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Mangone A, Favero V, Prete A, Elhassan YS, Asia M, Hardy R, Mantovani G, Chiodini I, Ronchi CL. Inflammation-based scores in a large cohort of adrenocortical carcinoma and adrenocortical adenoma: role of the hormonal secretion pattern. J Endocrinol Invest 2024:10.1007/s40618-024-02426-y. [PMID: 38965182 DOI: 10.1007/s40618-024-02426-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Serum inflammation-based scores can predict clinical outcome in several cancer types, including adrenocortical carcinoma (ACC). It is unclear whether the extent of inflammation-based scores alterations in ACC reflects malignancy, steroid excess, or both. METHODS We investigated a large retrospective cohort of adrenocortical adenomas (ACA, n = 429) and ACC (n = 61) with available baseline full blood count and hormonal evaluation. We examined the relationship between different inflammation-based scores [neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), and prognostic nutrition index (PNI)] and both malignancy and steroid secretion patterns. RESULTS All inflammation-based scores differed between ACC and ACA: patients with ACC had higher NLR, PLR, SII and lower LMR and PNI levels compared to ACA (all p values < 0.001). NLR showed a positive correlation with cortisol levels after overnight 1 mg-dexamethasone suppression test (1 mg-DST), both in ACC and ACA (p < 0.01). The ROC curve analysis determined NLR > 2.6 as the best cut-off to discriminate ACC from ACA [AUC = 0.846, p < 0.01]. At multivariable analysis, NLR > 2.6 was independently associated with ACC, 1 mg-DST cortisol levels and age, but not with tumour size. Considering the ACC, NLR and SII were higher and PNI was lower in patients with cortisol excess compared to those without cortisol excess (p = 0.002, p = 0.007, and p = 0.044 respectively). Finally, LMR and NLR differed between inactive-ACC (n = 10) and inactive-ACA (n = 215) (p = 0.040 and p = 0.031, respectively). CONCLUSION Inflammation-based scores are related to steroid secretion both in ACC and ACA. ACCs present a higher grade of inflammation regardless of their hormonal secretion, likely as a feature of malignancy itself.
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Affiliation(s)
- A Mangone
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - V Favero
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Endocrinology Unit, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - A Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, B152TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Y S Elhassan
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, B152TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Asia
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Hardy
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, B152TT, UK
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - G Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - I Chiodini
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Endocrinology Unit, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - C L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, B152TT, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Di Dalmazi G, Goi J, Burrello J, Tucci L, Cicero AFG, Mancusi C, Coletti Moia E, Iaccarino G, Borghi C, Muiesan ML, Ferri C, Mulatero P. Screening of hypercortisolism among patients with hypertension: an Italian nationwide survey. J Endocrinol Invest 2024:10.1007/s40618-024-02387-2. [PMID: 38913251 DOI: 10.1007/s40618-024-02387-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/25/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE Screening of Cushing Syndrome (CS) and Mild Autonomous Cortisol Secretion (MACS) in hypertensive patients is crucial for proper treatment. The aim of the study was to investigate screening and management of hypercortisolism among patients with hypertension in Italy. METHODS A 10 item-questionnaire was delivered to referral centres of European and Italian Society of Hypertension (ESH and SIIA) in a nationwide survey. Data were analyzed according to type of centre (excellence vs non-excellence), geographical area, and medical specialty. RESULTS Within 14 Italian regions, 82 centres (30% excellence, 78.790 patients during the last year, average 600 patients/year) participated to the survey. Internal medicine (44%) and cardiology (31%) were the most prevalent medical specialty. CS and MACS were diagnosed in 313 and 490 patients during the previous 5 years. The highest number of diagnoses was reported by internal medicine and excellence centres. Screening for hypercortisolism was reported by 77% in the presence of specific features of CS, 61% in resistant hypertension, and 38% in patients with adrenal mass. Among screening tests, the 24 h urinary free cortisol was the most used (66%), followed by morning cortisol and ACTH (54%), 1 mg-dexamethasone suppression test (49%), adrenal CT or MRI scans (12%), and late night salivary cortisol (11%). Awareness of referral centres with expertise in management of CS was reported by 67% of the participants, which reduced to 44% among non-excellence centres. CONCLUSIONS Current screening of hypercortisolism among hypertensive patients is unsatisfactory. Strategies tailored to different medical specialties and type of centres should be conceived.
