature. Pediatric patients with APTs have higher risk of harboring germline genetic defects, most commonly in the MEN1 and AIP genes. Since certain genetic defects confer a more aggressive behavior to PAs, genetic testing should be considered in tumors with young onset and positive family history. The management of pediatric APTs involves usually a combination of standard therapies (surgical, medical, radiation). Newer agents, such as temozolomide, have been used in few cases of pediatric pituitary tumors with promising results. In the elderly, PAs are more commonly non-functioning. Their management often poses dilemmas given the coexistence of age-related comorbidities. However, standard surgical treatment and temozolomide seem to be safe and well tolerated in elderly patients.
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Affiliation(s)
- Christina Tatsi
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA.
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17
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Cortez GM, Monteiro A, Agnoletto G, Bit-Ivan EN, Sauvageau E, Hanel RA. Aggressive Pituitary Tumor with Crooke's Cells and Invasion of the Posterior Fossa. World Neurosurg 2020; 138:530-534.e1. [PMID: 32145418 DOI: 10.1016/j.wneu.2020.02.137] [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: 01/17/2020] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pituitary adenomas are mostly benign in character and are managed via a transsphenoidal approach in most cases. Crooke's cell adenoma (CCA) is a particular variant accounting for less than 1% of the pituitary adenomas. They have a distinctive histopathologic pattern and behavior. CASE DESCRIPTION We present a case of a 56-year-old man with recurrent pituitary adenoma and complicated neurosurgical history. Imaging follow-up showed a suprasellar mass with progressive growth into the posterior fossa. Surgical management via retrosigmoid craniectomy was performed, and histopathology elucidated Crooke's cells. CONCLUSIONS CCA is recognized by its local aggressiveness and high recurrence rates. They tend to be locally invasive; however, posterior fossa invasion has not been reported to date. We aim to contribute to the arsenal of differential diagnosis of similar pituitary tumor cases.
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Affiliation(s)
- Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA; Jacksonville University, Jacksonville, Florida, USA
| | - Andre Monteiro
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Guilherme Agnoletto
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Esther N Bit-Ivan
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA.
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18
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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.
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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
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19
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Villa C, Vasiljevic A, Jaffrain-Rea ML, Ansorge O, Asioli S, Barresi V, Chinezu L, Gardiman MP, Lania A, Lapshina AM, Poliani L, Reiniger L, Righi A, Saeger W, Soukup J, Theodoropoulou M, Uccella S, Trouillas J, Roncaroli F. A standardised diagnostic approach to pituitary neuroendocrine tumours (PitNETs): a European Pituitary Pathology Group (EPPG) proposal. Virchows Arch 2019; 475:687-692. [PMID: 31578606 DOI: 10.1007/s00428-019-02655-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 05/23/2019] [Accepted: 08/22/2019] [Indexed: 10/25/2022]
Abstract
The 2017 World Health Organization (WHO) classification proposes to type and subtype primary adenohypophyseal tumours according to their cell lineages with the aim to establish more uniform tumour groups. The definition of atypical adenoma was removed in favour of high-risk adenoma, and the assessment of proliferative activity and invasion was recommended to diagnose aggressive tumours. Recently, the International Pituitary Pathology Club proposed to replace adenoma with the term of pituitary neuroendocrine tumour (PitNET) to better reflect the similarities between adenohypophyseal and neuroendocrine tumours of other organs. The European Pituitary Pathology Group (EPPG) endorses this terminology and develops practical recommendations for standardised reports of PitNETs that are addressed to histo- and neuropathologists. This brief report presents the results of EPPG's consensus for the reporting of PitNETs and proposes a diagnostic algorithm.
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Affiliation(s)
- C Villa
- Department of Pathological Cytology and Anatomy, Foch Hospital, 40 rue Worth, 92151, Suresnes, France. .,INSERM U1016, CNRS UMR 8104, Cochin Institute, Paris Descartes University, 24 rue du faubourg Saint Jacques, 75014, Paris, France. .,Department of Endocrinology, CHU de Liège, University of Liège, Sart Tilman B35, 4000, Liège, Belgium.
| | - A Vasiljevic
- Université de Lyon 1, Université de Lyon, F-69000, Lyon, France.,Faculté de Médecine Lyon-Est, F-69372, Lyon, France.,Centre de Recherche en Cancérologie de Lyon (CRCL), INSERM U1052, CNRS UMR5286, Université de Lyon, Lyon, France.,Centre de Pathologie et de Neuropathologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - M L Jaffrain-Rea
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.,Neuromed Institute, IRCCS, Pozzilli, Italy
| | - O Ansorge
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - S Asioli
- Department of Biomedical and Neuromuscular Sciences, Section of Anatomic Pathology 'M. Malpighi' at Bellaria Hospital, University of Bologna, Bologna, Italy.,Pituitary Unit - Center for the Diagnosis and Treatment of Hypothalamic and Pituitary Diseases, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - V Barresi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - L Chinezu
- Department of Histology, Pharmacy, Sciences and Technology of Tirgu Mures, University of Medicine, Târgu Mureș, Romania
| | - M P Gardiman
- Department of Medicine DIMED, Surgical Pathology & Cytopathology Unit, University Hospital of Padova, Padova, Italy
| | - A Lania
- Endocrinology Unit, Department of Biomedical Sciences, Humanitas University and Humanitas Research Hospital, Rozzano, Italy
| | - A M Lapshina
- Department of Fundamental Pathomorphology, Endocrine Research Center, Ministry of Health of Russia, Moscow, Russia
| | - L Poliani
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - L Reiniger
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - A Righi
- Department of Pathology, Rizzoli Institute, Bologna, Italy
| | - W Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Soukup
- The Fingerland Department of Pathology, University Hospital and Faculty of Medicine, Hradec Kralove, Charles University, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - M Theodoropoulou
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| | - S Uccella
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - J Trouillas
- Université de Lyon 1, Université de Lyon, F-69000, Lyon, France.,Faculté de Médecine Lyon-Est, F-69372, Lyon, France
| | - F Roncaroli
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Tanaka S, Yamamoto M, Morita M, Takeno A, Kanazawa I, Yamaguchi T, Yamada S, Inoshita N, Oki Y, Kurosaki M, Sugimoto T. Successful reduction of ACTH secretion in a case of intractable Cushing's disease with pituitary Crooke's cell adenoma by combined modality therapy including temozolomide. Endocr J 2019; 66:701-708. [PMID: 31130573 DOI: 10.1507/endocrj.ej18-0547] [Citation(s) in RCA: 10] [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: 11/23/2022] Open
Abstract
Crooke's cell adenoma (CCA) is an aggressive subtype of corticotroph adenoma; however, CCA is associated with a high incidence of low expression of methyl guanine methyl transferase (MGMT), suggesting that temozolomide (TMZ) treatment might be effective for this tumor type. The case of a 56-year-old woman with Cushing's disease caused by a pituitary CCA is presented. At the age of 38 years, the patient presented to our hospital with polyuria and a visual field defect. MRI and laboratory studies showed a 4.5-cm-diameter pituitary tumor with plasma adrenocorticotropic hormone (ACTH) and serum cortisol levels of more than 500 pg/mL and 40 μg/dL, respectively. At 39 years of age, the patient underwent a craniotomy, and her plasma ACTH and cortisol levels decreased to less than 200 pg/mL and 10 μg/dL, respectively; however, these hormone levels increased gradually to 3,940 pg/mL and 70 μg/dL, respectively, by the time the patient was 56 years old. Histopathological re-examination of the previously resected specimen showed that the pituitary tumor was MGMT-negative CCA. TMZ treatment after the second operation decreased the plasma ACTH levels from 600-800 pg/mL to 70-300 pg/mL. No signs of recurrence were observed in the seven years following these treatments with added prophylactic radiation therapy. These clinical findings suggest that TMZ treatment to patients with CCA accompanied with elevated ACTH may be good indication to induce lowering ACTH levels and tumor shrinkage.
