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Everaert K, Holm-Larsen T, Bou Kheir G, Rottey S, Weiss JP, Vande Walle J, Kabarriti AE, Dossche L, Hervé F, Spinoit AF, Nørgaard JP, Juul KV. Potential clinical applications of current and future oral forms of desmopressin (Review). Exp Ther Med 2024; 28:303. [PMID: 38873038 PMCID: PMC11170333 DOI: 10.3892/etm.2024.12592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 03/06/2024] [Indexed: 06/15/2024] Open
Abstract
Desmopressin is a synthetic analogue of vasopressin and a selective vasopressin receptor 2 agonist. It was first synthesised in 1967 and utilised for its antidiuretic properties. It is also used in bleeding disorders to enhance clotting. Other potential uses of the drug have been reported. The present review aims to provide a broad overview of the literature on potential further uses of oral forms of desmopressin. Key therapeutic areas of interest were identified based on known physiological activities/targets of desmopressin or reports of an effect of desmopressin in the literature. The feasibility of adequate dosing with oral forms of the drug was also considered. Systematic literature searches were carried out using the silvi.ai software for the identified areas, and summaries of available papers were included in tables and discussed. The results of the searches showed that desmopressin has been investigated for its efficacy in a number of areas, including bleeding control, renal colic, the central nervous system and oncology. Evidence suggests that oral desmopressin may have the potential to be of clinical benefit for renal colic and bleeding control in particular. However, further research is needed to clarify its effect in these areas, including randomised controlled studies and studies specifically of oral formulations (and doses). Further research may also yield findings for cancer, cognition and overactive bladder.
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Affiliation(s)
- Karel Everaert
- Faculty of Medicine and Health Sciences, Department of Human Structure and Repair, Ghent University Hospital, 9000 Ghent, Belgium
| | - Tove Holm-Larsen
- Faculty of Medicine and Health Sciences, Department of Human Structure and Repair, Ghent University Hospital, 9000 Ghent, Belgium
| | - George Bou Kheir
- Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Sylvie Rottey
- Drug Research Unit and Department of Medical Oncology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Jeffrey P. Weiss
- Department of Urology, State University of New York Downstate Health Sciences University, New York City, NY 11203, USA
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Abdo E. Kabarriti
- Department of Urology, State University of New York Downstate Health Sciences University, New York City, NY 11203, USA
| | - Lien Dossche
- Faculty of Medicine and Health Sciences, Department of Internal Medicine and Pediatrics, Ghent University Hospital, 9000 Ghent, Belgium
| | - François Hervé
- Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Anne-Françoise Spinoit
- Department of Pediatric & Reconstructive Urology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Jens Peter Nørgaard
- Research & Development, Ferring Pharmaceuticals A/S, Ferring International PharmaScience Center, 2770 Copenhagen, Denmark
| | - Kristian Vinter Juul
- Research & Development, Ferring Pharmaceuticals A/S, Ferring International PharmaScience Center, 2770 Copenhagen, Denmark
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Vassiliadi DA, Delivanis DA, Papalou O, Tsagarakis S. Approach to the Patient With Bilateral Adrenal Masses. J Clin Endocrinol Metab 2024; 109:2136-2148. [PMID: 38478374 DOI: 10.1210/clinem/dgae164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Indexed: 07/13/2024]
Abstract
Bilateral adrenal masses, increasingly encountered in clinical practice, manifest across diverse contexts, including incidental discovery, malignancy staging, and targeted imaging after hormonal diagnosis of adrenal disorders. The spectrum encompasses various pathologies, such as cortical adenomas, macronodular adrenal disease, pheochromocytomas, myelolipomas, infiltrative disorders, and primary and secondary malignancies. Notably, not all masses in both adrenal glands necessarily share the same etiology, often exhibiting diverse causes. Recently, the European Society of Endocrinology and the European Network for the Study of Adrenal Tumors updated guidelines, introduced a 4-option schema based on imaging, aiding in targeted hormonal testing and management. This "Approach to the Patient" review delves into the latest advancements in imaging, biochemical, and genetic approaches for the diagnostic and management nuances of bilateral adrenal masses. It provides insights and a contemporary framework for navigating the complexities associated with this clinical entity.
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Affiliation(s)
- Dimitra Argyro Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, European Reference Network on Rare Endocrine Conditions (ENDO-ERN), Evangelismos Hospital, 10676, Athens, Greece
| | - Danae Anastasia Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Olga Papalou
- Department of Endocrinology, Diabetes and Metabolism, European Reference Network on Rare Endocrine Conditions (ENDO-ERN), Evangelismos Hospital, 10676, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, European Reference Network on Rare Endocrine Conditions (ENDO-ERN), Evangelismos Hospital, 10676, Athens, Greece
- Private Practice, 10675, Athens, Greece
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Hinojosa-Amaya JM, González-Colmenero FD, Alvarez-Villalobos NA, Salcido-Montenegro A, Quintanilla-Sánchez C, Moreno-Peña PJ, Manzanares-Gallegos DM, Gutiérrez-Dávila LF, Castillo-Morales PL, García-Campa M, González-González JG, Varlamov E, Rodriguez-Gutiérrez R, Fleseriu M. The conundrum of differentiating Cushing's syndrome from non-neoplastic hypercortisolism: a systematic review and meta-analysis. Pituitary 2024:10.1007/s11102-024-01408-w. [PMID: 38888685 DOI: 10.1007/s11102-024-01408-w] [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: 05/22/2024] [Indexed: 06/20/2024]
Abstract
CONTEXT Once hypercortisolemia is confirmed, differential diagnosis between Cushing's syndrome (CS) due to neoplastic endogenous hypercortisolism and non-neoplastic hypercortisolism (NNH, pseudo-Cushing's syndrome) is crucial. Due to worldwide corticotropin-releasing hormone (CRH) unavailability, accuracy of alternative tests to dexamethasone (Dex)-CRH, is clearly needed. OBJECTIVE Assess the diagnostic accuracy of Dex-CRH test, desmopressin stimulation test, midnight serum cortisol (MSC), and late-night salivary cortisol (LNSC) levels to distinguish CS from NNH. METHODS Articles through March 2022 were identified from Scopus, Web of Science, MEDLINE, EMBASE, and PubMed. All steps through the systematic review were performed independently and in duplicate and strictly adhered to the updated PRISMA-DTA checklist. DATA SYNTHESIS A total of 24 articles (1900 patients) were included. Dex-CRH had a pooled sensitivity and specificity of 91% (95%CI 87-94%; I2 0%) and 82% (73-88%; I2 50%), desmopressin test 86% (81-90%; I2 28%) and 90% (84-94%; I2 15%), MSC 91% (85-94%; I2 66%) and 81% (70-89%; I2 71%), and LNSC 80% (67-89%; I2 57%) and 90% (84-93%; I2 21%), respectively. Summary receiver operating characteristics areas under the curve were Dex-CRH 0.949, desmopressin test 0.936, MSC 0.942, and LNSC 0.950 without visual or statistical significance. The overall risk of studies bias was moderate. CONCLUSION Dex-CRH, the desmopressin stimulation test, and MSC have similar diagnostic accuracy, with Dex-CRH and MSC having slightly higher sensitivity, and the desmopressin test being more specific. LNSC was the least accurate, probably due to high heterogeneity, intrinsic variability, different assays, and lack of consistent reported cutoffs. When facing this challenging differential diagnosis, the results presented here should increase clinicians' confidence when deciding which test to perform.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Pituitary Clinic, Endocrinology Division, Department of Medicine, Hospital Universitario "Dr. José E. González" Universidad Autónoma de Nuevo León, (Gonzalitos) S/N, Mitras Centro, 64460, Monterrey, Mexico
| | - Fernando Díaz González-Colmenero
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | | | - Alejandro Salcido-Montenegro
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | - Carolina Quintanilla-Sánchez
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | - Pablo José Moreno-Peña
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | - Dulce María Manzanares-Gallegos
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | - Luis Fernando Gutiérrez-Dávila
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | - Patricia Lizeth Castillo-Morales
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | - Mariano García-Campa
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico
| | - José Gerardo González-González
- Pituitary Clinic, Endocrinology Division, Department of Medicine, Hospital Universitario "Dr. José E. González" Universidad Autónoma de Nuevo León, (Gonzalitos) S/N, Mitras Centro, 64460, Monterrey, Mexico
| | - Elena Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - René Rodriguez-Gutiérrez
- Pituitary Clinic, Endocrinology Division, Department of Medicine, Hospital Universitario "Dr. José E. González" Universidad Autónoma de Nuevo León, (Gonzalitos) S/N, Mitras Centro, 64460, Monterrey, Mexico.
- Advanced Analysis Center of Scientific Information, Universidad Autónoma de Nuevo León School of Medicine, 64460, Monterrey, Mexico.