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Affiliation(s)
- G Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - J Goi
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
| | - J Burrello
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
| | - L Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - A F G Cicero
- Hypertension and Cardiovascular Risk Research Unit, Medical and Surgery Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - C Mancusi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - E Coletti Moia
- ARCA (Associazioni Regionali Cardiologi Ambulatoriali) sezione Piemonte, Turin, Italy
| | - G Iaccarino
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - C Borghi
- Hypertension and Cardiovascular Risk Research Unit, Medical and Surgery Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - C Ferri
- Department of Life, Health and Environmental Sciences University of L'Aquila, L'Aquila, Italy
| | - P Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
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Detomas M, Deutschbein T, Altieri B. Medical Therapy of Endogenous Cushing's Syndrome with Steroidogenesis Inhibitors: Treatment Rationale, Available Drugs, and Therapeutic Effects. Exp Clin Endocrinol Diabetes 2024. [PMID: 38688315 DOI: 10.1055/a-2317-0801] [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: 05/02/2024]
Abstract
Endogenous Cushing's syndrome (CS) is a rare disease characterized by a glucocorticoid excess. If inadequately treated, hypercortisolism can lead to increased morbidity and mortality. Surgical removal of the underlying tumor is the first-line treatment but is sometimes not feasible or even contraindicated. Additionally, in cases with severe CS, rapid control of hypercortisolism may be required. In these scenarios, steroidogenesis inhibitors represent a therapeutic alternative to surgery. Over the last years, the knowledge of the broad therapeutic effects of steroidogenesis inhibitors per se and the number of available drugs have increased. However, large comparative studies are still lacking. Accordingly, the decision on which drug to be used in a certain patient or clinical setting may be difficult. This review aims to summarize the main characteristics of steroidogenesis inhibitors.
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Affiliation(s)
- Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
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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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Detomas M, Deutschbein T, Tamburello M, Chifu I, Kimpel O, Sbiera S, Kroiss M, Fassnacht M, Altieri B. Erythropoiesis in Cushing syndrome: sex-related and subtype-specific differences. Results from a monocentric study. J Endocrinol Invest 2024; 47:101-113. [PMID: 37314685 PMCID: PMC10776705 DOI: 10.1007/s40618-023-02128-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
CONTEXT Cushing syndrome (CS) is associated with different hematological abnormalities. Nevertheless, conflicting data about erythropoiesis in CS have been reported. Furthermore, it is unclear whether CS sex and subtype-specific alterations in red blood cells (RBC) parameters are present. OBJECTIVE To investigate sex and subtype-specific changes in RBC in patients with CS at initial diagnosis and after remission. DESIGN Retrospective, monocentric study including 210 patients with CS (women, n = 162) matched 1:1 for sex and age to patients with pituitary microadenomas or adrenal incidentalomas (both hormonally inactive). RBC parameters were evaluated at initial diagnosis and after remission. RESULTS Women with CS had higher hematocrit (median 42.2 vs 39.7%), hemoglobin (14.1 vs 13.4 g/dl) and mean corpuscular volume (MCV) (91.2 vs 87.9 fl) compared to the controls (all p < 0.0001). Women with Cushing disease (CD) showed higher hematocrit, RBC and hemoglobin levels than those with ectopic Cushing (ECS) (all p < 0.005). Men with CS had lower hematocrit (42.9 vs 44.7%), RBC count (4.8 vs 5.1n*106/µl) and hemoglobin (14.2 vs 15.4 g/dl), but higher MCV (90.8 vs 87.5 fl) than controls (all p < 0.05). In men with CS, no subtype-specific differences were identified. Three months after remission hemoglobin decreased in both sexes. CONCLUSION CS is characterized by sexual and subtype-specific differences in RBC parameters. Compared to controls, women with CS showed higher hematocrit/hemoglobin levels, whereas men had lower hematocrit/hemoglobin, which further decreased directly after remission. Therefore, anemia should be considered as complication of CS in men. In women, differences in RBC parameters may help to differentiate CD from ECS.
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Affiliation(s)
- M Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
| | - T Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - M Tamburello
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Section of Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, 25124, Brescia, Italy
| | - I Chifu
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - O Kimpel
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - S Sbiera
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - M Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Department of Internal Medicine IV, University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - M Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Central Laboratory, University Hospital Würzburg, Würzburg, Germany
| | - B Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
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Detomas M, Deutschbein T. Reply to the letter to the editor from Piazzola and Castinetti: "Bilateral inferior petrosal sinus sampling with human CRH stimulation in ACTH dependent Cushing's syndrome: results from a retrospective multicenter study". Eur J Endocrinol 2023; 189:R17-R18. [PMID: 37956461 DOI: 10.1093/ejendo/lvad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023]
Affiliation(s)
- Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
- Medicover Oldenburg MVZ, 26122 Oldenburg, Germany
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Favero V, Prete A, Mangone A, Elhassan YS, Pucino V, Asia M, Hardy R, Chiodini I, Ronchi CL. Inflammation-based scores in benign adrenocortical tumours are linked to the degree of cortisol excess: a retrospective single-centre study. Eur J Endocrinol 2023; 189:517-526. [PMID: 37962923 DOI: 10.1093/ejendo/lvad151] [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: 04/20/2023] [Revised: 09/05/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVE Benign adrenocortical tumours are diagnosed in ∼5% of adults and are associated with cortisol excess in 30%-50% of cases. Adrenal Cushing's syndrome (CS) is rare and leads to multiple haematological alterations. However, little is known about the effects of the much more frequent mild autonomous cortisol secretion (MACS) on immune function. The aim of this study was to evaluate the haematological alterations in benign adrenocortical tumours with different degrees of cortisol excess. DESIGN AND METHODS We investigated 375 patients: 215 with non-functioning adrenal tumours (NFAT), 138 with MACS, and 22 with CS. We evaluated the relationship between the degree of cortisol excess and full blood count as well as multiple inflammation-based scores, including the neutrophil-to-lymphocyte ratio (NLR), the lymphocyte-to-monocyte ratio (LMR), and the systemic immune-inflammation index (SII). RESULTS We observed a gradual and significant increase of leucocytes, neutrophils, and monocytes across the spectrum of cortisol excess, from NFAT over MACS to CS. Neutrophil-to-lymphocyte ratio and SII were significantly higher in both MACS and CS when compared to NFAT (P < .001 and P = .002 for NLR and P = .006 and P = .021 for SII, respectively). Conversely, LMR was lower in MACS and CS than in NFAT (P = .01 and <.001, respectively) but also significantly lower in CS compared to MACS (P = .007). CONCLUSIONS Neutrophil-to-lymphocyte ratio, SII, and LMR correlated with the degree of cortisol excess in benign adrenocortical tumours and were altered in patients with CS and MACS. These findings suggest that, similar to clinically overt CS, MACS also affects the immune function, potentially contributing to the MACS-associated comorbidities.
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Affiliation(s)
- Vittoria Favero
- Department of Biotechnology and Translational Medicine, University of Milan, Milan 20010, Italy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B152TT, United Kingdom
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B152TT, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B152TT, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B152GW, United Kingdom
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B152GW, United Kingdom
| | - Alessandra Mangone
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20100, