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Shakir MK, Ebrahim IC, Spiro A, Mai VQ, Hoang TD. Coexistence of Cushing Disease With a Solitary Adrenocorticotrophic Hormone-Dependent Adrenal Adenoma. AACE Clin Case Rep 2022; 8:41-44. [PMID: 35097202 PMCID: PMC8784700 DOI: 10.1016/j.aace.2020.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective We report a 49-year-old woman who had minimal features of Cushing syndrome and an incidentally discovered adrenal adenoma. She was subsequently diagnosed with pituitary-dependent Cushing syndrome. Methods Laboratory and imaging studies including serum cortisol, plasma adrenocorticotrophic hormone (ACTH), high dose dexamethasone test, corticotropin-releasing hormone test, computed tomography (CT) scan, and magnetic resonance imaging were performed. Results A 49-year-old woman was admitted for urosepsis. An abdominal CT scan performed during the urosepsis workup showed a 2.7-cm right adrenal adenoma. She denied any abdominal striae or other symptoms. Physical examination showed normal vital signs, minimal facial fullness without central obesity, and striae. Laboratory results were as follows: 24-hour-urine cortisol 294 μg (reference 4.0-50.0), midnight serum cortisol 23.0 μg/dL (reference < 7.5), and plasma ACTH level 39 pg/mL (reference 5-27). A corticotropin-releasing hormone stimulation test showed >20% rise in serum cortisol and >35% rise in ACTH levels. A pituitary magnetic resonance image showed a 5 mm pituitary lesion. The patient underwent transsphenoidal pituitary surgery, which confirmed an ACTH-secreting lesion. Postoperatively, she required hydrocortisone replacement for the next 10 months. A follow-up adrenal CT performed 6 months later showed a decrease in the size of the adrenal adenoma (1.8 cm). Conclusion This case highlights the importance of recognizing the coexistence of ACTH-dependent Cushing disease with an adrenal adenoma and partial ACTH dependency of the adrenal adenoma.
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Affiliation(s)
- Mohamed K.M. Shakir
- Division of Endocrinology, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
- Division of Endocrinology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Ismail C. Ebrahim
- Division of Endocrinology, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
- Division of Endocrinology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew Spiro
- Division of Endocrinology, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
- Division of Endocrinology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Vinh Q. Mai
- Division of Endocrinology, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
- Division of Endocrinology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Thanh D. Hoang
- Division of Endocrinology, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
- Division of Endocrinology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Address correspondence and reprint requests to Dr. Thanh D. Hoang, Division of Endocrinology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889.
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Collazo-Gutiérrez N, de Jesús O, Villamil-Jarauta M, Alvarado M, González L, Ramírez M, Carlo-Chevere VJ. Double Pituitary Adenomas with Synchronous Somatotroph and Corticotroph Clinical Presentation of Acromegaly and Cushing's Disease. World Neurosurg 2019; 132:161-164. [PMID: 31505284 DOI: 10.1016/j.wneu.2019.08.224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Double pituitary adenomas are a rare occurrence. Synchronous clinical manifestation is extremely rare. CASE DESCRIPTION We report a case of a 51-year-old female with symptoms of both hypercortisolism and acromegaly during the past 2 years. Endocrine evaluation confirmed active acromegaly and revealed adrenocorticotropin hormone-dependent hypercortisolemia. Preoperative magnetic resonance imaging of the pituitary demonstrated separated double microadenomas with different intensity. Immunohistochemical analysis of each separate adenoma confirmed an exact diagnosis. The diagnosis of acromegaly and adrenocorticotropin hormone-dependent Cushing's disease was confirmed. CONCLUSIONS This is the third reported case in the literature of synchronous clinical manifestation of acromegaly and Cushing's disease. Extensive surgical exploration of the sella must be performed to avoid surgical failures from residual tumor. Immunohistochemical analysis is required to confirm an exact diagnosis for each of the double pituitary adenomas.
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Affiliation(s)
| | - Orlando de Jesús
- Section of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico.
| | | | - Milliette Alvarado
- Section of Endocrinology, University of Puerto Rico, San Juan, Puerto Rico
| | - Loida González
- Section of Endocrinology, University of Puerto Rico, San Juan, Puerto Rico
| | - Margarita Ramírez
- Section of Endocrinology, University of Puerto Rico, San Juan, Puerto Rico
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Schorr M, Zhang X, Zhao W, Abedi P, Lines KE, Hedley-Whyte ET, Swearingen B, Klibanski A, Miller KK, Thakker RV, Nachtigall LB. TWO SYNCHRONOUS PITUITARY ADENOMAS CAUSING CUSHING DISEASE AND ACROMEGALY. AACE Clin Case Rep 2019; 5:e276-e281. [PMID: 31967052 PMCID: PMC6876961 DOI: 10.4158/accr-2019-0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/11/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To report the first case of 2 synchronous pituitary adenomas, 1 corticotroph and 1 somatotroph, with distinct molecular lineages confirmed by differential hormone and S-100 protein expression. METHODS A case report followed by a literature review are presented. RESULTS A 68-year-old woman presented for evaluation of resistant hypertension. Biochemical testing demonstrated adrenocorticotropic hormone (ACTH)-dependent hypercortisolemia and growth hormone (GH) excess. Pituitary magnetic resonance imaging (MRI) revealed a 2 cm left sellar lesion consistent with a pituitary macroadenoma. The patient therefore underwent transsphenoidal surgery for a presumed cosecreting ACTH and GH macroadenoma. Tumor immunohistochemical staining (IHC) was positive for ACTH, but negative for GH. Postoperative biochemical testing confirmed remission from Cushing disease, but the insulin-like growth factor 1 (IGF-1) level remained elevated. Postoperative MRI demonstrated a small right sellar lesion that, in retrospect, had been present on the preoperative MRI. Resection of the right lesion confirmed a GH-secreting adenoma with negative ACTH staining. After the second surgery, the IGF-1 level normalized and blood pressure improved. Further pathologic examination of both surgical specimens demonstrated differential expression of S-100 protein, a folliculostellate cell marker. Reverse transcription polymerase chain reaction of messenger ribonucleic acid from the left sellar lesion was positive for ACTH and negative for GH, confirming the IHC results. Germline mutations in genes known to be associated with pituitary adenoma syndromes (MEN1, CDC73, CDKN1A, CDKN1B, CDKN2B, CDKN2C, and AIP) were not detected. CONCLUSION Although the pathogenesis of synchronous pituitary adenomas has not been fully elucidated, this case report suggests that they can have distinct molecular lineages.
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Ogando-Rivas E, Alalade AF, Boatey J, Schwartz TH. Double pituitary adenomas are most commonly associated with GH- and ACTH-secreting tumors: systematic review of the literature. Pituitary 2017; 20:702-708. [PMID: 28766078 DOI: 10.1007/s11102-017-0826-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Double adenomas in the pituitary gland are a rare occurrence. The ability to cure a hormone-producing adenoma with surgery is dependent on the ability to identify and completely remove the correct adenoma. The relative frequency of each subtype of hormone-secreting adenomas confirmed with magnetic resonance image (MRI), surgery and immunohistochemistry is not defined. METHODS Following PRISMA guidelines, we performed a systematic review of PubMed Central, Google Scholar, Scopus Database, Cochrane database and Science Research, using the key-words: "double pituitary adenomas", "multiple pituitary adenomas" and only papers where multiple or truly separate double pituitary adenomas were identified pre-surgically by MRI and/or confirmed by pathology/immunohistochemistry staining were included. RESULTS We reviewed papers from 1975 to 2016 and found 17 cases with two pituitary adenomas and 1 with three pituitary adenomas. The ages ranged from 22 to 67 years old, and there were twelve females and five males. Immunohistochemical staining showed that the most common double pituitary adenomas were growth hormone (GH)- followed by adrenocorticotropic (ACTH)-secreting. CONCLUSION Double pituitary adenomas are rare but most commonly found with GH- or ACTH-producing tumors. It is critical to remove all identified possible adenomas to achieve biochemical cure and clinicians should have heightened sensitivity in patients with acromegaly or Cushing's Disease.
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Affiliation(s)
- Elizabeth Ogando-Rivas
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Andrew F Alalade
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Jerome Boatey
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
- Department of Otolaryngology, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
- Department of Neuroscience, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
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Roberts S, Borges MT, Lillehei KO, Kleinschmidt-DeMasters BK. Double separate versus contiguous pituitary adenomas: MRI features and endocrinological follow up. Pituitary 2016; 19:472-81. [PMID: 27209585 DOI: 10.1007/s11102-016-0727-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Double pituitary adenomas are defined as two adenomas within a gland. These have distinct light microscopic and immunohistochemical features and may be clearly-separate or contiguous. Most reports have focused on the various hormonal combinations in double tumors rather than on any potential increased risk for residual mass or endocrinopathy. METHODS Departmental files were searched to identify all double adenomas from 1/1/2000 to 3/1/2016, with review of magnetic resonance imaging (MRI) to determine if the dual nature of the lesions could be discerned retrospectively after histologic diagnosis of double adenoma. All cases were immunostained for standard anterior pituitary hormones. RESULTS Eight cases were identified: 2 follicle-stimulating hormone (FSH)/alpha subunit (ASU) + prolactinoma (PRL); 1 PRL + corticotroph (ACTH); 1 hormone-negative + PRL; 1 ACTH + ASU/growth hormone (GH)/PRL; 1 GH/PR + PRL; 1 FSH/ASU, + ACTH; 1 GH + luteinizing hormone (LH). One patient had clearly-separate lesions identified preoperatively and required two surgical procedures for gross total resection. A second patient had 2 lesions recognized at surgery and afterwards on retrospective neuroimaging. The remaining 6 patients had double adenomas discovered at the time of histologic examination that were not resolvable at surgery or on retrospective neuroimaging. Four patients, 2 with clearly-separate and 2 with contiguous double adenomas, had persistent MRI abnormalities, and one had continued endocrine abnormalities. CONCLUSIONS Double contiguous pituitary adenomas are difficult to anticipate preoperatively or to resolve intraoperatively. Although double contiguous adenomas are much more common than double separate lesions, both have a risk for subtotal resection and, thus, residual mass and/or endocrinopathy may ensue.
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Affiliation(s)
- Sammie Roberts
- Department of Pathology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA
| | - Manuel Thomas Borges
- Department of Neuroradiology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA
| | - Kevin O Lillehei
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA
| | - B K Kleinschmidt-DeMasters
- Department of Pathology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA.
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA.
- Department of Neurology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA.
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Pu J, Wang Z, Zhou H, Zhong A, Jin K, Ruan L, Yang G. Isolated double adrenocorticotropic hormone-secreting pituitary adenomas: A case report and review of the literature. Oncol Lett 2016; 12:585-590. [PMID: 27347184 DOI: 10.3892/ol.2016.4673] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/12/2016] [Indexed: 11/06/2022] Open
Abstract
Only a few cases of double or multiple pituitary adenomas have previously been reported in the literature; however, isolated double adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas are even more rare. The present study reports a rare case of a 50-year-old female patient who presented with typical clinical features of Cushing's disease and was diagnosed with isolated double ACTH-secreting pituitary adenomas. Endocrinological examination revealed an ACTH-producing pituitary adenoma, and preoperative magnetic resonance imaging (MRI) demonstrated a microadenoma with a lower intensity on the right side of the pituitary gland. The patient underwent endoscopic endonasal transsphenoidal surgery, which revealed another pituitary tumor in the left side of the pituitary gland. The two, clearly separated, pituitary adenomas identified in the same gland were completely resected. Immunohistochemistry and pathology revealed that the clearly separated double pituitary adenomas were positive for ACTH, thyroid-stimulating, growth and prolactin hormones. Postoperatively, the levels of ACTH and cortisol hormone decreased rapidly. The case reported in the present study is considerably rare, due to the presence of a second pituitary adenoma in the same gland, which was not detected by preoperative MRI scan, but was noticed during surgery. Intraoperative evaluation may be important in the identification of double or multiple pituitary adenomas.
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Affiliation(s)
- Jiujun Pu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 410000, P.R. China
| | - Zhiming Wang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 410000, P.R. China
| | - Hui Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 410000, P.R. China
| | - Ailing Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 410000, P.R. China
| | - Kai Jin
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 410000, P.R. China
| | - Lunliang Ruan
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 410000, P.R. China
| | - Gang Yang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 410000, P.R. China
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Budan RM, Georgescu CE. Multiple Pituitary Adenomas: A Systematic Review. Front Endocrinol (Lausanne) 2016; 7:1. [PMID: 26869991 PMCID: PMC4740733 DOI: 10.3389/fendo.2016.00001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/08/2016] [Indexed: 12/20/2022] Open
Abstract
PubMed, Scopus, and Web of Science Core Collection databases were systematically searched for studies reporting synchronous double or multiple pituitary adenomas (MPA), a rare clinical condition, with a vague pathogenesis. Multiple adenomas of the pituitary gland are referred to as morphologically and/or immunocytochemically distinct tumors that are frequently small-sized and hormonally non-functional, to account for the low detection rate. There is no general agreement on how to classify MPA, various criteria, such as tumor contiguity, immunoreactivity, and clonality analysis are being used. Among the component tumors, prolactin (PRL)-immunopositive adenomas are highly prevalent, albeit mute in the majority of cases. The most frequent clinical presentation of MPA is Cushing's syndrome, given the fact that in more than 50% of reported cases at least one lesion stains for adrenocorticotrophic hormone (ACTH). Plurihormonal hyperactivity may be diagnosed in a patient with MPA when more than one tumor is clinically active (e.g., ACTH and PRL) or in cases with at least one composite tumor (e.g., GH and PRL), to complicate the clinical scenario. Specific challenges associated with MPA include high surgical failure rates, enforcing second-look surgery in certain cases, and difficult preoperative neuroradiological imaging evaluation, with an overall sensitivity of only 25% for magnetic resonance imaging to detect distinct multiple tumors. Alternatively, minor pituitary imaging abnormalities may raise suspicion, as these are not uncommon. Postoperative immunohistochemistry is mandatory and in conjunction to electron microscopy scanning and testing for transcription factors (i.e., Pit-1, T-pit, and SF-1) accurately define and classify the distinct cytodifferentiation of MPA.
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Affiliation(s)
- Renata M. Budan
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carmen E. Georgescu
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Endocrinology Clinic, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
- *Correspondence: Carmen E. Georgescu,
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Curtò L, Trimarchi F. Comment on "A somatotropin-producing pituitary adenoma with an isolated adrenocorticotropin-producing pituitary adenoma in a female patient with acromegaly, subclinical Cushing's disease and a left adrenal tumor" . Endocr J 2014; 61:645-6. [PMID: 24826865 DOI: 10.1507/endocrj.ej14-0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Lorenzo Curtò
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Messina, Messina, Italy
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