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Tan L, Zhao L, Tang G, Ren Y, Tian H, Chen T. Unexpected exacerbation of cryptococcal meningitis after unilateral adrenalectomy in a PMAH patient: a case report and literature review. BMC Endocr Disord 2023; 23:199. [PMID: 37723545 PMCID: PMC10506208 DOI: 10.1186/s12902-023-01457-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 09/13/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Primary bilateral macronodular adrenal hyperplasia (PMAH) combined with infection by an opportunistic pathogen is complicated. Clinical evidence on managing PMAH patients with infections by opportunistic pathogens is insufficient. CASE PRESENTATION A 66-year-old male was admitted with bilateral adrenal masses and was diagnosed with PMAH. Fever and disturbance of consciousness appeared after laparoscopic left adrenalectomy. Cryptococcal meningitis was confirmed by cerebrospinal fluid (CSF) culture. The exacerbation of his medical condition was suspected to result from immune reconstitution inflammatory syndrome (IRIS), and he had been treated with antifungal therapy and glucocorticoid replacement, but he responded poorly and eventually died of multiorgan failure. We summarized the clinical observations of 12 Cushing's syndrome (CS) patients infected by Cryptococcus. Seven out of nine patients who were treated for cryptococcus infection before receiving CS survived, while three patients treated for cryptococcus infection after CS treatment developed signs of IRIS and eventually died. CONCLUSION Cushing's syndrome, complicated with cryptococcal infection, has a high mortality rate, mainly when IRIS emerges. Carefully identifying the presence of the suspected infection, and controlling cryptococcal infection before removing the culprit adrenals could be the rational choice.
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Affiliation(s)
- Lu Tan
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Lianling Zhao
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Guangmin Tang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, P. R. China
| | - Yan Ren
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Tao Chen
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China.
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Guo M, Hu S, Xiao Y, Cao Z, Huang Z, Liu Y, An X, Zhang G, Zheng X. Visual analysis of lung neuroendocrine tumors based on CiteSpace knowledge graph. Front Endocrinol (Lausanne) 2023; 14:1214404. [PMID: 37745715 PMCID: PMC10516576 DOI: 10.3389/fendo.2023.1214404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/16/2023] [Indexed: 09/26/2023] Open
Abstract
Objective The relevant literatures in the field of pulmonary neuroendocrine tumor were analyzed to understand the lineage, hot spots and development trends of research in this tumor. Method The Web of Science core collection was searched for English-language literature about neuroendocrine tumors of the lung published between 2000 and 2022. CiteSpace software was imported for visualization analysis of countries, institutions, co-cited authors and co-cited journals and sorting of high-frequency keywords, as well as co-cited references and keyword co-occurrence, clustering and bursting display. Results A total of 594 publications on neuroendocrine tumours of the lung were available, from 2000 to 2022, with an overall upward trend of annual publications in the literature. Authors or institutions from the United States, Italy, Japan and China were more active in this field, but there was little cooperation among the major countries. Co-cited references and keyword co-occurrence and cluster analysis showed that research on diagnostic instruments, pathogenesis, ectopic ACTH signs, staging and prognosis and treatment was a current research hotspot. The keyword bursts suggested that therapeutic approaches might be a key focus of future research into the field for pulmonary neuroendocrine tumors. Conclusion Over these 20 years, research related to neuroendocrine tumors of the lung has increased in fervour, with research on diagnostic instruments, pathogenesis, ectopic ACTH signs, staging and prognosis, and treatment being the main focus of research. Therapeutic treatments may be the future research trend in this field.