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
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Attri B, Goyal A, Kalaivani M, Kandasamy D, Gupta Y, Agarwal S, Shamim SA, Damle N, Sharma MC, Jyotsna VP, Suri A, Tandon N. Utility of Simple and Non-Invasive Strategies Alternative to Inferior Petrosal Sinus Sampling and Peripheral CRH Stimulation in Differential Diagnosis of ACTH-Dependent Cushing Syndrome. Horm Metab Res 2024. [PMID: 38154481 DOI: 10.1055/a-2236-0864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
We aimed to evaluate the utility of simple, cost-effective, and non-invasive strategies alternative to BIPSS and peripheral CRH stimulation in differential diagnosis of ACTH-dependent CS. First, we performed ROC analysis to evaluate the performance of various tests for differential diagnosis of ACTH-dependent CS in our cohort (CD, n=76 and EAS, n=23) and derived their optimal cut-offs. Subsequently, combining various demographic (gender), clinical (hypokalemia), biochemical (plasma ACTH, HDDST, peripheral CRH stimulation) and imaging (MRI pituitary) parameters, we derived non-invasive models with 100% PPV for CD. Patients with pituitary macroadenoma (n=14) were excluded from the analysis involving non-invasive models. Relative percent ACTH (AUC: 0.933) and cortisol (AUC: 0.975) increase on peripheral CRH stimulation demonstrated excellent accuracy in discriminating CD from EAS. Best cut-offs for CD were plasma ACTH<97.3 pg/ml, HDDST≥57% cortisol suppression, CRH stimulation≥77% ACTH increase and≥11% cortisol increase. We derived six models that provided 100% PPV for CD and precluded the need for BIPPS in 35/85 (41.2%) patients with ACTH-dependent CS and no macroadenoma (in whom BIPSS would have otherwise been recommended). The first three models included basic parameters and avoided both peripheral CRH stimulation and BIPSS in 19 (22.4%) patients, while the next three models included peripheral CRH stimulation and avoided BIPSS in another 16 (18.8%) patients. Using simple and non-invasive alternative strategies, BIPSS can be avoided in 41% and peripheral CRH stimulation in 22% of patients with ACTH-dependent CS and no macroadenoma; such patients can be directly referred for a pituitary surgery.
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Affiliation(s)
- Bhawna Attri
- Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Alpesh Goyal
- Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Yashdeep Gupta
- Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Shipra Agarwal
- Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Shamim A Shamim
- Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nishikant Damle
- Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Viveka P Jyotsna
- Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Giampietro RR, Cabral MVG, Pereira EG, Machado MC, Vilar L, Nunes-Nogueira VDS. Accuracy of the 10 μg desmopressin test for differential diagnosis of Cushing syndrome: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1332120. [PMID: 38352712 PMCID: PMC10861662 DOI: 10.3389/fendo.2024.1332120] [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: 11/02/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
We evaluated the accuracy of the 10 μg desmopressin test in differentiating Cushing disease (CD) from non-neoplastic hypercortisolism (NNH) and ectopic ACTH syndrome (EAS). A systematic review of studies on diagnostic test accuracy in patients with CD, NNH, or EAS subjected to the desmopressin test obtained from LILACS, PubMed, EMBASE, and CENTRAL databases was performed. Two reviewers independently selected the studies, assessed the risk of bias, and extracted the data. Hierarchical and bivariate models on Stata software were used for meta-analytical summaries. The certainty of evidence was measured using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation Working Group) approach. In total, 14 studies were included: 3 studies on differentiated CD versus NNH and 11 studies on differentiated CD versus EAS. Considering ΔACTH in 8 studies involving 429 patients, the pooled sensitivity for distinguishing CD from EAS was 0.85 (95% confidence interval [CI]: 0.80-0.89, I2 = 17.6%) and specificity was 0.64 (95% CI: 0.49-0.76, I2 = 9.46%). Regarding Δcortisol in 6 studies involving 233 participants, the sensitivity for distinguishing CD from EAS was 0.81 (95% CI: 0.74-0.87, I2 = 7.98%) and specificity was 0.80 (95% CI: 0.61-0.91, I2 = 12.89%). The sensitivity and specificity of the combination of ΔACTH > 35% and Δcortisol > 20% in 5 studies involving 511 participants were 0.88 (95% CI: 0.79-0.93, I2 = 35%) and 0.74 (95% CI: 0.55-0.87, I2 = 27%), respectively. The pooled sensitivity for distinguishing CD from NNH in 3 studies involving 170 participants was 0.88 (95% CI: 0.79-0.93) and the specificity was 0.94 (95% CI: 0.86-0.97). Based on the desmopressin test for differentiating CD from EAS, considering ΔACTH, Δcortisol, or both percent increments, 15%, 19%, or 20% of patients with CD, respectively, would be incorrectly classified as having EAS. For CD versus NNH, 11% of patients with CD would be falsely diagnosed as having NNH, whereas 7% of patients with NNH would be falsely diagnosed as having CD. However, in all hierarchical plots, the prediction intervals were considerably wider than the confidence intervals. This indicates low confidence in the estimated accuracy, and the true accuracy is likely to be different. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=85634, identifier CRD42018085634; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=68317, identifier CRD42017068317.
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Affiliation(s)
- Rodrigo Rosa Giampietro
- Department of Internal Medicine, Sao Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | | | - Elizandra Gomes Pereira
- Department of Internal Medicine, Sao Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | - Marcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
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Elenius H, McGlotten R, Nieman LK. Ovine CRH Stimulation and 8 mg Dexamethasone Suppression Tests in 323 Patients With ACTH-Dependent Cushing's Syndrome. J Clin Endocrinol Metab 2023; 109:e182-e189. [PMID: 37531629 PMCID: PMC11032243 DOI: 10.1210/clinem/dgad454] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/07/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Determining the etiology of adrenocorticotropin (ACTH)-dependent Cushing's syndrome (CS) is often difficult. The gold standard test, inferior petrosal sinus sampling (IPSS), is expensive and not widely available. OBJECTIVE Evaluate the performance of the corticotropin-releasing hormone stimulation test (CRH-ST) and the 8 mg high-dose dexamethasone suppression test (HDDST) in distinguishing Cushing's disease (CD) from ectopic ACTH syndrome (EAS). METHODS Retrospective review in a tertiary referral center. A total of 323 patients with CD or EAS (n = 78) confirmed by pathology or biochemical cure (n = 15) in 96% underwent CRH-ST and HDDST performed between 1986 and 2019. We calculated test sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value, and diagnostic accuracy (DA) for the diagnosis of CD, and determined optimal response criteria for each test, alone and in combination. RESULTS The CRH-ST performed better than the HDDST (DA 91%, 95% CI 87-94% vs 75%, 95% CI 69-79%). Optimal response criteria were a ≥40% increase of ACTH and/or cortisol during the CRH test and a ≥69% suppression of cortisol during the HDDST. A ≥40% cortisol increase during the CRH test was the most specific measure, PPV 99%. Seventy-four percent of subjects had concordant positive CRH test and HDDST results, yielding Se 93%, Sp 98%, DA 95%, and PPV 99%, with a pretest likelihood of 85%. A proposed algorithm diagnosed 64% of patients with CD with near perfect accuracy (99%), obviating the need for IPSS. CONCLUSION CRH is a valuable tool to correctly diagnose the etiology of ACTH-dependent CS. Its current worldwide unavailability impedes optimal management of these patients.
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Affiliation(s)
- Henrik Elenius
- Diabetes and Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, Bethesda, MD 20892, USA
| | - Raven McGlotten
- Diabetes and Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, Bethesda, MD 20892, USA
| | - Lynnette K Nieman
- Diabetes and Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, Bethesda, MD 20892, USA
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Mondin A, Barbot M, Voltan G, Tizianel I, Vedolin CK, Mazzeo P, Lazzara M, Boscaro M, Scaroni C, Ceccato F. Second-line tests in the differential diagnosis of neoplastic and non-neoplastic hypercortisolism: a systematic review and meta-analysis. J Endocrinol Invest 2023; 46:1947-1959. [PMID: 37079177 PMCID: PMC10514124 DOI: 10.1007/s40618-023-02099-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/13/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE The clinical and hormonal overlap between neoplastic (CS) and non-neoplastic (NNH/pCS) hypercortisolism is a challenge. Various dynamic tests have been proposed to allow an early discrimination between these conditions, but to date there is no agreement on which of them should be used. AIM To provide an overview of the available tests and to obtain a quantitative synthesis of their diagnostic performance in discriminating NNH/pCS from CS. METHODS The included articles, published between 1990 and 2022, applied one or more second line tests to differentiate NNH/pCS from CS patients. For the NNH/pCS group, we admitted the inclusion of patients presenting clinical features and/or biochemical findings suggestive of hypercortisolism despite apparent lack of a pCS-related condition. RESULTS The electronic search identified 339 articles. After references analysis and study selection, we identified 9 studies on combined dexamethasone-corticotropin releasing hormone (Dex-CRH) test, 4 on Desmopressin test and 3 on CRH test; no study on Dex-Desmopressin met the inclusion criteria. Dex-CRH test provided the highest sensitivity (97%, 95 CI% [88%; 99%]). CRH tests showed excellent specificity (99%, 95% CI [0%; 100%]), with low sensitivity. Although metaregression analysis based on diagnostic odds ratio failed to provide a gold standard, CRH test (64.77, 95% CI [0.15; 27,174.73]) seemed to lack in performance compared to the others (Dex-CRH 138.83, 95% CI [49.38; 390.32] and Desmopressin 110.44, 95% CI [32.13; 379.63]). DISCUSSION Both Dex-CRH and Desmopressin tests can be valid tools in helping discrimination between NNH/pCS and CS. Further studies are needed on this topic, possibly focusing on mild Cushing's Disease and well-characterized NNH/pCS patients. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022359774 , identifier CRD42022359774.
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Affiliation(s)
- A Mondin
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
- Department of Neuroscience DNS, University of Padova, Padua, Italy
| | - G Voltan
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - I Tizianel
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - C K Vedolin
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - P Mazzeo
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - M Lazzara
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - M Boscaro
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy.
- Department of Neuroscience DNS, University of Padova, Padua, Italy.