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Affiliation(s)
- Sayuri Tanaka
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Masahiro Yamamoto
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Miwa Morita
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Ayumu Takeno
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Ippei Kanazawa
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Toru Yamaguchi
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Shozo Yamada
- Endocrine Center, Division of Hypothalamic & Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Naoko Inoshita
- Department of Pathology, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Yutaka Oki
- Second Division Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Masamichi Kurosaki
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine Tottori University, Yonago 683-8504, Japan
| | - Toshitsugu Sugimoto
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
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Andereggen L, Gralla J, Schroth G, Mordasini P, Andres RH, Widmer HR, Luedi MM, Kellner F, Beck J, Mariani L, Ozdoba C, Christ E. Influence of inferior petrosal sinus drainage symmetry on detection of adenomas in Cushing's syndrome. J Neuroradiol 2019; 48:10-15. [PMID: 31228539 DOI: 10.1016/j.neurad.2019.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Asymmetric inferior petrosal sinuses (IPS) are not infrequently encountered during bilateral IPS sampling. There is little data on whether IPS symmetry influences success in predicting the adenoma side in patients with ACTH-dependent Cushing's syndrome (CS). OBJECTIVE To assess the influence of IPS drainage patterns on detection of an adenoma in CS. METHODS Retrospective single-center cohort analysis reviewing records of patients with CS and negative MRI findings who subsequently underwent BIPSS. RESULTS BIPSS was performed in 38 patients with a mean age of 45±15 years. The overall technical success rate was 97% for bilateral cannulation. Asymmetric IPS were observed in 11 (39%) patients with Cushing's disease (CD). A side-to-side ACTH ratio was not significantly different between patients with symmetric outflow and those with asymmetric outflow at baseline (8.6±2.7 versus 16.4±6.0; P=0.45), but ratios were significantly different after ovine corticotropin-releasing hormone (oCRH) stimulation (6.0±2.5 versus 35.7±22.5; P=0.03). BIPSS correctly predicted the side of the adenoma in 25 (96%) patients with CD. Prediction was better when the venous outflow was symmetric (100%) rather than asymmetric (93%), although the difference was not significant (P=0.42). Remission from CS was achieved in 32 patients (87%), independent of the symmetry of IPS. CONCLUSIONS Bearing in mind the sample size of this audit, asymmetric IPS at least do not seem to diminish the accuracy of diagnosis of ACTH-dependent CS, nor do they influence the clinical outcome.
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Affiliation(s)
- Lukas Andereggen
- Department of neurosurgery, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Robert H Andres
- Department of neurosurgery, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Hans Rudolf Widmer
- Department of neurosurgery, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of anaesthesiology and pain medicine, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Frauke Kellner
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of neurosurgery, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Luigi Mariani
- Department of neurosurgery, university hospital of Basel, Basel, Switzerland
| | - Christoph Ozdoba
- Department of neuroradiology, Inselspital, Bern university hospital, university of Bern, Bern, Switzerland
| | - Emanuel Christ
- Department of endocrinology, diabetology and metabolism, university hospital of Basel, Basel, Switzerland.
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22
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Cordeiro D, Xu Z, Nasser M, Lopes B, Vance ML, Sheehan J. The role of Crooke's changes in recurrence and remission after gamma knife radiosurgery. J Neurooncol 2019; 142:171-181. [PMID: 30607704 DOI: 10.1007/s11060-018-03078-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE The objective of this study is to evaluate the role of Crooke's changes (CC) in normal the peri-tumoral anterior pituitary gland, in patients with Cushing's disease (CD) with a histopathological confirmed corticotroph adenoma, and determine if there is any difference in the recurrence and remission rates in CD patients after treatment with Gamma Knife Radiosurgery (GKRS). METHODS All patients treated with GKRS for CD from 2005 to 2016 at our institution were identified. Patients had a confirmed adrenocorticotropic (ACTH)-secreting adenoma, i.e. corticotroph adenoma, and normal pituitary gland included in the surgical specimen, and specimens were stained with hematoxylin and eosin and also immunostaining for cytokeratin and ACTH. Statistical analyses were performed in a total of 61 patients who met the inclusion criteria. Additionally, we analyzed 20 patients in each group, with and without CC, after they were matched in a propensity score fashion. RESULTS Endocrine remission defined as, a normal 24 h urine free cortisol while off suppressive medication, occurred in 48 patients (78.7%), with 76.9% in those with CC and 81.8% in those without CC. There was no statistical significant difference between the two groups in regarding remission (p = 0.312) or recurrence (p = 0.659) in either the unmatched or matched cohorts. CONCLUSION The presence or absence of CC in normal pituitary gland does not appear to confer a lower rate of remission or a higher rate of recurrence after GKRS. Patients with pituitary corticotroph adenomas that present with CC features may be well served by Stereotactic radiosurgery (SRS).
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Affiliation(s)
- Diogo Cordeiro
- Department of Neurological Surgery, University of Virginia, Room G512 1221 Lee St., Charlottesville, VA, 22908, USA. .,Department of Neurological Surgery, University of Virginia Health System, P. O. Box 800212, Charlottesville, VA, 22908, USA.
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Room G512 1221 Lee St., Charlottesville, VA, 22908, USA
| | - Mohammed Nasser
- Department of Neurological Surgery, University of Virginia, Room G512 1221 Lee St., Charlottesville, VA, 22908, USA
| | - Beatriz Lopes
- Department of Pathology, University of Virginia, Neuropathology, 800214, Charlottesville, VA, 22908-0214, USA
| | - Mary Lee Vance
- Department of Medicine and Neurological Surgery, University of Virginia, Pituitary Clinic, 2nd Floor, Suite 2100, 415 Ray C. Hunt Dr., Charlottesville, VA, 22903, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Room G512 1221 Lee St., Charlottesville, VA, 22908, USA
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23
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Khatri KJ, Javanmard P, Pawha PS, Miller JD. CLINICALLY SILENT ADRENOCORTICOTROPIC HORMONE-SECRETING CROOKE CELL ADENOMA PRESENTING AS UNILATERAL EAR PAIN. AACE Clin Case Rep 2018; 5:e150-e153. [PMID: 31967022 DOI: 10.4158/accr-2018-0347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/10/2018] [Indexed: 12/26/2022] Open
Abstract
Objective Crooke cell adenoma (CCA) is a rare tumor of the anterior pituitary. It is highly aggressive and carries significant risk of morbidity and mortality. Methods This report focuses on the presentation of this disease process and review diagnosis and treatment. The patient is a 64-year-old male with a history of resected pituitary adenoma of unknown pathology. Results The patient underwent serial magnetic resonance imaging surveillance for numerous years without recurrence of tumor, however eventually developed symptoms of worsening left ear pain over 3 weeks that rapidly evolved to include ptosis. Imaging revealed a new pituitary macroadenoma. Urgent surgical resection revealed histopathological diagnosis of CCA. Corticotroph adenomas represent a rare subset of pituitary tumors. Clinically silent pituitary tumors demonstrate relatively higher rates of cavernous sinus invasion (30% versus 18%) and progression or recurrence (34% versus 6%) when compared to nonfunctioning adenomas. In CCA, only 65% of patients have clinical features of Cushing disease at presentation. Twenty-four-hour urinary free cortisol is discussed in the literature as a potential tool, where a value 4 times the upper limit of normal was predictive of higher risk of having Crooke cell changes. With a recurrence rate of up to 60%, multimodal treatment (surgery and radiation) is preferred. Conclusion This case highlights early detection and treatment as keys to reducing the risk of morbidity and mortality from CCA. Currently, there are limited tools for identifying patients who are high risk for developing Crooke cell changes. Treatment modalities classically include surgery and radiotherapy. Adjuvant and novel chemotherapies are being explored.
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24
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Renner U, Ciato D, Stalla GK. Recent advances in understanding corticotroph pituitary tumor initiation and progression. F1000Res 2018; 7. [PMID: 30228864 PMCID: PMC6117851 DOI: 10.12688/f1000research.14789.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2018] [Indexed: 11/20/2022] Open
Abstract
Cushing’s disease is the most frequent form of hypercortisolism and is caused by hypophyseal corticotroph adenomas secreting excessive amounts of adrenocorticotropic hormone. Most of the tumors develop sporadically and only a limited number of corticotroph adenomas have been found to be associated with different neuroendocrine syndromes or with familial isolated pituitary adenomas. The pathogenic mechanisms of corticotroph adenomas are largely unknown, but the discovered aberrant chaperoning activity of heat shock protein 90 on the one hand and the presence of ubiquitin-specific protease 8 mutations on the other hand partially explained the causes of their development. Corticotroph tumors arise initially as benign microadenomas but with time form invasively growing aggressive macroadenomas which can switch to corticotroph carcinomas in extremely rare cases. The mechanisms through which corticotroph tumors escape from glucocorticoid negative feedback are still poorly understood, as are the processes that trigger the progression of benign corticotroph adenomas toward aggressive and malignant phenotypes. This review summarizes recent findings regarding initiation and progression of corticotroph pituitary tumors.
