ACTH-secreting medullary carcinoma of the thyroid presenting a severe idiopathic osteoporosis and senile purpura: report of a case and review of the literature

Medullary Thyroid Cancer with Ectopic Cushing's Syndrome: A Case Report and Systematic Review of Detailed Cases from the Literature

Background: Medullary thyroid cancer (MTC) is a neuroendocrine tumor arising from parafollicular C-cells of the thyroid gland that, in rare cases, can cause a paraneoplastic ectopic Cushing's syndrome (ECS). The development of Cushing's syndrome (CS) in MTC patients is generally associated with advanced disease and poor prognosis. Summary: We described a case of severe CS due to MTC in a young male. We performed a systematic review to identify cases of ECS due to MTC. We searched PubMed, Scopus, and Web of Science for publications between database inception and February 2022 and we collected the patient characteristics, disease presentation, employed treatment strategies, and disease outcomes. In addition to our patient, we identified 96 cases of ECS due to MTC reported in literature. Mean age at diagnosis was 44.4 years (range 10-84), and there was a male predominance (male:female [M:F] = 1.8:1). Most patients (51%) presented with metastatic disease at diagnosis and showed severe hypercortisolism. Seventeen patients developed distant metastasis and hypercortisolism during follow-up. Interestingly, in 48% of patients, the diagnosis of CS followed the diagnosis of MTC with a median time of 48 months but, among patients in whom the diagnosis was concomitant (38%), symptoms due to hypercortisolism were frequently the reason for seeking medical advice. Pathology results showed evidence of adrenocorticotropic hormone (ACTH) or corticotropin releasing hormone (CRH) positive cells in 76% of patients in whom they were tested. The management of hypercortisolism was challenging in most patients with 48% requiring, eventually, definitive treatment with bilateral adrenalectomy (BLA). Recently, some limited evidence has emerged regarding tyrosine kinase inhibitors (TKIs) treatment for hypercortisolism in patients with ECS due to MTC. Despite limited information on survival, prognosis was generally poor and the main causes of death were either complications of CS or disease progression. Conclusions: Despite its rarity, MTC should be considered in the differential diagnosis of ECS. Management of hypercortisolism is a key factor to improve the patient's symptoms but it is often challenging and BLA is frequently required. Further studies are needed for investigating the role of TKIs in patients with MTC with ECS.

Pulmonary lymphangitis carcinomatosis: systematic review and meta-analysis of case reports, 1970-2018

Pulmonary lymphangitis carcinomatosis (PLC) is a life-threating complication in patients suffering from malignancies. Misleading and nonspecific symptoms often result in a delayed diagnosis. This review was aimed at evaluating epidemiology, clinical manifestations, and survival of patients with PLC reported in the literature. According to our knowledge, this study is the first such extensive analysis of PLC. We searched for the literature in the PubMed database for articles published from 1970 to 2018 using keywords: lung, pulmonary, lymphangitic, carcinoma, carcinomatosis. Pulmonary lymphangitis carcinomatosis rarely occurs, thus all data were extracted from case reports and case series consisted of a method for identifying individual-level patient data. In the final analysis, 108 articles (139 individual patient cases) were included. The mean age of PLC occurrence is 49.21 years. There is no difference in the prevalence between men and women. The most common underlying primary tumors coexisting with PLC are breast (17.3%), lung (10.8%), and gastric cancers (10.8%). Dyspnea and dry cough were the most common symptoms occurring in 59.0% and 33.8% of patients, respectively. In half the patients, PLC developed in fewer than ten months after first diagnosis of cancer. Pulmonary lymphangitis carcinomatosis diagnosis is associated with a poor prognosis: approximately half of patients die within two months of their first respiratory symptoms and three weeks from admission to hospital. Regarding survival time, we observed better results achieved in patients described between 2000 and 2018 compared to 1970 through 1999. In the presence of progressive dyspnea, cough, and lesions comparable to interstitial lung disease, diagnosis of PLC should be considered. Pulmonary lymphangitis carcinomatosis can be the first manifestation of primary occult neoplasm and may occur at any age. Adenocarcinoma, especially primary lung, breast, and gastric cancers is the most common cancer coexisting with PLC.