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Affiliation(s)
- Mingjie Guo
- Department of Thoracic Surgery, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Shaowen Hu
- Department of Clinical Medicine, Medical School of Henan University, Kaifeng, China
| | - Yaifei Xiao
- Department of Clinical Medicine, Medical School of Henan University, Kaifeng, China
| | - Zhan Cao
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhichao Huang
- Department of Thoracic Surgery, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Yalong Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Xiaokang An
- Department of Thoracic Surgery, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Guoyu Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Xianjie Zheng
- Department of Thoracic Surgery, The First Affiliated Hospital of Henan University, Kaifeng, China
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Takagi H, Matsumura Y, Fukuhara M, Inomata S, Yamaguchi H, Watanabe M, Ozaki Y, Muto S, Okabe N, Shio Y, Saito H, Tanabe H, Shimabukuro M, Suzuki H. Ectopic adrenocorticotropic hormone-secreting carcinoid with solitary cryptococcosis in the lungs. Cancer Rep (Hoboken) 2022; 5:e1731. [PMID: 36196010 PMCID: PMC9675365 DOI: 10.1002/cnr2.1731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 08/30/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Carcinoid tumors can on rare occasions ectopically produce adrenocorticotropic hormone (ACTH), causing Cushing's syndrome, and patients could become immunocompromised. Care must therefore be taken regarding infectious complications. In particular, ACTH-producing pulmonary carcinoid is not easy to diagnose by itself, and when combined with pulmonary nodules as infectious foci, each is very difficult to diagnose. CASE The patient was a 71-year-old woman with refractory diabetes. She showed clinical symptoms of Cushing's syndrome during treatment for diabetes and ectopic ACTH production was suspected based on biochemical and imaging tests. Nodules were identified in the left lung apex and lingual segment. Examination of resected nodules revealed that the nodule in the apex was pulmonary cryptococcosis, while the nodule in the lingual segment represented typical carcinoid. After surgery, clinical symptoms, laboratory findings, and diabetes all improved. CONCLUSION We present this very instructive case in terms of the difficulty of diagnosing ACTH-producing tumors, the possibility of infection complicating the immunodeficiency caused by ACTH-producing tumors, and the surgical strategy.
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Affiliation(s)
- Hironori Takagi
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan,Department of Chest SurgeryIwaki City Medical CenterIwakiJapan
| | - Yuki Matsumura
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | | | - Sho Inomata
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | - Hikaru Yamaguchi
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | - Masayuki Watanabe
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | - Yuki Ozaki
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | - Satoshi Muto
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | - Naoyuki Okabe
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | - Yutaka Shio
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
| | - Haruka Saito
- Department of Diabetes, Endocrinology and MetabolismFukushima Medical UniversityFukushimaJapan
| | - Hayato Tanabe
- Department of Diabetes, Endocrinology and MetabolismFukushima Medical UniversityFukushimaJapan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology and MetabolismFukushima Medical UniversityFukushimaJapan
| | - Hiroyuki Suzuki
- Department of Chest SurgeryFukushima Medical UniversityFukushimaJapan
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Fukuoka H, Shichi H, Yamamoto M, Takahashi Y. The Mechanisms Underlying Autonomous Adrenocorticotropic Hormone Secretion in Cushing's Disease. Int J Mol Sci 2020; 21:ijms21239132. [PMID: 33266265 PMCID: PMC7730156 DOI: 10.3390/ijms21239132] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/21/2020] [Accepted: 11/29/2020] [Indexed: 12/16/2022] Open
Abstract
Cushing’s disease caused due to adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas (ACTHomas) leads to hypercortisolemia, resulting in increased morbidity and mortality. Autonomous ACTH secretion is attributed to the impaired glucocorticoid negative feedback (glucocorticoid resistance) response. Interestingly, other conditions, such as ectopic ACTH syndrome (EAS) and non-neoplastic hypercortisolemia (NNH, also known as pseudo-Cushing’s syndrome) also exhibit glucocorticoid resistance. Therefore, to differentiate between these conditions, several dynamic tests, including those with desmopressin (DDAVP), corticotrophin-releasing hormone (CRH), and Dex/CRH have been developed. In normal pituitary corticotrophs, ACTH synthesis and secretion are regulated mainly by CRH and glucocorticoids, which are the ACTH secretion-stimulating and -suppressing factors, respectively. These factors regulate ACTH synthesis and secretion through genomic and non-genomic mechanisms. Conversely, glucocorticoid negative feedback is impaired in ACTHomas, which could be due to the overexpression of 11β-HSD2, HSP90, or TR4, or loss of expression of CABLES1 or nuclear BRG1 proteins. Genetic analysis has indicated the involvement of several genes in the etiology of ACTHomas, including USP8, USP48, BRAF, and TP53. However, the association between glucocorticoid resistance and these genes remains unclear. Here, we review the clinical aspects and molecular mechanisms of ACTHomas and compare them to those of other related conditions.
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Affiliation(s)
- Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan;
- Correspondence: ; Tel.: +81-78-382-5861; Fax: +81-78-382-2080
| | - Hiroki Shichi
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan; (H.S.); (Y.T.)
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan;
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan; (H.S.); (Y.T.)
- Department of Diabetes and Endocrinology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
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Aljassem G, Aljasem H. Case report: Ectopic Cushing's syndrome in a young male with hidden lung carcinoid tumor. Int J Surg Case Rep 2017; 42:13-16. [PMID: 29202350 PMCID: PMC5723367 DOI: 10.1016/j.ijscr.2017.11.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/10/2017] [Accepted: 11/12/2017] [Indexed: 11/29/2022] Open
Abstract
Ectopic Cushing’s syndrome is a form of Cushing’s in which a tumor outside the pituitary gland produces a hormone called (ACTH). Small cell carcinoma and carcinoid of the lung comprises half of its cases. Ectopic cushing syndrome is a complicated medical problem especially when it comes to identification of the ectopic spot. The surgical treatment could be curative when the spot is determined.
Introduction Ectopic Cushing syndrome is a form of Cushing’s in which a tumor outside the pituitary gland produces adrenocorticotropic hormone (ACTH). Small cell carcinoma and carcinoid of the lung comprises half of its cases. The main purpose of this study is to present a case of ectopic Cushing syndrome caused by a hidden lung carcinoid and how to manage it. Presentation of case Here we present a case of a 26 year old young male complains of increased weight and appetite, proximal muscle weakness, easy bruising and appearing of purple striae on his abdomen, with a final diagnosis of ACTH secreting lung carcinoid. Discussion The diagnosis was made by non-invasive radiological procedures (CT scan and MRI) and serological tests. The management consisted of medical treatment which was not useful, then bilateral adrenalectomy to limit the patient symptoms. The ectopic spot was finally detected and excised surgically through thoracotomy. After six months of follow up there was no recurrence, signs and symptoms of Cushing syndrome begin to disappear. Conclusion Ectopic cushing syndrome is a complicated medical problem especially when it comes to identification of the ectopic spot. The surgical treatment could be curative when the spot is determined.
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Affiliation(s)
| | - Hazem Aljasem
- Department of Surgery, Damascus University Hospital, Syria.
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Sphenoid sinus carcinoid tumour causing ectopic ACTH syndrome. J Clin Neurosci 2017; 39:92-95. [PMID: 28202381 DOI: 10.1016/j.jocn.2017.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/22/2017] [Indexed: 11/24/2022]
Abstract
A thirty-eight year old patient presented with a gradual increase in weight and Cushingoid facies of two years duration. He also had orbital congestion, with puffy eyelids and corkscrew conjunctival vessels, associated with painful eye movements. An endocrine evaluation revealed raised cortisol and ACTH. Head imaging was performed which showed an enhancing tumour arising from the sphenoid sinus, with osseous erosion of the sphenoid sinus, extending to the nasopharynx, sellar and a small amount extending intracranially. He underwent an endoscopic endonasal resection of the tumour and histology revealed a low-grade carcinoid tumour with ACTH staining. The patient also underwent radiotherapy for the intracranial extension. He is currently in his fourth year of follow-up and imaging has showed a small, stable intracranial remnant. His anterior pituitary hormonal profile remains normal.