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Affiliation(s)
- Ulrich Renner
- Max Planck Institute of Psychiatry, Clinical Neuroendocrinology Group, Munich, Germany
| | - Denis Ciato
- Max Planck Institute of Psychiatry, Clinical Neuroendocrinology Group, Munich, Germany
| | - Günter K Stalla
- Max Planck Institute of Psychiatry, Clinical Neuroendocrinology Group, Munich, Germany
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25
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Wang Z, Gao L, Xing B. Letter to the Editor. Questionable value of 7-T MRI in Cushing's disease and relationship to inferior petrosal sinus sampling. J Neurosurg 2018; 130:668-670. [PMID: 30141755 DOI: 10.3171/2018.4.jns181113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zihao Wang
- 1Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; and
- 2China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China
| | - Lu Gao
- 1Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; and
- 2China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China
| | - Bing Xing
- 1Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; and
- 2China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China
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26
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Todnem N, Ward A, Segar S, Rojiani AM, Rahimi SY. Clinically Silent Adrenocorticotropic Hormone-Positive Crooke Cell Adenoma: Case Report and Review of Literature. World Neurosurg 2018; 119:197-200. [PMID: 30077745 DOI: 10.1016/j.wneu.2018.07.233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pituitary adenomas are one of the most common tumors of adulthood; however, subtypes such as Crooke cell adenoma are relatively rare. CASE DESCRIPTION We present the case of a 55-year-old woman who presented with new-onset intermittent headache and dizziness. Clinical and laboratory investigations were not suggestive of corticotroph tumor. However, subsequent computed tomography and magnetic resonance imaging scans revealed the presence of a suprasellar pituitary adenoma displacing the optic chiasma superiorly, with hemorrhage and sellar expansion. The lesion was removed by transsphenoidal surgery and the biopsy confirmed the lesion to be a nonfunctioning pituitary macroadenoma. Further investigation revealed that the specimen demonstrated Crooke hyaline changes, with strong immunoreactivity for adrenocorticotropic hormone. However, initial workup and postoperative testing lacked evidence of Cushing disease. There was no sign of recurrence after 1-year follow-up. CONCLUSIONS Clinically silent Crooke cell adenomas are rare occurrences, and as such we report this case with investigation of past cases.
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Affiliation(s)
- Nathan Todnem
- Department of Neurosurgery, The Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Ayobami Ward
- Department of Neurosurgery, The Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Sharmila Segar
- Department of Neurosurgery, The Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Amyn M Rojiani
- Department of Pathology, The Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Scott Y Rahimi
- Department of Neurosurgery, The Medical College of Georgia at Augusta University, Augusta, Georgia, USA.
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27
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Polledo L, Grinwis GCM, Graham P, Dunning M, Baiker K. Pathological Findings in the Pituitary Glands of Dogs and Cats. Vet Pathol 2018; 55:880-888. [DOI: 10.1177/0300985818784162] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With the exception of classic functional adenomas in dogs and horses, pituitary lesions are infrequently described in the veterinary literature. Approximately 10% of pituitary glands from asymptomatic humans contain abnormalities, but the equivalent proportion in small animals is unknown. Pituitary glands from 136 dogs and 65 cats collected during routine necropsies were examined to determine the prevalence of pituitary lesions and their histopathological diagnosis. Lesions were characterized in sections stained with hematoxylin and eosin, periodic acid-Schiff (PAS), Gordon and Sweet’s and reticulin stains, and immunohistochemistry for adrenocorticotropic hormone (ACTH), growth hormone, melanocyte stimulating hormone–α, and prolactin. Pituitary abnormalities were identified in 36 of 136 (26.4%) dogs and 10 of 65 (15.3%) cats. Cystic changes were the most common lesion, occurring in 18 (13.2%) dogs and 8 (12.3%) cats. Pituitary neoplasia was detected in 14.1% (12/85) of middle-aged and old dogs; 1 (1.5%) cat had pituitary nodular hyperplasia. PAS and reticulin stains helped differentiate ACTH-immunoreactive adenomas from hyperplastic nodules: adenomas contained PAS-positive intracytoplasmic granules and loss of the normal reticulin network. One dog had a pituitary carcinoma with infiltration into the thalamus. Other pituitary abnormalities included secondary metastases (2 dogs) and hypophysitis (4 dogs, 1 cat). In most cases, the lesion appeared to be subclinical and could be considered incidental, whereas clinical manifestations were apparent in only 4 dogs (2.9%) and none of the cats with pituitary lesions. Pituitary abnormalities are common in dogs and cats, and their clinical relevance requires further investigation.
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Affiliation(s)
- Laura Polledo
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Guy C. M. Grinwis
- Department of Pathobiology, Faculty of Veterinary Medicine, Utrecht, the Netherlands
| | - Peter Graham
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Mark Dunning
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Kerstin Baiker
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
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28
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Wang W, Fu L, Li S, Xu Z, Li X. Histone deacetylase 11 suppresses p53 expression in pituitary tumor cells. Cell Biol Int 2017; 41:1290-1295. [PMID: 28782861 DOI: 10.1002/cbin.10834] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/03/2017] [Indexed: 01/12/2023]
Affiliation(s)
- Weimin Wang
- School of Medicine; Shandong University; Jinan 250012 China
- Department of Neurosurgery and Surgery Room; Qingdao Municipal Hospital; Qingdao 266071 China
| | - Li Fu
- Department of Neurosurgery and Surgery Room; Qingdao Municipal Hospital; Qingdao 266071 China
| | - Shengli Li
- Department of Neurosurgery and Surgery Room; Qingdao Municipal Hospital; Qingdao 266071 China
| | - Zhiming Xu
- Department of Neurosurgery and Surgery Room; Qingdao Municipal Hospital; Qingdao 266071 China
| | - Xingang Li
- School of Medicine; Shandong University; Jinan 250012 China
- Department of Neurosurgery; Qilu Hospital of Shandong University; Jinan 250012 China
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29
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Lonser RR, Nieman L, Oldfield EH. Cushing's disease: pathobiology, diagnosis, and management. J Neurosurg 2016; 126:404-417. [PMID: 27104844 DOI: 10.3171/2016.1.jns152119] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cushing's disease (CD) is the result of excess secretion of adrenocorticotropic hormone (ACTH) by a benign monoclonal pituitary adenoma. The excessive secretion of ACTH stimulates secretion of cortisol by the adrenal glands, resulting in supraphysiological levels of circulating cortisol. The pathophysiological levels of cortisol are associated with hypertension, diabetes, obesity, and early death. Successful resection of the CD-associated ACTH-secreting pituitary adenoma is the treatment of choice and results in immediate biochemical remission with preservation of pituitary function. Accurate and early identification of CD is critical for effective surgical management and optimal prognosis. The authors review the current pathophysiological principles, diagnostic methods, and management of CD.
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Affiliation(s)
- Russell R Lonser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lynnette Nieman
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; and
| | - Edward H Oldfield
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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30
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Asa SL, Ezzat S. Aggressive Pituitary Tumors or Localized Pituitary Carcinomas: Defining Pituitary Tumors. Expert Rev Endocrinol Metab 2016; 11:149-162. [PMID: 30058871 DOI: 10.1586/17446651.2016.1153422] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pituitary tumors are common and exhibit a wide spectrum of hormonal, proliferative and invasive behaviors. Traditional classifications consider them malignant only when they exhibit metastasis. Patients who suffer morbidity and mortality from aggressive tumors classified as "adenomas" are denied support provided to patients with "cancers" and in many jurisdictions, these tumors are considered curiosities that do not warrant reporting in health registries. We propose use of the term "tumor" rather than "adenoma" to align with other neuroendocrine tumors. The features that can serve as diagnostic, prognostic and predictive markers are reviewed. Clinico-pathological and radiographic classifications provide important information and to date, no single biomarker has been able to offer valuable insight to guide the management of patients with pituitary tumors.
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Affiliation(s)
- Sylvia L Asa
- a Department of Pathology , University Health Network, University of Toronto , Toronto , Canada
- b Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada
| | - Shereen Ezzat
- c Department of Medicine , University Health Network, University of Toronto , Toronto , Canada
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