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de Almeida TS, Rodrigues TDC, Costenaro F, Scaffaro LA, Farenzena M, Gastaldo F, Czepielewski MA. Enhancing Cushing's disease diagnosis: exploring the impact of desmopressin on ACTH gradient during BIPSS. Front Endocrinol (Lausanne) 2023; 14:1224001. [PMID: 37600715 PMCID: PMC10436086 DOI: 10.3389/fendo.2023.1224001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction The differential diagnosis between Cushing's disease (CD) and ectopic ACTH syndrome (EAS) is complex, and bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold-standard test. However, BIPSS with corticotropin-releasing hormone (CRH) stimulation is rarely available. Objective This retrospective cohort study aimed to assess the accuracy of the inferior petrosal sinus to peripheral ACTH gradient (IPS:P) before and after desmopressin stimulation for the differential diagnosis of ACTH-dependent Cushing's syndrome (CS), applying different cutoff values. Methods A total of 50 patients (48 with CD and 2 with EAS) who underwent BIPSS were included in this study. The sensitivity and specificity of IPS:P in BIPSS before and after desmopressin stimulation were evaluated. Various cutoff values for IPS:P were examined to determine their diagnostic accuracy. Results Using the traditional IPS:P cutoff, the sensitivity was 85.1% before stimulation, 89.6% after stimulation, and a combined sensitivity of 91.7%. Applying cutoff values of IPS:P >1.4 before and >2.8 after stimulation, the sensitivity was 87.2% and 89.6%, respectively, with a combined sensitivity of 91.7%. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values of 1.2 before stimulation and 1.57 after stimulation, resulting in a sensitivity of 93.6% and 93.8%, respectively, with a combined sensitivity of 97.9%. Specificity remained at 100% throughout all analyses. Among the 43 patients who responded positively to stimulation, 42 (97.7%) did so within the first three minutes, and all 43 (100%) did so within the first five minutes. None of the assessed clinical variables predicted the ACTH response to stimulation in BIPSS with statistical significance. Discussion ACTH stimulation with desmopressin during BIPSS improves the accuracy of IPS:P, making it a valuable tool for investigating ACTH-dependent Cushing's syndrome. Considering the low risk of complications, we recommend the use of desmopressin stimulation during BIPSS for the differential diagnosis of ACTH-dependent CS.
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Affiliation(s)
- Tobias Skrebsky de Almeida
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Ticiana da Costa Rodrigues
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fabíola Costenaro
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Leandro Armani Scaffaro
- Radiology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Maurício Farenzena
- Radiology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fernando Gastaldo
- Department of Radiology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mauro Antônio Czepielewski
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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9
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Wright K, van Rossum EFC, Zan E, Werner N, Harris A, Feelders RA, Agrawal N. Emerging diagnostic methods and imaging modalities in cushing's syndrome. Front Endocrinol (Lausanne) 2023; 14:1230447. [PMID: 37560300 PMCID: PMC10407789 DOI: 10.3389/fendo.2023.1230447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/05/2023] [Indexed: 08/11/2023] Open
Abstract
Endogenous Cushing's syndrome (CS) is a rare disease characterized by prolonged glucocorticoid excess. Timely diagnosis is critical to allow prompt treatment and limit long-term disease morbidity and risk for mortality. Traditional biochemical diagnostic modalities each have limitations and sensitivities and specificities that vary significantly with diagnostic cutoff values. Biochemical evaluation is particularly complex in patients whose hypercortisolemia fluctuates daily, often requiring repetition of tests to confirm or exclude disease, and when delineating CS from physiologic, nonneoplastic states of hypercortisolism. Lastly, traditional pituitary MRI may be negative in up to 60% of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas (termed "Cushing's disease" [CD]) whereas false positive pituitary MRI findings may exist in patients with ectopic ACTH secretion. Thus, differentiating CD from ectopic ACTH secretion may necessitate dynamic testing or even invasive procedures such as bilateral inferior petrosal sinus sampling. Newer methods may relieve some of the diagnostic uncertainty in CS, providing a more definitive diagnosis prior to subjecting patients to additional imaging or invasive procedures. For example, a novel method of cortisol measurement in patients with CS is scalp hair analysis, a non-invasive method yielding cortisol and cortisone values representing long-term glucocorticoid exposure of the past months. Hair cortisol and cortisone have both shown to differentiate between CS patients and controls with a high sensitivity and specificity. Moreover, advances in imaging techniques may enhance detection of ACTH-secreting pituitary adenomas. While conventional pituitary MRI may fail to identify microadenomas in patients with CD, high-resolution 3T-MRI with 3D-spoiled gradient-echo sequence has thinner sections and superior soft-tissue contrast that can detect adenomas as small as 2 mm. Similarly, functional imaging may improve the identification of ACTH-secreting adenomas noninvasively; Gallium-68-tagged corticotropin-releasing hormone (CRH) combined with PET-CT can be used to detect CRH receptors, which are upregulated on corticotroph adenomas. This technique can delineate functionality of adenomas in patients with CD from patients with ectopic ACTH secretion and false positive pituitary lesions on MRI. Here, we review emerging methods and imaging modalities for the diagnosis of CS, discussing their diagnostic accuracy, strengths and limitations, and applicability to clinical practice.
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Affiliation(s)
- Kyla Wright
- New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Elisabeth F. C. van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical College (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Elcin Zan
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Nicole Werner
- New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Alan Harris
- Department of Medicine, Division of Endocrinology, New York University (NYU) Langone Medical Center, New York, NY, United States
| | - Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical College (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nidhi Agrawal
- Department of Medicine, Division of Endocrinology, New York University (NYU) Langone Medical Center, New York, NY, United States
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10
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Findling JW, Raff H. Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome. J Endocr Soc 2023; 7:bvad087. [PMID: 37440963 PMCID: PMC10334485 DOI: 10.1210/jendso/bvad087] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 07/15/2023] Open
Abstract
The evaluation of suspected hypercortisolism is one of the most challenging problems in medicine. The signs and symptoms described by Dr Harvey Cushing are common and often create diagnostic confusion to even experienced endocrinologists. Cushing syndrome is classically defined as neoplastic hypercortisolism resulting from an ACTH-secreting tumor or from autonomous secretion of excess cortisol associated with benign or malignant adrenal neoplasia. The increasing recognition of the negative cardiometabolic effects of mild cortisol excess without overt physical signs of Cushing syndrome has led to more screening for endogenous hypercortisolism in patients with adrenal nodular disease, osteoporosis, and the metabolic syndrome. However, sustained or intermittent activation of the dynamic hypothalamic-pituitary-adrenal axis caused by chemical (alcohol), inflammatory (chronic kidney disease), psychologic (major depression), and physical (starvation/chronic intense exercise) stimuli can result in clinical and/or biochemical features indistinguishable from neoplastic hypercortisolism. Nonneoplastic hypercortisolism (formerly known as pseudo-Cushing syndrome) has been recognized for more than 50 years and often causes diagnostic uncertainty. This expert consultation describes two patients with features of Cushing syndrome who were referred for inferior petrosal sinus sampling for the differential diagnosis of ACTH-dependent hypercortisolism. Both patients were discovered to have nonneoplastic hypercortisolism: one from a covert alcohol use disorder and the other to chronic kidney disease. This consultation emphasizes the value of a good history and physical examination, appropriate laboratory testing, and the desmopressin acetate stimulation test to aid in distinguishing neoplastic from nonneoplastic hypercortisolism.
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Affiliation(s)
- James W Findling
- Department of Medicine (Endocrinology and Molecular Medicine), Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Hershel Raff
- Correspondence: Hershel Raff, PhD, Endocrinology Research HRC4150, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
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11
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Simonds WF. Expressions of Cushing's syndrome in multiple endocrine neoplasia type 1. Front Endocrinol (Lausanne) 2023; 14:1183297. [PMID: 37409236 PMCID: PMC10319112 DOI: 10.3389/fendo.2023.1183297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Cushing's syndrome (CS) resulting from endogenous hypercortisolism can be sporadic or can occur in the context of familial disease because of pituitary or extra-pituitary neuroendocrine tumors. Multiple endocrine neoplasia type 1 (MEN1) is unique among familial endocrine tumor syndromes because hypercortisolism in this context can result from pituitary, adrenal, or thymic neuroendocrine tumors and can therefore reflect either ACTH-dependent or ACTH-independent pathophysiologies. The prominent expressions of MEN1 include primary hyperparathyroidism, tumors of the anterior pituitary, gastroenteropancreatic neuroendocrine tumors, and bronchial carcinoid tumors along with several common non-endocrine manifestations such as cutaneous angiofibromas and leiomyomas. Pituitary tumors are present in about 40% of MEN1 patients, and up to 10% of such tumors secrete ACTH that can result in Cushing's disease. Adrenocortical neoplasms occur frequently in MEN1. Although such adrenal tumors are mostly clinically silent, this category can include benign or malignant tumors causing hypercortisolism and CS. Ectopic tumoral ACTH secretion has also been observed in MEN1, almost exclusively originating from thymic neuroendocrine tumors. The range of clinical presentations, etiologies, and diagnostic challenges of CS in MEN1 are reviewed herein with an emphasis on the medical literature since 1997, when the MEN1 gene was identified.
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12
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Surani A, Carroll TB, Javorsky BR, Raff H, Findling JW. Alcohol-induced Cushing syndrome: report of eight cases and review of the literature. Front Endocrinol (Lausanne) 2023; 14:1199091. [PMID: 37409223 PMCID: PMC10319132 DOI: 10.3389/fendo.2023.1199091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Introduction Alcohol-induced hypercortisolism (AIH) is underrecognized and may masquerade as neoplastic hypercortisolism [Cushing syndrome (CS)] obscuring its diagnosis. Objective and methods In order to characterize AIH, we performed a chart review of eight patients (4 males and 4 females; 2014-2022) referred for evaluation and treatment of neoplastic hypercortisolism - six for inferior petrosal sinus sampling, one due to persistent CS after unilateral adrenalectomy, and one for pituitary surgery for Cushing disease (CD). Five underwent dDAVP stimulation testing. Results All eight patients had clinical features of hypercortisolism and plasma ACTH levels within or above the reference interval confirming hypothalamic-pituitary mediation. All had abnormal low-dose dexamethasone suppression test and increased late-night salivary cortisol. Only one had increased urine cortisol excretion. In contrast to CD, the 5 patients tested had blunted or absent ACTH and cortisol responses to desmopressin. Two had adrenal nodules and one had abnormal pituitary imaging. Most patients underreported their alcohol consumption and one denied alcohol use. Elevated blood phosphatidyl ethanol (PEth) was required in one patient to confirm excessive alcohol use. All patients had elevations of liver function tests (LFTs) with AST>ALT. Conclusion AIH is an under-appreciated, reversible cause of non-neoplastic hypercortisolism that is indistinguishable from neoplastic CS. Incidental pituitary and adrenal imaging abnormalities as well as under-reporting of alcohol consumption further confound the diagnosis. Measurement of PEth helps to confirm an alcohol use disorder. Elevations of LFTs (AST>ALT) and subnormal ACTH and cortisol responses to dDAVP help to distinguish AIH from neoplastic hypercortisolism.
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Affiliation(s)
- Asif Surani
- Departments of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ty B. Carroll
- Departments of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Bradley R. Javorsky
- Departments of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine. Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States
| | - Hershel Raff
- Departments of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
- Departments of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
- Departments of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States
| | - James W. Findling
- Departments of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
- Departments of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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13
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Asuzu DT, Bhatt S, Nwokoye D, Hayes C, Cortes M, McGlotten R, Keil M, Tatsi C, Nieman L, Chittiboina P. Cortisol and ACTH Measurements at Extubation From Pituitary Surgery Predicts Hypothalamic-Pituitary-Adrenal Axis Function. J Endocr Soc 2023; 7:bvad025. [PMID: 36846212 PMCID: PMC9954986 DOI: 10.1210/jendso/bvad025] [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] [Received: 12/08/2022] [Indexed: 02/09/2023] Open
Abstract
Context Early prediction of hypothalamic-pituitary-adrenal (HPA) axis function following transsphenoidal surgery (TSS) can improve patient safety and reduce costs. Objective Systematic measurement of ACTH and cortisol at extubation following anesthesia to predict remission from Cushing's disease (CD) and HPA axis preservation following non-CD surgery. Design Retrospective analysis of clinical data between August 2015 and May 2022. Setting Referral center. Patients Consecutive patients (n = 129) undergoing TSS who had perioperative ACTH and cortisol measurements. Interventions ACTH and cortisol measurement at extubation. Further serial 6-hourly measurements in CD patients. Main outcome measures Prediction of future HPA axis status based on ACTH/cortisol at extubation. Results ACTH and cortisol increased sharply in all patients at extubation. CD patients (n = 101) had lower ACTH values than non-CD patients (110.1 vs 293.1 pg/mL; P < 0.01). In non-CD patients, lower plasma ACTH at extubation predicted the need for eventual corticosteroid replacement (105.8 vs 449.1 pg/mL, P < 0.01). In CD patients, the peak post-extubation cortisol at 6 hours was a robust predictor for nonremission (60.7 vs 219.2 µg/dL, P = 0.03). However, normalized early postoperative value (NEPV; the post-extubation values minus the peak preoperative CRH or desmopressin test values) of cortisol reliably distinguished nonremission earlier, at the time of extubation (-6.1 vs 5.9, P = 0.01), and later. Conclusions We found that at extubation following TSS, ACTH can predict the need for eventual steroid replacement in non-Cushing's patients. In patients with CD, we found a robust prediction of nonremission with NEPV cortisol at extubation and later.
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Affiliation(s)
- David T Asuzu
- Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA,Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA,Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Shyama Bhatt
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | - Diana Nwokoye
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | - Christina Hayes
- Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | - Michaela Cortes
- Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | - Raven McGlotten
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Meg Keil
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Christina Tatsi
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Lynnette Nieman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Prashant Chittiboina
- Correspondence: Prashant Chittiboina, MD, MPH. Tenure Track Investigator, Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, National Institutes of Health. 10 Center Dr, Rm 3D20, Bethesda, MD 20892-1414, USA.
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14
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Ceccato F, Barbot M, Mondin A, Boscaro M, Fleseriu M, Scaroni C. Dynamic testing for differential diagnosis of ACTH-dependent Cushing Syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab 2022; 108:e178-e188. [PMID: 36453141 DOI: 10.1210/clinem/dgac686] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Diagnostic accuracy of testing currently used for the differential diagnosis of Cushing's disease (CD) vs ectopic -ACTH secretion (EAS) is difficult to interpret. The present study aimed to identify and evaluate the diagnostic accuracy of corticotropin-releasing hormone (CRH) test, desmopressin test, and high-dose dexamethasone suppression test (HDDST) when used to establish a CD or EAS diagnosis. DESIGN This study is a systematic review of the literature and meta-analysis. METHODS MEDLINE, OVID, and Web of Science databases were searched for articles published between the years 1990-2021. Articles included described at least one test(s) (CRH, desmopressin, or HDDST) and the diagnostic reference standard(s) (histopathology, petrosal sinus sampling, surgical remission, imaging, and long-term follow-up) used to establish a CD or EAS diagnosis. RESULTS Sixty-two studies were included: 43 reported the use of HDDST, 32 CRH test, and 21 desmopressin test. CRH test was found to have the highest sensitivity in detecting CD (ACTH 86.9%, 95% confidence interval [CI] 82.1-90.6, cortisol 86.2%, 95%CI 78.3-91.5) and the highest specificity in detecting EAS (ACTH 93.9%, 95%CI 87-98.3, cortisol 89.4%, 95%CI 82.8-93.7). This resulted in a high diagnostic odds ratio (58, 95%CI 43.25-77.47), large area under the curve, and a receiver-operating characteristic (ROC) of 0.934. The diagnostic accuracy of HDDST and desmopressin test(s) was lower than that of the CRH test. CONCLUSION The meta-analysis indicates that a patient with a positive ACTH response after a CRH test is highly likely to have CD. Further studies analysing role of dynamic testing in addition to imaging are needed.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Alessandro Mondin
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Maria Fleseriu
- Oregon Health & Science University, Pituitary Center, Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition and Department of Neurological Surgery, Portland, USA
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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15
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Castinetti F, Lacroix A. Is Desmopressin Useful in the Evaluation of Cushing Syndrome? J Clin Endocrinol Metab 2022; 107:e4295-e4301. [PMID: 36103267 DOI: 10.1210/clinem/dgac533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Indexed: 02/13/2023]
Abstract
The desmopressin test was first described 30 years ago. Based on the differential secretagogue properties of desmopressin on adrenocorticotropin (ACTH) release between normal and corticotroph tumor cells, this test was intended to facilitate the diagnosis of Cushing syndrome (CS). The distinct expression of the various arginine vasopressin receptors between normal pituitary, corticotroph tumors, or neuroendocrine tumors cells secreting ACTH ectopically suggested that this test could facilitate the etiological diagnosis of ACTH-dependent CS. In this review, we analyze the merits and pitfalls of desmopressin use in the diagnostic procedures of CS. Desmopressin response is not able to completely differentiate the various etiologies of CS; its wider availability has allowed its use for inferior petrosal sinus sampling confirmation of a pituitary source of ACTH excess. In addition, desmopressin can be useful to demonstrate adequate corticotroph tumor resection when its stimulatory effect is lost following pituitary surgery of patients with Cushing disease. Desmopressin response can also be a marker of the risk of longer-term postoperative recurrence. However, this review also highlights the lack of consensual criteria of normal or abnormal response to desmopressin in its various uses and requirement for further research on its usefulness.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology, Aix Marseille University, Assistance Publique-Hopitaux de Marseille, INSERM, Marseille Medical Genetics, Marmara Institute, French Reference Center for Rare Pituitary Diseases, Endo-European Reference Network and EURACAN European Expert Center on Rare Pituitary Tumors, La Conception Hospital, 13385 Marseille Cedex 05, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), H2X 0C1, Montreal, Quebec, Canada
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16
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Balomenaki M, Vassiliadi DA, Tsagarakis S. Cushing's disease: risk of recurrence following trans-sphenoidal surgery, timing and methods for evaluation. Pituitary 2022; 25:718-721. [PMID: 35579775 DOI: 10.1007/s11102-022-01226-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
The treatment of choice for Cushing's disease (CD) is trans-sphenoidal surgery (TSS). However, TSS is not always curative and, even when curative it is associated with a substantial rate of recurrence. Published recurrence rates vary between 5 and 20%; half of these recurrences appear within 5-years and the remaining half within or even after 10 years post-surgery. A low or undetectable cortisol in the immediate post-op period is regarded as the best criterion of remission. However, low post-op cortisol levels do not accurately predict long-term remission. Moreover, there are no other robust predictors providing certainty about the long-term outcomes. Interestingly, several studies have shown that the desmopressin test performed in the early post-op period may have some promise in predicting more precisely the risk of recurrence. In view of the lack of robust ways to predict long-term outcomes, current guidelines suggest that every patient in remission should be monitored for the possibility of recurrence. The methods used to detect recurrence are similar to those used to assess the cortisol secretory status and include assessment of: (i) abnormal circadian rhythm by late night salivary cortisol (LNSC) or midnight serum cortisol; (ii) impaired cortisol feedback by the dexamethasone suppression test and; (iii) increased 24-h bioavailable cortisol by urinary free cortisol. The timing of evaluation begins when HPA axis recovers, and then annually or sooner in case of clinical suspicion. Currently LNSC is regarded as the earliest and most sensitive biochemical alteration in detecting recurrence; a major caveat for LNSC, however, is its great variability. In practice, the diagnosis of recurrence is a challenge due to the fact that recurrence is usually a slow process with apparent clinical manifestations that may be delayed and alterations of classical biomarkers that may be delayed as well.
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Affiliation(s)
- Maria Balomenaki
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45-47 Ipsilantou St., 106 76, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45-47 Ipsilantou St., 106 76, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45-47 Ipsilantou St., 106 76, Athens, Greece.
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17
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Ferriere A, Tabarin A. Biochemical testing to differentiate Cushing's disease from ectopic ACTH syndrome. Pituitary 2022; 25:705-708. [PMID: 35759056 DOI: 10.1007/s11102-022-01241-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
The differential diagnosis of ACTH-dependent Cushing's syndrome is often a diagnostic challenge that has been debated in numerous studies. In this short article, we will discuss the performance and main drawbacks of the biochemical tests used for this diagnosis.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, 33604, Pessac, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, 33604, Pessac, France.
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18
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Scaroni C, Mondin A, Ceccato F. How to rule out non-neoplastic hypercortisolemia (previously known as pseudo-cushing). Pituitary 2022; 25:701-704. [PMID: 35616760 PMCID: PMC9587923 DOI: 10.1007/s11102-022-01222-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Carla Scaroni
- Department of Medicine (DIMED) and Rare Diseases (DIMAR), University of Padova, Padova, Italy.
- Endocrinology Unit, Hospital-University of Padova, Padova, Italy.
- Endocrinology Unit, Department of Medicine DIMED and of Rare Diseases DIMAR, Via Ospedale Civile, 105-35128, Padova, Italy.
| | - Alessandro Mondin
- Department of Medicine (DIMED) and Rare Diseases (DIMAR), University of Padova, Padova, Italy
- Endocrinology Unit, Hospital-University of Padova, Padova, Italy
| | - Filippo Ceccato
- Department of Medicine (DIMED) and Rare Diseases (DIMAR), University of Padova, Padova, Italy
- Endocrinology Unit, Hospital-University of Padova, Padova, Italy
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19
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Abstract
Endogenous Cushing's syndrome (CS) is associated with morbidities (diabetes, hypertension, clotting disorders) and shortens life because of infections, pulmonary thromboembolism, and cardiovascular disease. Its clinical presentation is immensely variable, and diagnosis and treatment are often delayed. Thus, there are many opportunities for basic and clinical research leading to better tests, faster diagnosis, and optimized medical treatments. This review focuses on CS caused by excessive adrenocorticotropin (ACTH) production. It describes current concepts of the regulation of ACTH synthesis and secretion by normal corticotropes and mechanisms by which dysregulation occurs in corticotrope (termed "Cushing's disease") and noncorticotrope (so-called ectopic) ACTH-producing tumors. ACTH causes adrenal gland synthesis and pulsatile release of cortisol; the excess ACTH in these forms of CS leads to the hypercortisolism of endogenous CS. Again, the differences between healthy individuals and those with CS are highlighted. The clinical presentations and their use in the interpretation of CS screening tests are described. The tests used for screening and differential diagnosis of CS are presented, along with their relationship to cortisol dynamics, pathophysiology, and negative glucocorticoid feedback regulation in the two forms of ACTH-dependent CS. Finally, several gaps in current understanding are highlighted in the hope of stimulating additional research into this challenging disorder.
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Affiliation(s)
- Lynnette K Nieman
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
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20
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Balomenaki M, Margaritopoulos D, Vassiliadi DA, Tsagarakis S. Diagnostic workup of Cushing's syndrome. J Neuroendocrinol 2022; 34:e13111. [PMID: 35979805 DOI: 10.1111/jne.13111] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Abstract
Cushing's syndrome (CS) is a rare but detrimental endocrine disorder. Early diagnosis and prompt treatment are essential since the duration of hypercortisolism has an adverse impact on the extent of comorbidities and overall survival. The diagnostic approach involves a stepwise process that includes (1) screening and confirming the diagnosis and (2) establishing the aetiology of CS. The tests currently used to confirm the diagnosis of CS include urinary free cortisol measurements, the dexamethasone suppression test and late- night salivary cortisol or midnight serum cortisol measurements. None of these tests are ideal; all have pitfalls and require careful interpretation. Following confirmation of CS, measurement of ACTH discriminates between ACTH-dependent and non-ACTH dependent causes of CS. Adrenal imaging provides clues for the aetiology of non-ACTH dependent forms. Differentiation between the ACTH-dependent forms that involve pituitary corticotroph adenomas and ectopic ACTH sources is more complex and include pituitary MRI imaging, the high dose dexamethasone suppression test, the CRH test, bilateral inferior petrosal sinus sampling and, when required imaging modalities to detect ectopic ACTH secreting lesions. This review, which is part of a special issue on "Update of Cushing's syndrome: 100 years after Minnie G" will provide an update on our current diagnostic workup for the confirmation and differential diagnosis of CS.
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Affiliation(s)
- Maria Balomenaki
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
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21
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Cai Y, Ren L, Tan S, Liu X, Li C, Gang X, Wang G. Mechanism, diagnosis, and treatment of cyclic Cushing's syndrome: A review. Biomed Pharmacother 2022; 153:113301. [PMID: 35717778 DOI: 10.1016/j.biopha.2022.113301] [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: 05/01/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022] Open
Abstract
Cushing's syndrome (CS) is caused by hypercortisolemia, leading to the occurrence of characteristic clinical symptoms. A small number of patients with CS have periodic and intermittent increases in cortisol levels, resulting in recurrent episodes of clinical symptoms. Such patients are known as having cyclic CS (CCS). The cortisol secretion cycle of patients with CCS is unpredictable, and laboratory tests often show negative results during the normal cortisol secretion period; therefore, the diagnosis and treatment of the disease are currently difficult. Although the pathogenesis of CCS remains uncertain, recent studies have suggested that it may be closely related to hypothalamic factors, feedback mechanisms, and tumor infarction. Our review summarizes the current state of research on the potential mechanisms, diagnosis, and treatment of CS and provides an outlook for future studies.
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Affiliation(s)
- Yunjia Cai
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Linan Ren
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Shuwen Tan
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Xinming Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Chen Li
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China.
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China.
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22
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Alba EL, Japp EA, Fernandez-Ranvier G, Badani K, Wilck E, Ghesani M, Wolf A, Wolin EM, Corbett V, Steinmetz D, Skamagas M, Levine AC. The Mount Sinai Clinical Pathway for the Diagnosis and Management of Hypercortisolism due to Ectopic ACTH Syndrome. J Endocr Soc 2022; 6:bvac073. [PMID: 35668997 PMCID: PMC9155620 DOI: 10.1210/jendso/bvac073] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
Abstract
Neoplasms that secrete ectopic ACTH may cause severe, life-threatening hypercortisolism. These tumors are often difficult to localize and treat, requiring a comprehensive and systematic management plan orchestrated by a multidisciplinary team. The Mount Sinai Adrenal Center hosted an interdisciplinary retreat of experts in adrenal disorders and neuroendocrine tumors with the aim of developing a clinical pathway for the management of Cushing syndrome due to ectopic ACTH production. The result was institutional recommendations for the diagnosis, localization, surgical approaches to intrathoracic tumors and bilateral adrenalectomy, perioperative and postoperative medical management of hypercortisolism and its sequelae. Specific recommendations were made regarding the timing and selection of therapies based on the considerations of our team as well as a review of the current literature. Our clinical pathway can be applied by other institutions directly or serve as a guide for institution-specific management.
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Affiliation(s)
- Eva L Alba
- The Adrenal Center, Division of Endocrine, Diabetes and Bone Diseases, Department of Medicine at the Icahn School of Medicine at Mount Sinai
| | - Emily A Japp
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine at the University of Maryland School of Medicine
| | - Gustavo Fernandez-Ranvier
- Division of Metabolic, Endocrine, and Minimally Invasive Surgery, Department of Surgery at the Icahn School of Medicine at Mount Sinai
| | - Ketan Badani
- Division of Urology, Department of Surgery at the Icahn School of Medicine at Mount Sinai
| | - Eric Wilck
- Department of Diagnostic, Molecular and Interventional Radiology at the Icahn School of Medicine at Mount Sinai
| | - Munir Ghesani
- Department of Diagnostic, Molecular and Interventional Radiology at the Icahn School of Medicine at Mount Sinai
| | - Andrea Wolf
- Division of Thoracic Surgery, Department of Surgery at the Icahn School of Medicine at Mount Sinai
| | - Edward M Wolin
- The Center for Carcinoid and Neuroendocrine Tumors, Tisch Cancer Institute, Division of Hematology and Oncology, Department of Medicine at the Icahn School of Medicine at Mount Sinai
| | - Virginia Corbett
- Division of Hematology and Oncology, Department of Medicine at the Icahn School of Medicine at Mount Sinai
| | - David Steinmetz
- Division of Metabolic, Endocrine, and Minimally Invasive Surgery, Department of Surgery at the Icahn School of Medicine at Mount Sinai
| | - Maria Skamagas
- The Adrenal Center, Division of Endocrine, Diabetes and Bone Diseases, Department of Medicine at the Icahn School of Medicine at Mount Sinai
| | - Alice C Levine
- The Adrenal Center, Division of Endocrine, Diabetes and Bone Diseases, Department of Medicine at the Icahn School of Medicine at Mount Sinai
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Flippo C, Tatsi C, Sinaii N, Sierra MDLL, Belyavskaya E, Lyssikatos C, Keil M, Spanakis E, Stratakis CA. Copeptin Levels Before and After Transsphenoidal Surgery for Cushing Disease: A Potential Early Marker of Remission. J Endocr Soc 2022; 6:bvac053. [DOI: 10.1210/jendso/bvac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
Arginine-vasopressin (AVP) and corticotropin-releasing hormone (CRH) act synergistically to stimulate secretion of adrenocorticotropic hormone (ACTH). There is evidence that glucocorticoids act via negative feedback to suppress AVP secretion.