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Isidori AM, Sbardella E, Zatelli MC, Boschetti M, Vitale G, Colao A, Pivonello R. Conventional and Nuclear Medicine Imaging in Ectopic Cushing's Syndrome: A Systematic Review. J Clin Endocrinol Metab 2015; 100:3231-44. [PMID: 26158607 PMCID: PMC4570166 DOI: 10.1210/jc.2015-1589] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
CONTEXT Ectopic Cushing's Syndrome (ECS) can be a diagnostic challenge with the hormonal source difficult to find. This study analyzes the accuracy of imaging studies in ECS localization. EVIDENCE ACQUISITION Systematic review of medical literature for ECS case series providing individual patient data on at least one conventional imaging technique (computed tomography [CT]/magnetic resonance imaging) and one of the following: 111In-pentetreotide (OCT), 131I/123I-metaiodobenzylguanidine, 18Ffluoro-2-deoxyglucose-positron emission tomography (FDG-PET), 18F-fluorodopa-PET (F-DOPA-PET), 68Ga- DOTATATE-PET/CT or 68Ga-DOTATOC-PET/CT scan (68Gallium-SSTR-PET/CT). EVIDENCE SUMMARY The analysis comprised 231 patients (females, 50.2%; age, 42.617 y). Overall, 52.4%(121/231) had "overt" ECS,18.6% had "occult" ECS, and 29% had "covert" ECS. Tumors were located in the lung (55.3%), mediastinum-thymus (7.9%), pancreas (8.5%), adrenal glands (6.4%), gastrointestinal tract (5.4%), thyroid (3.7%), and other sites (12.8%), and primary tumors were mostly bronchial neuroendocrine tumors (NETs) (54.8%), pancreatic NETs (8%), mediastinum-thymus NETs (6.9%), gastrointestinal NETs (5.3%), pheochromocytoma (6.4%), neuroblastoma (3.2%), and medullary thyroid carcinoma (3.2%). Tumors were localized byCTin66.2%(137/207), magnetic resonance imaging in 51.5% (53/103), OCT in 48.9% (84/172), FDG-PET in 51.7% (46/89), F-DOPAPET in 57.1% (12/21), 131/123I-metaiodobenzylguanidine in 30.8% (4/13), and 68Gallium-SSTRPET/CT in 81.8% (18/22) of cases. Molecular imaging discovered 79.1% (53/67) of tumors unidentified by conventional radiology, with OCT the most commonly used, revealing the tumor in 64%, followed by FDG-PET in 59.4%. F-DOPA-PET was used in only seven covert cases (sensitivity, 85.7%). Notably, 68Gallium-SSTR-PET/CT had 100% sensitivity among covert cases. CONCLUSIONS Nuclear medicine improves the sensitivity of conventional radiology when tumor site identification is problematic. OCT offers a good availability/reliability ratio, and FDG-PET was proven useful. 68Gallium-SSTR-PET/CT use was infrequent, despite offering the highest sensitivity.
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Giraldi FP, Cavallo LM, Tortora F, Pivonello R, Colao A, Cappabianca P, Mantero F. The role of inferior petrosal sinus sampling in ACTH-dependent Cushing's syndrome: review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology. Neurosurg Focus 2015; 38:E5. [DOI: 10.3171/2014.11.focus14766] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the management of adrenocorticotropic hormone (ACTH)–dependent Cushing's syndrome, inferior petrosal sinus sampling (IPSS) provides information for the endocrinologist, the neurosurgeon, and the neuroradiologist. To the endocrinologist who performs the etiological diagnosis, results of IPSS confirm or exclude the diagnosis of Cushing's disease with 80%–100% sensitivity and over 95% specificity. Baseline central-peripheral gradients have suboptimal accuracy, and stimulation with corticotropin-releasing hormone (CRH), possibly desmopressin, has to be performed. The rationale for the use of IPSS in this context depends on other diagnostic means, taking availability of CRH and reliability of dynamic testing and pituitary imaging into account. As regards the other specialists, the neuroradiologist may collate results of IPSS with findings at imaging, while IPSS may prove useful to the neurosurgeon to chart a surgical course. The present review illustrates the current standpoint of these 3 specialists on the role of IPSS.