Location of ectopic adrenocortical hormone-secreting tumors causing Cushing's syndrome in the paranasal sinuses

BACKGROUND

The majority of ectopic adrenocorticotropic hormone (ACTH)-secreting tumors are localized in the chest or abdomen. Occasionally, these tumors are found in the paranasal sinuses.

METHODS

We present 2 unusual cases of ectopic ACTH syndrome whose ACTH-secreting tumors were localized in the paranasal sinuses and describe their biochemical and radiological presentation.

RESULTS

The first patient had an ACTH-secreting olphactory neuroblastoma originating in the ethmoid sinuses. The second patient had a clinical course and biochemical findings indistinguishable from pituitary ACTH-dependent Cushing's syndrome, except for negative petrosal sinus sampling. Head imaging showed a "polyp" in the left maxillary sinus-secreting ACTH. Both patients went into remission following surgical resection and recovered normal pituitary-adrenal axis function.

CONCLUSION

Ectopic ACTH secretion may originate from lesions in the paranasal sinuses. This accessible location allows for direct immunohistochemical diagnosis with ACTH staining. Surgical resection/radiation therapy can result in complete remission of the disease and restoration of normal pituitary-adrenal function.

Cushing's syndrome due to an ACTH-producing neuroendocrine tumour in the nasal roof

A patient with ectopic adrenocorticotrophic hormone (ACTH) production from a neuroendocrine tumour of the nasal roof is presented. By indirect immunoperoxidase techniques the tumour cells were shown to be distinctly positive for ACTH and beta-endorphin but negative for other peptides derived from pro-opiomelanocortin. Neither corticotropin releasing hormone (CRF) found in some tumours associated with ectopic Cushing's syndrome, nor gastrin immunoreactivity, which coexists with ACTH in normal rat pituitary and in rat and human gastrointestinal cells, were demonstrable in the tumour. A review of other, previously recognized locations of CRF/ACTH producing tumours is given to increase the awareness of the ectopic Cushing's syndrome, which may lack the classical features and is characterized by fulminant clinical course, extreme fatigue, weakness, pale facial swelling, oedema and hypokalaemic alkalosis.

Ectopic pro-opiomelanocortin syndrome

Ectopic POMC syndrome remains one of the most challenging differential diagnoses in endocrinology. Recent progress in the understanding of the tissue specific regulation of POMC gene expression and new insights into the processing of the POMC peptide in nonpituitary tissues has helped elucidate some of the molecular events leading to ectopic expression and secretion of POMC peptides. Corticotropin and other POMC-derived peptides have diverse effects on adrenal steroidogenesis, growth, and extra-adrenal tissues. Differences in POMC gene regulation in the corticotrope versus ectopic POMC-producing tumors provides a scientific framework for the clinical distinction between eutopic and ectopic Cushing's syndrome. In an attempt to revisit recent basic and clinical advances in the diagnosis of ectopic POMC syndrome the authors undertook an extensive literature review of 530 cases in 197 published papers and provided a molecular biologic, demographic and diagnostic update. According to this review, the four most common causes of ectopic POMC syndrome are the small cell carcinoma of the lung (27%), bronchial carcinoids (21%), islet cell tumor of the pancreas (16%), and thymic carcinoids (10%). Although the clinical features of patients with ectopic POMC syndrome are similar to those with Cushing's disease, subgroup analysis reveals a broad spectrum of severity and progression of signs and symptoms of hypercortisolism. The endocrine workup of a patient with suspected ectopic POMC syndrome includes the establishment of pathologic hypercortisolism, diagnosis of corticotropin dependency, and the differential diagnosis of corticotropin-dependent Cushing's syndrome. The use of a variety of baseline endocrine values, dynamic endocrine testing, and invasive procedures leads to the correct diagnosis in the majority of patients with ectopic POMC syndrome. Diagnostic imaging, including conventional radiological techniques and somatostatin receptor scintigraphy, aids in the correct localization and eventual treatment of ectopic POMC production.

Cushing's syndrome in medullary thyroid carcinoma

Ectopic ACTH secretion is a rare cause of hypercortisolism. Induced metabolic disturbances are often serious, and the management of such patients may be difficult. We report here our experience with four medullary thyroid carcinoma (MTC) patients with distant metastases in whom an ectopic ACTH syndrome occurred. The clinical presentation was significant by the severity and the rapidity of the hypercortisolism. Diagnosis and follow-up were realized by measurements of plasma cortisol, urinary free cortisol, urinary 17-hydroxycorticosteroid, plasma ACTH, plasma LPH, serum calcitonin and carcino-embryonic antigen. Initial treatment with adrenalytic medical therapy failed to control the disease. Only bilateral adrenalectomy cured the excessive cortisol production, and for a long time despite tumor progression. In conclusion, bilateral adrenalectomy should be considered in MTC patients with Cushing's syndrome even at the stage of distant spread. In fact, with regard to the slow growth rate of most MTC's, they may survive for years.

Medullary carcinoma of the thyroid as a cause of Cushing's syndrome: a case with ectopic adrenocorticotropin secretion characterized by double enzyme immunostaining

A case of a medullary carcinoma of the thyroid gland that secreted both calcitonin and adrenocorticotropin (ACTH) is reported. The patient was a 32-year-old man who was referred to the Clinical Center of the National Institutes of Health with radiologic evidence of intrathoracic and hepatic masses accompanied by florid Cushing's syndrome. Serum levels of calcitonin and ACTH were elevated. The thoracic and hepatic masses were resected. The histologic findings were typical of medullary carcinoma of the thyroid with extensive metastases to the liver. The neoplasm had a predominantly solid pattern, and the neoplastic cells were either round or spindled, many with cytologic atypia. Immunohistochemical analysis of fixed, paraffin-embedded sections demonstrated chromogranin, calcitonin, and ACTH in the neoplastic cells. The immunostaining for chromogranin was intense in all of the cells, whereas weaker staining for calcitonin and ACTH was present in scattered cells. Electron microscopy revealed sparse secretory granules in the majority of tumor cells; a minority of neoplastic cells contained numerous granules. We further characterized this neoplasm by performing dual immunohistochemical analysis. This technique clearly demonstrated the presence of ACTH and calcitonin within the same neoplastic cells. Thus, the medullary carcinoma of the thyroid in this patient was the source of ectopic ACTH secretion causing Cushing's syndrome. In addition, this report highlights the value of using double immunostaining to localize both the ACTH and calcitonin within the same cells.

Melanin production in black medullary thyroid carcinoma (MTC)

Melanin production by two medullary carcinomas of the thyroid is reported and discussed. In both tumours, melanin and calcitonin could be detected in the same cells.

Plasma calcitonin and ACTH responses to lysine vasopressin, calcium and pentagastrin in a patient with medullary thyroid carcinoma associated with Cushing's syndrome

In a case study of medullary thyroid carcinoma (MTC) associated with Cushing's syndrome, elevated levels of urinary 17-hydroxycorticosteroids, plasma ACTH, cortisol, calcitonin (CT) and somatostatin (GHRIH) were documented. Lysine vasopressin administration further increased the levels of plasma ACTH, cortisol and CT, whereas the administration of calcium and pentagastrin increased only the level of plasma CT. Immunoreactive ACTH, CT and GHRIH were highly concentrated in the tumour tissues. Basal plasma ACTH levels were more progressively increased than plasma CT during the postoperative course when the patient was treated with o,p'-DDD, since the tumour was not completely resected. These findings suggest that the secretion of ACTH and CT from MTC were regulated in a different manner.