Objective
Our hypothesis was that a post-operative increase in plasma copeptin may serve as a marker of remission of Cushing Disease (CD).
Design
Plasma copeptin was obtained in patients with CD before and daily on post-operative days 1-8 after transsphenoidal surgery. Peak post-operative copeptin levels and Δcopeptin values were compared among those in remission versus no remission.
Results
Forty-four patients (64% female, 7-55 years old) were included, and 19 developed neither DI nor SIADH. Thirty-three had follow-up at least 3 months post-operatively. There was no difference in peak post-operative copeptin in remission [6.1 pmol/L (4.3-12.1)] versus no remission [7.3 pmol/L (5.4-8.4), p=0.88].. Excluding those who developed DI or SIADH, there was no difference in peak post-operative copeptin in remission [10.2 pmol/L (6.9-21.0)] versus no remission [5.4 pmol/L (4.6-7.3), p= 0.20]. However, a higher peak post-operative copeptin was found in those in remission [14.6 pmol/L (±10.9) vs. 5.8 (±1.4), p=0.03]] with parametric testing. There was no difference in the Δcopeptin by remission status.
Conclusions
A difference in peak post-operative plasma copeptin as an early marker to predict remission of CD was not consistently present, although the data point to the need for a larger sample size to further evaluate this. However, the utility of this test may be limited to those who develop neither DI nor SIADH post-operatively.
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Affiliation(s)
- Chelsi Flippo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD
| | - Christina Tatsi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, MD
| | - Maria De La Luz Sierra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD
| | - Elena Belyavskaya
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD
| | - Charalampos Lyssikatos
- Indiana Center for Musculoskeletal Health, Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Meg Keil
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD
| | - Elias Spanakis
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland, Baltimore, MD
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD
- Foundation for Research & Technology (FORTH), Greece & Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD, USA
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24
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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25
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Paepegaey AC, Dot JM, Beauvy J, Juttet P, Berre JPL. Pembrolizumab-induced cyclic ACTH-dependent Cushing's syndrome treated by a block-and-replace approach with osilodrostat. ANNALES D'ENDOCRINOLOGIE 2021; 83:73-75. [PMID: 34871599 DOI: 10.1016/j.ando.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/07/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - Jean-Marc Dot
- Department of Pneumology, Medipole, Lyon Villeurbanne, France
| | - Julie Beauvy
- Department of Endocrinology, Medipole, Lyon Villeurbanne, France
| | - Pauline Juttet
- Department of Endocrinology, Medipole, Lyon Villeurbanne, France
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26
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Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, Casanueva FF, Castinetti F, Chanson P, Findling J, Gadelha M, Geer EB, Giustina A, Grossman A, Gurnell M, Ho K, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Kelly DF, Lacroix A, McCormack A, Melmed S, Molitch M, Mortini P, Newell-Price J, Nieman L, Pereira AM, Petersenn S, Pivonello R, Raff H, Reincke M, Salvatori R, Scaroni C, Shimon I, Stratakis CA, Swearingen B, Tabarin A, Takahashi Y, Theodoropoulou M, Tsagarakis S, Valassi E, Varlamov EV, Vila G, Wass J, Webb SM, Zatelli MC, Biller BMK. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol 2021; 9:847-875. [PMID: 34687601 PMCID: PMC8743006 DOI: 10.1016/s2213-8587(21)00235-7] [Citation(s) in RCA: 298] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
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Affiliation(s)
| | | | | | | | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, Hôpital Cochin, Paris, France
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | | | | | | | - John D Carmichael
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Felipe F Casanueva
- Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM, Marseille, France; Assistance Publique Hopitaux de Marseille, Marseille, France; Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza B Geer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Ashley Grossman
- University of London, London, UK; University of Oxford, Oxford, UK
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK; NIHR Cambridge Biomedical Research Center, Cambridge, UK; Addenbrooke's Hospital, Cambridge, UK
| | - Ken Ho
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Ursula B Kaiser
- Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - André Lacroix
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ann McCormack
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Alberto M Pereira
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | | | - Hershel Raff
- Medical College of Wisconsin, Milwaukee, WI, USA; Advocate Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Martin Reincke
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | | | - Ilan Shimon
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | | | | | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | | | - Marily Theodoropoulou
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital General de Catalunya, Barcelona, Spain; Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- Churchill Hospital, Oxford, United Kingdom
| | - Susan M Webb
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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27
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Pinelli S, Barbot M, Scaroni C, Ceccato F. Second-Line Tests in the Diagnosis of Adrenocorticotropic Hormone-Dependent Hypercortisolism. Ann Lab Med 2021; 41:521-531. [PMID: 34108279 PMCID: PMC8203434 DOI: 10.3343/alm.2021.41.6.521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/17/2020] [Accepted: 05/17/2021] [Indexed: 11/19/2022] Open
Abstract
Cushing’s syndrome (CS) is a rare disease caused by chronic and excessive cortisol secretion. When adrenocorticotropin hormone (ACTH) is measurable, autonomous adrenal cortisol secretion could be reasonably ruled out in a differential diagnosis of CS. ACTH-dependent CS accounts for 80%–85% of cases and involves cortisol production stimulated by uncontrolled pituitary or ectopic ACTH secretion. Pituitary adenoma is not detected in up to one-third of cases with pituitary ACTH secretion, whereas cases of CS due to ectopic ACTH secretion may be associated with either malignant neoplasia (such as small cell lung carcinoma) or less aggressive neuroendocrine tumors, exhibiting only the typical symptoms and signs of CS. Since the differential diagnosis of ACTH-dependent CS may be a challenge, many strategies have been proposed. Since none of the available tests show 100% diagnostic accuracy, a step-by-step approach combining several diagnostic tools and a multidisciplinary evaluation in a referral center is suggested. In this review, we present a clinical case to demonstrate the diagnostic work-up of ACTH-dependent CS. We describe the most commonly used dynamic tests, as well as the applications of conventional or nuclear imaging and invasive procedures.
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Affiliation(s)
- Silvia Pinelli
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine (DIMED), University-Hospital of Padova, Padova, Italy.,Department of Neuroscience DNS, University of Padova, Padova, Italy
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Abstract
Cushing's disease (CD) is the most prevalent cause of endogenous hypercortisolism. CD is responsible for multiple co-morbidities and increased mortality. Accurate and prompt diagnosis and optimal treatment are essential to improve the prognosis of CD. However, the diagnosis of CD is probably one of the most difficult in endocrinology and, therefore, diagnostic workup should be performed in an experienced center. Transsphenoidal surgery performed by an expert surgeon is the only therapeutic option that can offer definitive cure and remains the first-line treatment in most patients. Second-line treatments include pharmacotherapy, pituitary radiotherapy and bilateral adrenalectomy. The second-line therapeutic strategy is complex, must be individualized and performed in a multidisciplinary expert center. Symptomatic treatments of persisting co-morbidities after remission, which are responsible for increased mortality and impaired quality of life is an important part of medical management.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France; INSERM U1215, NeuroCentre Magendie, University of Bordeaux, France.
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Vassiliadi DA, Mourelatos P, Kratimenos T, Tsagarakis S. Inferior petrosal sinus sampling in Cushing's syndrome: usefulness and pitfalls. Endocrine 2021; 73:530-539. [PMID: 34080096 DOI: 10.1007/s12020-021-02764-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/10/2021] [Indexed: 12/24/2022]
Abstract
In patients with ACTH-dependent Cushing's syndrome (CS), the differentiation between Cushing's disease (CD) and ectopic ACTH secretion (EAS) can often be challenging. The traditionally used biochemical tests have limited diagnostic accuracy and imaging modalities may fail to detect the culprit lesion. Inferior petrosal sinus sampling (IPSS) was introduced more than 3 decades ago as a test with optimal diagnostic accuracy and has since become the gold standard in the differential diagnosis between CD and EAS. However, several, albeit rare, pitfalls may limit its diagnostic accuracy and awareness is needed to avoid incorrect interventions. Moreover, it is an invasive and demanding procedure, available in a limited number of centers worldwide. This review aims to critically present the usefulness and pitfalls of IPSS and define strategies for its optimal place in the contemporary management of CS.
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Affiliation(s)
- D A Vassiliadi
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
| | - P Mourelatos
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
| | - T Kratimenos
- Department of Interventional Radiology, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece.
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Qiao J, Li J, Zhang W, Wang C, Li J, Jiang S, Tan H, Chen Y, Liu H, Cai B, Yu Y. The usefulness of the combined high-dose dexamethasone suppression test and desmopressin stimulation test in establishing the source of ACTH secretion in ACTH-dependent Cushing's syndrome. Endocr J 2021; 68:839-848. [PMID: 33790062 DOI: 10.1507/endocrj.ej20-0837] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Bilateral inferior petrosal sinus sampling (BIPSS) is the current gold standard test for differentially diagnosing ACTH-dependent Cushing's syndrome (CS). However, BIPSS is an invasive procedure, and its availability is limited. We retrospectively analysed the 24-hour urinary free cortisol (UFC) level during the high-dose dexamethasone suppression test (HDDST) and plasma ACTH/cortisol levels after the desmopressin stimulation test (DDAVP test) in subjects with confirmed Cushing's disease (CD) (n = 92) and ectopic ACTH-dependent CS (EAS) (n = 16), and evaluated the positive predictive value (PPV) of the two combined-tests in the aetiological diagnosis of ACTH-dependent CS. The percent changes in UFC levels after the HDDST and in ACTH/cortisol levels after DDAVP administration relative to the corresponding basal levels and the area under the receiver operating characteristic (ROC) curve (AUC) were analysed. UFC suppression below 62.7% suggested a pituitary origin with a sensitivity (SE) of 80% (95% CI: 70-88) and a specificity (SP) of 80% (95% CI: 52-96). A threshold increase in the ACTH level after DDAVP stimulation of 44.6% identified CD with an SE of 91% (95% CI: 83-97) and an SP of 75% (95% CI: 48-93). The combination of both tests yielded an SE of 95.5% and PPV of 98.4% for CD, and significantly improved the efficiency of the differential diagnosis between CD and EAS. These dual non-invasive endocrine tests may substantially reduce the need for BIPSS in the etiological investigation of ACTH-dependent CS.
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Affiliation(s)
- Jingtao Qiao
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jiaqi Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Weiwei Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Chun Wang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shu Jiang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yaxi Chen
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Hui Liu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bowen Cai
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yerong Yu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Yu S, Karsy M, Miller J, Beldick SR, Curtis MT, Rosen M, Evans JJ. Rapidly progressive ACTH-dependent Cushing’s disease masquerading as ectopic ACTH-producing Cushing’s syndrome: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21151. [PMID: 35854960 PMCID: PMC9272366 DOI: 10.3171/case21151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/26/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Cushing’s disease (CD) remains a challenging condition to diagnose and treat. This case study highlights the challenges of diagnosing CD when faced with discrepant clinical, biochemical, and radiological findings.
OBSERVATIONS
A 62-year-old man presented with rapid evolution of symptoms, including depression, fatigue, and extreme muscle atrophy, which resulted in the patient being a wheelchair user over the course of a few months. His rapid clinical course in conjunction with hypercortisolemia in the setting of a pituitary macroadenoma involving the cavernous sinus, two large pulmonary nodules, and urine-free cortisol levels in the thousands suggested an aggressive ectopic adrenocorticotropic hormone (ACTH) source. After extensive testing ruled out CD from an ectopic source and because of the patient’s abrupt clinical deterioration, the authors concluded that the source was likely an aggressive pituitary adenoma. Therefore, the authors performed an endonasal transsphenoidal approach for resection of the pituitary adenoma involving the cavernous sinus, and the patient was scheduled for radiosurgery to control tumor progression.
LESSONS
Although extremely high levels of cortisol and ACTH are associated with ectopic Cushing’s syndrome, they may also indicate an aggressive form of CD. Suspicion should be maintained for hypercortisolemia from a pituitary source even when faced with discrepant information that may suggest an ectopic source.
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Affiliation(s)
| | | | | | | | | | - Marc Rosen
- Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - James J. Evans
- Departments of Neurological Surgery
- Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Świątkowska-Stodulska R, Berlińska A, Stefańska K, Kłosowski P, Sworczak K. Cyclic Cushing's Syndrome - A Diagnostic Challenge. Front Endocrinol (Lausanne) 2021; 12:658429. [PMID: 33967962 PMCID: PMC8101412 DOI: 10.3389/fendo.2021.658429] [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: 01/25/2021] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
Cyclic Cushing's syndrome (also known as intermittent or periodic) is a disease characterized by periods of transient hypercortisolemia shifting into periods of normo- and/or hypocortisolemia. Diagnosis of cyclic Cushing's syndrome is based on at least three periods of confirmed hypercortisolemia interspersed by two periods of normocortisolemia. Cyclic Cushing's syndrome is one of the greatest challenges in modern endocrinology due to its diverse clinical picture, unpredictable duration and frequency of phases, and various etiologies. We discuss a diagnostic algorithm for periodic hypercortisolemia with special regard to hair cortisol analysis and desmopressin stimulation test which both seem to be helpful in finding the correct answer.
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Affiliation(s)
- Renata Świątkowska-Stodulska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Agata Berlińska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Katarzyna Stefańska
- Department of Obstetrics, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Przemysław Kłosowski
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Fontaine-Sylvestre C, Létourneau-Guillon L, Moumdjian RA, Berthelet F, Lacroix A. Corticotroph tumor progression during long-term therapy with osilodrostat in a patient with persistent Cushing's disease. Pituitary 2021; 24:207-215. [PMID: 33074401 DOI: 10.1007/s11102-020-01097-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Corticotroph tumor progression (CTP) or Nelson's syndrome (NS) can occur in patients with Cushing's disease (CD) following bilateral adrenalectomy. It has rarely been observed in patients treated with long-term medical therapy for persistent CD. Osilodrostat (LCI699) is a new steroidogenesis inhibitor of 11β-hydroxylase (CYP11β1) that induced remission of hypercortisolism in 86% of patients with refractory CD in the randomized placebo-controlled trial LINC-3 (NCT02180217). METHODS A 40-year-old woman with persistent CD following transsphenoidal surgery was treated with osilodrostat in the LINC-3 trial and was followed with regular hormonal assessments and imaging of residual corticotroph tumor. RESULTS Under oral therapy with osilodrostat 10 mg twice daily, urinary free cortisol (UFC) normalized and clinical signs of CD regressed during therapy. However after 4 years of treatment, ACTH levels increased from 73 to 500 pmol/L and corticotroph tumor size increased rapidly from 3 to 14 mm, while UFCs remained well controlled. Surgical resection of an atypical tumor with weak ACTH expression and increased proliferative index (Ki-67 ≥ 8%) resulted in current remission but will require close follow-up. CONCLUSION This case highlights the importance of monitoring ACTH and corticotroph tumor size in patients with persistent CD, either under effective treatment with steroidogenesis inhibitors or after bilateral adrenalectomy.
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Affiliation(s)
- Cédric Fontaine-Sylvestre
- Division of Endocrinology, Department of Medicine, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, 900 Saint-Denis Street, Montréal, Québec, H2X 0A9, Canada
| | - Laurent Létourneau-Guillon
- Neuroradiology Division, Department of Radiology, Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montréal, Québec, Canada
| | - Robert A Moumdjian
- Neurosurgery Division, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montréal, Québec, Canada
| | - France Berthelet
- Neuropathology Division, Department of Pathology, Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montréal, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, 900 Saint-Denis Street, Montréal, Québec, H2X 0A9, Canada.
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Cheng Y, Li J, Dou J, Ba J, Du J, Zhang S, Mu Y, Lv Z, Gu W. Case Report: Three Rare Cases of Ectopic ACTH Syndrome Caused by Adrenal Medullary Hyperplasia. Front Endocrinol (Lausanne) 2021; 12:687809. [PMID: 34276563 PMCID: PMC8281927 DOI: 10.3389/fendo.2021.687809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/07/2021] [Indexed: 11/30/2022] Open
Abstract
Ectopic ACTH syndrome (EAS) accounts for 10-20% of endogenous Cushing's syndrome (CS). Hardly any cases of adrenal medullary hyperplasia have been reported to ectopically secrete adrenocorticotropic hormone (ACTH). Here we describe a series of three patients with hypercortisolism secondary to ectopic production of ACTH from adrenal medulla. Cushingoid features were absent in case 1 but evident in the other two cases. Marked hypokalemia was found in all three patients, but hyperglycemia and osteoporosis were present only in case 2. All three patients showed significantly elevated serum cortisol and 24-h urinary cortisol levels. The ACTH levels ranged from 19.8 to 103.0pmol/L, favoring ACTH-dependent Cushing's syndrome. Results of bilateral inferior petrosal sinus sampling (BIPSS) for case 1 and case 3 confirmed ectopic origin of ACTH. The extremely high level of ACTH and failure to suppress cortisol with high dose dexamethasone suppression test (HDDST) suggested EAS for patient 2. However, image studies failed to identify the source of ACTH secretion. Bilateral adrenalectomy was performed for rapid control of hypercortisolism. After surgery, cushingoid features gradually disappeared for case 2 and case 3. Blood pressure, blood glucose and potassium levels returned to normal ranges without medication for case 2. The level of serum potassium also normalized without any supplementation for case 1 and case 3. The ACTH levels of all three patients significantly decreased 3-6 months after surgery. Histopathology revealed bilateral adrenal medullary hyperplasia and immunostaining showed positive ACTH staining located in adrenal medulla cells. In summary, our case series reveals the adrenal medulla to be a site of ectopic ACTH secretion. Adrenal medulla-originated EAS makes the differential diagnosis of ACTH-dependent Cushing's syndrome much more difficult. Control of the hypercortisolism is mandatory for such patients.
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Affiliation(s)
- Yu Cheng
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Jie Li
- Department of Pathology, Chinese PLA General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Jianming Ba
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Saichun Zhang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Zhaohui Lv, ; Weijun Gu,
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Zhaohui Lv, ; Weijun Gu,
| | - Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Zhaohui Lv, ; Weijun Gu,
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35
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Hinojosa-Amaya JM, Cuevas-Ramos D. The definition of remission and recurrence of Cushing's disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101485. [PMID: 33472761 DOI: 10.1016/j.beem.2021.101485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Accurate classification of postsurgical remission, and early recognition of recurrence are crucial to timely treat and prevent excess mortality in Cushing's Disease, yet the criteria used to define remission are variable and there is no consensus to define recurrence. Remission is defined as postsurgical hypocortisolemia, but delayed remission may occur. Recurrence is the return of clinical manifestations with biochemical evidence of hypercortisolism. The proper combination of tests and their timing are controversial. Reliable predicting tools may lead to earlier diagnosis upon recurrence. Many factors have been studied independently for prediction with variable performance. Novel artificial intelligence approaches seek to integrate these variables into risk calculators and machine-learning algorithms with an acceptable short-term predictive performance but lack longer-term accuracy. Prospective studies using these approaches are needed. This review summarizes the evidence behind the definitions of remission and recurrence and provide an overview of the available tools to predict and/or diagnose them.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Pituitary Clinic, Endocrinology Division and Department of Medicine, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Nieman LK. Is it Time for a New Approach to the Differential Diagnosis of ACTH-Dependent Cushing Syndrome? J Clin Endocrinol Metab 2020; 105:5918510. [PMID: 33022714 PMCID: PMC7538021 DOI: 10.1210/clinem/dgaa493] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Lynnette K Nieman
- Diabetes, Endocrine and Obesity Branch, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda Maryland
- Correspondence and Reprint Requests: Lynnette K. Nieman, MD, Building 10, CRC, 1 East, Rm 1-3140, 10 Center Dr, MSC 1109, Bethesda, MD 20892–1109, USA. E-mail:
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Frete C, Corcuff JB, Kuhn E, Salenave S, Gaye D, Young J, Chanson P, Tabarin A. Non-invasive Diagnostic Strategy in ACTH-dependent Cushing's Syndrome. J Clin Endocrinol Metab 2020; 105:5864157. [PMID: 32594169 DOI: 10.1210/clinem/dgaa409] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 06/22/2020] [Indexed: 01/29/2023]
Abstract
CONTEXT Inferior petrosal sinus sampling (IPSS) is used to diagnose Cushing's disease (CD) when dexamethasone-suppression and CRH tests, and pituitary magnetic resonance imaging (MRI), are negative or give discordant results. However, IPSS is an invasive procedure and its availability is limited. OBJECTIVE To test a noninvasive diagnostic strategy associated with 100% positive predictive value (PPV) for CD. DESIGN Retrospective study. SETTING Two university hospitals. PATIENTS A total of 167 patients with CD and 27 patients with ectopic ACTH-syndrome investigated between 2001 and 2016. MAIN OUTCOME MEASURE(S) Performance of a strategy involving the CRH and desmopressin tests with pituitary MRI followed by thin-slice whole-body computed tomography (CT) scan in patients with inconclusive results. RESULTS Using thresholds of a cortisol increase > 17% with an ACTH increase > 37% during the CRH test and a cortisol increase > 18% with an ACTH increase > 33% during the desmopressin test, the combination of both tests gave 73% sensitivity and 98% PPV of CD. The sensitivity and PPV for pituitary MRI were 71% and 99%, respectively. CT scan identified 67% EAS at presentation with no false-positives. The PPV for CD was 100% in patients with positive responses to both tests, with negative pituitary MRI and CT scan. The Negative Predictive Value was 100% in patients with negative responses to both tests, with negative pituitary MRI and positive CT scan. Using this strategy, IPPS could have been avoided in 47% of patients in whom it is currently recommended. CONCLUSIONS In conjunction with expert radiologic interpretation, the non-invasive algorithm studied significantly reduces the need for IPSS in the investigation of ACTH-dependent Cushing's syndrome.
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Affiliation(s)
- Caroline Frete
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Pessac, France
| | - Jean-Benoît Corcuff
- Department of Nuclear Medicine, University Hospital of Bordeaux, Pessac, France
- Nutrition et Neurobiologie Intégrée, UMR 1286, University of Bordeaux, Bordeaux, France
| | - Emmanuelle Kuhn
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Sylvie Salenave
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Delphine Gaye
- Department of Radiology, University Hospital of Bordeaux, Pessac, France
| | - Jacques Young
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
- Université Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
- Université Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Le Kremlin-Bicêtre, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Pessac, France
- Physiopathologie de la Plasticité Neuronale, INSERM U1215, Neurocentre Magendie, Bordeaux, France
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Capatina C, Hinojosa-Amaya JM, Poiana C, Fleseriu M. Management of patients with persistent or recurrent Cushing's disease after initial pituitary surgery. Expert Rev Endocrinol Metab 2020; 15:321-339. [PMID: 32813595 DOI: 10.1080/17446651.2020.1802243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Treatment options for persistent and recurrent Cushing's disease (CD) include an individualized approach for repeat surgery, medical treatment, radiation therapy (RT), and bilateral adrenalectomy (BLA). AREAS COVERED In this expert opinion perspective, the authors review the latest treatment(s) for persistent/recurrent CD. A PubMed search was undertaken (English articles through May 2020) and relevant articles discussed. Repeat pituitary surgery should be considered in most patients with proven hypercortisolism; there is potential for cure with low risk of major complications. Medical therapy is valuable either alone, while awaiting the effects of RT, or in preparation for BLA. Medical therapy includes steroidogenesis inhibitors, agents that act at the pituitary or glucocorticoid receptor level, and novel agents in development. Radiation therapy has been used successfully to treat CD, but hypopituitarism risk and delayed efficacy (improved with radiosurgery) are major drawbacks. Laparoscopic BLA is safe and effective in patients with severe, difficult-to-manage hypercortisolism, but long-term follow-up is required as corticotroph tumor progression can develop. EXPERT OPINION Treatment of persistent/recurrent CD is challenging. Most patients require >1 therapy to achieve long-lasting remission. There is currently no ideal single treatment option that provides high and rapid efficacy, low adverse effects, and preserves normal pituitary-adrenal axis function.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
- Endocrinology Division, Department of Medicine, Hospital Universitario Dr. José E. González, Universidad Autónoma De Nuevo León , Monterrey, Nuevo León, Mexico
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
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Ragnarsson O. Cushing's syndrome - Disease monitoring: Recurrence, surveillance with biomarkers or imaging studies. Best Pract Res Clin Endocrinol Metab 2020; 34:101382. [PMID: 32139169 DOI: 10.1016/j.beem.2020.101382] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pituitary surgery is the first-line treatment for patients with Cushing's disease. For patients who are not considered candidates for pituitary surgery, pituitary radiation and bilateral adrenalectomy are further treatment alternatives. Not all patients are cured with pituitary surgery, and a substantial number of patients develop recurrence, sometimes many years after an apparently successful treatment. The same applies to patients treated with radiotherapy. Far from all patients are cured, and in many cases the disease recurs. Bilateral adrenalectomy, although always curative, causes chronic adrenal insufficiency and the remaining pituitary tumour can continue to grow and cause symptoms due to pressure on adjacent tissues, a phenomenon called Nelson's syndrome. In this paper the rate of recurrence of hypercortisolism, as well as the rate of development of Nelson's syndrome, following treatment of patients with Cushing's syndrome, will be reviewed. The aim of the paper is also to summarize clinical and biochemical factors that are associated with recurrence of hypercortisolism and how the patients should be monitored following treatment.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, SE-41302, Sweden.
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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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Pasternak-Pietrzak K, Moszczyńska E, Szalecki M. Treatment challenges in pediatric Cushing's disease: Review of the literature with particular emphasis on predictive factors for the disease recurrence. Endocrine 2019; 66:125-136. [PMID: 31701434 PMCID: PMC6838046 DOI: 10.1007/s12020-019-02036-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Cushing's disease (CD) is a rare endocrine condition caused by a corticotroph pituitary tumor that produces adrenocorticotropic hormone. The current state of knowledge of CD treatment is presented in this article including factors that can be helpful in predicting remission and/or recurrence of the disease. The primary goals in CD treatment are quick diagnosis and effective, prompt treatment as the persistent disease is associated with increased morbidity and mortality. Cooperation of a team consisting of experienced pediatrician/adult endocrinologist, neuroradiologist, transsphenoidal neurosurgeon and (if necessary) radiotherapist contribute to the best treatment effects.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland.
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
- The Medicine and Health Sciences Faculty, University of Jan Kochanowski, Al. IX Wieków Kielc 19A, 25-317, Kielce, Poland
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Hinojosa-Amaya JM, Varlamov EV, McCartney S, Fleseriu M. Hypercortisolemia Recurrence in Cushing's Disease; a Diagnostic Challenge. Front Endocrinol (Lausanne) 2019; 10:740. [PMID: 31787930 PMCID: PMC6856050 DOI: 10.3389/fendo.2019.00740] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/14/2019] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease recurrence following successful pituitary surgery is common and merits prompt and careful diagnosis, as untreated hypercortisolism leads to increased morbidity and mortality. However, an established recurrence definition has not been forthcoming. This poses a diagnostic challenge especially early in the course of returning hypercortisolemia and/or in the presence of non-neoplastic hypercortisolemia. A late-night salivary cortisol (LNSC) test is the first test to reveal abnormal results, however, has limitations related to assay performance as well as individual patient variability. Dexamethasone suppression tests and 24-h urinary free cortisol (UFC) results are next to reveal abnormal results. Other tests including, corticotropin-releasing hormone (CRH) stimulation test and combined CRH-dexamethasone test, as well as desmopressin stimulation test with/without dexamethasone are also used, although, none have proven to be the preeminent diagnostic test for recurrence determination. There is a possible role for these tests in predicting recurrence in patients who have experienced remission, though, this also remains challenging due to lack of established cutoff values. This article details and summarizes evidence about different diagnostic tests currently used to diagnose and predict Cushing's disease recurrence.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Endocrinology Division, Department of Medicine, Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elena V. Varlamov
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Shirley McCartney
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu
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