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Affiliation(s)
- Francesca Pecori Giraldi
- 1Department of Clinical Sciences and Community Health, University of Milan
- 2Neuroendocrine Research Laboratory, Istituto Auxologico Italiano, Milan
| | - Luigi Maria Cavallo
- 3Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, and
| | - Fabio Tortora
- 4Department of Neuroradiology, “Magrassi Lanzara” Clinical-Surgical Department, Second University of Naples, Naples; and
| | - Rosario Pivonello
- 6Department of Clinical Medicine and Surgery, University of Naples Federico II
| | - Annamaria Colao
- 6Department of Clinical Medicine and Surgery, University of Naples Federico II
| | - Paolo Cappabianca
- 3Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, and
| | - Franco Mantero
- 5Endocrinology Unit, Department of Medicine, University of Padua, Italy
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A challenging case of an ectopic cushing syndrome. Case Rep Med 2014; 2014:413136. [PMID: 25431598 PMCID: PMC4241739 DOI: 10.1155/2014/413136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/15/2014] [Accepted: 10/21/2014] [Indexed: 11/25/2022] Open
Abstract
Bronchopulmonary carcinoids are rare pulmonary neoplasms although they account for most cases of ectopic ACTH syndromes. When feasible, the mainstay treatment is surgical resection of the tumor. We report the case of a 52-year-old woman with signs and symptoms suggestive of hypercortisolism for 12 months, admitted to our department because of community acquired pneumonia. Blood hormone analysis showed increased levels of ACTH and urinary free cortisol and nonsuppressibility to high- and low-dose dexamethasone tests. Pituitary MRI showed no lesion and no central-to-peripheral ACTH gradient was present in bilateral inferior petrosal sinus sampling. CRH stimulation test suggested an ectopic ACTH source. Thoracic CT scan revealed a nodular region measuring 12 mm located in the inferior lingular lobule of the left superior lung with negative uptake by 18-FDG-PET scan and negative SRS. The patient was successfully treated with an atypical lung resection and histology revealed an atypical bronchial carcinoid tumor with positive ACTH immunoreactivity. This was an interesting case because the patient was admitted due to pneumonia that may have been associated with her untreated and chronic hypercortisolism and a challenging case of ectopic ACTH syndrome due to conflicting results on the diagnostic exams.
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Goldberg AS, Stein R, Merritt NH, Inculet R, Van Uum S. A pediatric patient with Cushing syndrome caused by ectopic ACTH syndrome and concomitant pituitary incidentalomas. J Pediatr Endocrinol Metab 2014; 27:123-8. [PMID: 23945121 DOI: 10.1515/jpem-2013-0070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 07/16/2013] [Indexed: 11/15/2022]
Abstract
Ectopic ACTH syndrome is a rare but important cause of pediatric Cushing syndrome, for which management by a multidisciplinary team is required. Although diagnostic evaluation is similar to that in adults, the variation in epidemiology may sway investigations, leading to inappropriate and/or incomplete diagnostic interventions. We present a case of 15-year-old girl with symptoms of severe ACTH-dependent Cushing syndrome and two pituitary adenomas. The ectopic source of ACTH production was confirmed after petrosal venous sampling was performed. Diagnostics and perioperative management of a pulmonary carcinoid tumor producing ectopic ACTH is reviewed. In pediatric patients, as in adult patients, a pituitary lesion <6 mm on MRI is not sufficient confirmation of Cushing's disease, and appropriate diagnostic work-up should be performed to assess the source of the ACTH overproduction.
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Hunt BM, Horton MP, Vallières E. Bronchogenic carcinoid tumours that are 18F-fluorodeoxyglucose avid on positron emission tomography. Eur J Cardiothorac Surg 2013; 45:527-30. [PMID: 24047710 DOI: 10.1093/ejcts/ezt436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Bronchogenic carcinoid tumours are widely cited as non-fluorodeoxyglucose (FDG) avid. However, three case reports of FDG-avid bronchogenic carcinoid tumours have been published, leading to speculation as to which clinicopathological factors may be associated with increased activity on FDG-positron emission tomography. We reviewed a series of cases from our institution and compared them with the available reports in the literature, to attempt to identify the factors associated with FDG avidity in bronchogenic carcinoids. METHODS We performed a single-institution retrospective review. RESULTS One patient was identified at our institution who had a typical carcinoid tumour with a standardized uptake value (SUV) of 26, oncocytic features on histology and positive staining for glucose transporter 1 (GLUT1). Three additional patients were identified in the literature with typical bronchogenic carcinoids with SUVs of 39, 38 and 33. Two of these tumours stained positive for GLUT1, and the remaining patient was not tested. Two of these patients had oncocytic features on histology, and results on the remaining patient are not reported. Additionally, 4 patients at our institution were identified with bronchogenic carcinoids with average SUV of 2.6. All were GLUT1 negative, and none had oncocytic features. In the reported literature, excluding the four most FDG-avid tumours described above, atypical carcinoids had a higher mean SUV than typical carcinoids (5.7 vs 3.4, P = 0.02), but size was not correlated with SUV (r = 0.7, P = 0.3). CONCLUSIONS FDG uptake is commonly associated with worse prognosis in malignancy; however, bronchogenic carcinoids, particularly oncocytic typical carcinoids, are a possible source of extremely high SUVs on FDG-PET.
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Affiliation(s)
- Ben M Hunt
- Swedish Medical Center and Cancer Institute, Seattle, WA, USA
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Özkan ZG, Kuyumcu S, Balköse D, Ozkan B, Aksakal N, Yılmaz E, Sanlı Y, Türkmen C, Aral F, Adalet I. The value of somatostatin receptor imaging with In-111 Octreotide and/or Ga-68 DOTATATE in localizing Ectopic ACTH producing tumors. Mol Imaging Radionucl Ther 2013; 22:49-55. [PMID: 24003397 PMCID: PMC3759309 DOI: 10.4274/mirt.69775] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 06/19/2013] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the value of somatostatin receptor imaging (SRI) with In-111 octreotide and Ga-68 DOTATATE in localizing ectopic ACTH producing tumors. METHODS Nineteen patients who had In-111 octreotide somatostatin receptor scintigraphy (SRS) and/or Ga-68 DOTATATE PET-CT to localize ectopic ACTH producing tumors between the years 2000 and 2012 were included retrospectively in our study. The results of SRI were compared with clinical onset, radiological findings and surgical data of the patients. RESULTS Sixteen In-111 octreotide SRS and five Ga-68 DOTATATE PET-CT were performed in 19 patients. In eight out of 19 patients, ectopic ACTH secretion site could be detected. In five patients, SRS showed pathologic uptake. In four of these patients, surgery revealed pulmonary carcinoid tumors and in one patient pancreatic neuroendocrine tumor. In one patient, Ga-68 DOTATATE PET-CT revealed pathologic uptake in lung nodule which came out to be pulmonary carcinoid tumor. In another patient who had resection of metastases of atypical carcinoid tumor prior to scans, new metastatic foci were detected both with SRS and Ga-68 DOTATATE PET-CT imaging. In one patient, although SRS was negative, CT which was performed three years later showed a lung nodule diagnosed as pulmonary carcinoid tumor. In 11 patients, ectopic ACTH secretion site could not be detected. In 10 of those patients, scintigraphic and radiological imaging did not show any lesions and in one patient, Ga-68 DOTATATE PET-CT was false positive. CONCLUSION SRI has a complementary role with radiological imaging in localizing ectopic ACTH secretion sites. PET-CT imaging with Ga-68 peptide conjugates is a promising new modality for this indication. CONFLICT OF INTEREST None declared.
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Affiliation(s)
- Zeynep Gözde Özkan
- İstanbul University İstanbul Medical Faculty, Nuclear Medicine Department, İstanbul, Turkey
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Wahlberg J, Ekman B. Atypical or typical adrenocorticotropic hormone-producing pulmonary carcinoids and the usefulness of 11C-5-hydroxytryptophan positron emission tomography: two case reports. J Med Case Rep 2013; 7:80. [PMID: 23509950 PMCID: PMC3608321 DOI: 10.1186/1752-1947-7-80] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 02/10/2013] [Indexed: 11/10/2022] Open
Abstract
Introduction Pulmonary carcinoids associated with ectopic adrenocorticotropic hormone secretion have a good prognosis if histological examination shows typical pulmonary carcinoid and low proliferation, whereas a poor outcome is linked to atypical pulmonary carcinoid and high proliferation. Here we describe the diagnostic challenges to find the tumor in Cushing’s syndrome secondary to ectopic adrenocorticotropic hormone secretion in two cases with an atypical and a typical pulmonary carcinoid, respectively. Case presentation A 63-year-old Caucasian woman presented with aggressive clinical features related to Cushing’s syndrome, having very high levels of urinary cortisol and circulating adrenocorticotropic hormone and cortisol. Magnetic resonance imaging showed no pituitary tumor, and bilateral inferior petrosal sinus sampling revealed no central peripheral ratio of adrenocorticotropic hormone. Computed tomography and 111Indium-pentetreoide somatostatin receptor scintigraphy could not visualize any ectopic tumor. The patient was referred for an 11C-5-hydroxytryptophan positron emission tomography, and a small 8mm nodule in her left lung was found. The tumor was removed via a lateral thoracic incision and wedge excision. The histological examination showed an atypical carcinoid with Ki-67 index of 9 to 10%, and an additional lobectomy was performed. The second patient, a 22-year-old Caucasian man, also presented with aggressive Cushing’s syndrome, with very high urinary cortisol levels and increased circulating cortisol as well as adrenocorticotropic hormone levels. A magnetic resonance imaging scan of the pituitary showed no tumor, whereas a 12×9×14mm tumor was detected in the right lung on the primary computed tomography scan and no further investigation was performed. The tumor was removed via a lateral thoracic incision and wedge excision. A typical carcinoid with Ki-67 index of 1 to 2% was found and no further surgery was performed. After surgical removal, the biochemical disturbances resolved and significant clinical improvement were achieved in both patients after 24 months of follow up. Conclusions Diagnostic evaluation time is limited due to the aggressive course in ectopic adrenocorticotropic hormone-dependent Cushing’s syndrome. We suggest that 11C-5-hydroxytryptophan positron emission tomography could be considered early as a secondary diagnostic tool when primary computed tomography and/or magnetic resonance imaging scans fail to show any tumor.
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Affiliation(s)
- Jeanette Wahlberg
- Section of Endocrinology, Department of Medicine and Health Sciences, Faculty of Health, Sciences, Linköping University, Linköping, Sweden.
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Anaforoğlu I, Ersoy K, Aşık M, Karyağar S, Algün E. Diagnosis of an ectopic adrenocorticotropic hormonesecreting bronchial carcinoid by somatostatin receptor scintigraphy. Clinics (Sao Paulo) 2012; 67:973-5. [PMID: 22948470 PMCID: PMC3416908 DOI: 10.6061/clinics/2012(08)21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Inan Anaforoğlu
- Departments of Endocrinology and Metabolism, Trabzon Numune Education and Research Hospital, Trabzon, Turkey.
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Abstract
Cushing disease is caused by a corticotroph tumor of the pituitary gland. Patients with Cushing disease are usually treated with transsphenoidal surgery, as this approach leads to remission in 70-90% of cases and is associated with low morbidity when performed by experienced pituitary gland surgeons. Nonetheless, among patients in postoperative remission, the risk of recurrence of Cushing disease could reach 20-25% at 10 years after surgery. Patients with persistent or recurrent Cushing disease might, therefore, benefit from a second pituitary operation (which leads to remission in 50-70% of cases), radiation therapy to the pituitary gland or bilateral adrenalectomy. Remission after radiation therapy occurs in ∼85% of patients with Cushing disease after a considerable latency period. Interim medical therapy is generally advisable after patients receive radiation therapy because of the long latency period. Bilateral adrenalectomy might be considered in patients who do not improve following transsphenoidal surgery, particularly patients who are very ill and require rapid control of hypercortisolism, or those wishing to avoid the risk of hypopituitarism associated with radiation therapy. Adrenalectomized patients require lifelong adrenal hormone replacement and are at risk of Nelson syndrome. The development of medical therapies with improved efficacy might influence the management of this challenging condition.
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Affiliation(s)
- Nicholas A Tritos
- Neuroendocrine Unit, Zero Emerson Place, Suite 112, Massachusetts General Hospital, Boston, MA 02114, USA.
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Tani Y, Sugiyama T, Izumiyama H, Yoshimoto T, Yamada S, Hirata Y. Differential gene expression profiles of POMC-related enzymes, transcription factors and receptors between non-pituitary and pituitary ACTH-secreting tumors. Endocr J 2011; 58:297-303. [PMID: 21383526 DOI: 10.1507/endocrj.k10e-389] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The differential gene expression of proopiomelanocortin (POMC)-related processing enzymes, transcription factors, and receptors responsible for ACTH secretion between non-pituitary and pituitary ACTH-secreting tumors remains obscure. This study was attempted to determine the gene expression profiles of transcription factors (Tpit, NeuroD1 and IKZF1), proprotein convertase (PC) 1/3 and PC2, and several key receptors linked to ACTH secretion, including corticotrophin releasing hormone receptor (CRHR1), vasopressin receptor 1b (V1bR), somatostatin receptor (SSTR) subtype-2, -5 and dopamine receptor type 2 (D2R) in non-pituitary and pituitary ACTH-secreting tumors. Surgical tissue specimens from carcinoid tumors causing ectopic ACTH syndrome (EAS: n=4) and pituitary tumors causing Cushing's disease (CD: n=13), were subjected to real-time RT-PCR for measurements of each mRNA levels. POMC and CRHR1 mRNA levels in CD were far greater than those in EAS, whereas IKZF1, PC2, SSTR-2 and -5 mRNA levels in EAS were significantly greater than those in CD. NeuroD1, Tpit, PC1/3, V1bR and D2R mRNA levels were comparable between EAS and CD. In conclusion, differential gene expression profiles revealed more abundant mRNA expression in EAS than in CD of 1) IKZF1 with its potential implication of cell differentiation and hormone secretion, 2) PC2 with its possible enhanced processing activity of mature ACTH, and 3) SSTR-2 and -5 with their potential therapeutic application of more selective agonists in EAS patients.
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Affiliation(s)
- Yuji Tani
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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Doi M, Sugiyama T, Izumiyama H, Yoshimoto T, Hirata Y. Clinical features and management of ectopic ACTH syndrome at a single institute in Japan. Endocr J 2010; 57:1061-9. [PMID: 21076235 DOI: 10.1507/endocrj.k10e-265] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ectopic ACTH syndrome (EAS) is a diagnostic challenge because it is often indistinguishable from Cushing's disease. We describe our series of EAS patients referred to us during 1992-2009. Among 16 cases (9 females / 7 males), with mean age of 58.4 ± 19.0yr, the ectopic source was identified in ten (proven EAS), whereas unidentified in six (occult/unknown EAS). Their salient clinical manifestations included Cushingoid feature (88%), skin pigmentation (88%), profound hypokalemia (88%), hypertension (75%), diabetes/impaired glucose tolerance (75%), hyperlipidemia (69%), and severe infection (44%). Dynamic endocrine tests revealed markedly elevated plasma ACTH levels (211 ± 116pg/mL) and cortisol levels (60.9 ± 30.1µg/dL) which showed resistance to overnight high-dose (8mg) dexamethasone suppression test in 15 (94%) and unresponsiveness to CRH stimulation in 12 (75%). No ACTH gradient during inferior petrosal sampling was noted in 13 of 15 (87%). Imaging tests by CT/MRI identified the tumors in 8 of 16 (50%), in 4 of 11 (36%) and 4 of 6 (66.7%) octreotide-responders by somatostatin receptor scintigraphy, but in only one of 9 (11.1%) by FDG-PET scan. Six cases deceased, including small cell carcinoma (2) and adenocarcinoma (1) of lung, neuroendocrine carcinoma of pancreas (1) and stomach (1), and olfactory neuroblastoma (1), whereas 4 cases survived after removal of the tumors, including bronchial carcinoid tumor (3) and thymic hyperplasia (1). Six occult/unknown EAS patients survived for 67.5 months after medical treatment with metyrapone to control hypercortisolism. Thus, various endocrine tests combined with imaging studies are required to correctly localize the tumors. Control of hypercortisolemia by metyrapone, even if tumor is unrecognized, is critical for better prognosis, and the long-term follow-up by repeated endocrine and imaging tests is mandatory.
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Affiliation(s)
- Masaru Doi
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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