Calcitonin, somatostatin and ACTH immunoreactive cells in a case of familial bilateral thyroid medullary carcinoma

Bilateral medullary carcinoma of the thyroid (MCT) was discovered in a symptomless patient of a high-risk MCT family. Raised serum calcitonin responding abnormally to pentagastrin led to a thyroidectomy. Grossly, the thyroid showed one nodule in the upper third of each lobe. Light microscopy revealed typical MCT with amyloid deposits. Nontumoral thyroid tissue showed C cell parafollicular hyperplasia. Electron microscopy detected intracellular secretory granules (mean diameter, 150 nm) and typical amyloid fibrills. Immunochemistry revealed numerous calcitonin immunoreactive cells in the nodules, in normal para and intrafollicular C-cells and hyperplastic C-cells. Somatostatin and ACTH were detected in certain tumor cells, but not in normal and hyperplastic C-cells. MCT hormonal production potential is discussed.

Concomitant secretion of calcitonin, beta-endorphin and ACTH from medullary thyroid carcinoma in vivo and in vitro

The present study was performed to investigate the possible synthesis of a common precursor molecule for calcitonin (CT), adrenocporticotropin (ACTH) and beta-lipotropin (beta-LPH)/ beta-endorphin (beta-EP) by the human medullary thyroid carcinoma (MTC). In a patient with MTC but without Cushing's syndrome, the response of plasma CT, ACTH and cortisol levels to a calcium infusion, lysine vasopressin (LVP) and dexamethasone were measured. A parallel increase of these hormones in response to calcium and LVP was seen, while there was a paradoxical increase of CT during dexamethasone infusion. Incubation of MTC fragments obtained at surgery showed a significant correlation of the secretion of CT, ACTH and beta-LPH/ beta-EP in response to calcium, LVP and dexamethasone. The concomitant release of these hormones in vivo and in vitro could be compatible with the synthesis of a common precursor molecule for CT, ACTH and beta-LPH/ beta-EP in MTC, although this was not substantiated by gel-chromatography of the tumor extract. Corticotropin releasing factor, a regulator of the normal processing of pro-opiococorticoid precursor molecule in the anterior pituitary gland, is also able to activate ACTH, beta-LPH/ beta-EP and calcitonin secretion from the malignant C-cell of the thyroid.

ACTH-secreting medullary carcinoma of the thyroid: monitoring of clinical course with calcitonin and cortisol assays and immunohistochemical studies

The clinical course of a patient with Cushing's syndrome secondary to metastatic medullary carcinoma of the thyroid was documented with serial calcitonin and cortisol assays and tumor immunohistochemistry studies. Cortisol levels were originally markedly elevated but returned to normal after total thyroidectomy. These levels rose again when the patient developed liver metastases but normalized during chemotherapy, never to rise again despite the appearance of cervical lymph node metastasis. Calcitonin levels remained elevated throughout the course. The original tumor was composed of two cell lines: one containing both calcitonin and ACTH and another containing only calcitonin-reacting cells. However, the cervical metastasis showed a marked decrease in both cell lines with fever than 1% of cells reacting to ACTH, and only 25% to calcitonin. The almost total disappearance of ACTH-reacting cells may have been therapeutically induced or may represent a consequence of tumor progression.

Elevated prolactin levels in bronchogenic carcinoma

The frequency and significance of hyperprolactinemia was studied in 21 consecutive, untreated male patients with bronchogenic carcinoma. Seven patients (33%) were found to have elevated serum prolactin (hPRL) levels. No correlation was demonstrated between increased hPRL levels, tissue histology, or tumor burden. L-dopa suppression and/or TRH stimulation tests were obtained in three untreated patients with hyperprolactinemia. The results of these tests were considered normal suggesting hypothalamic control.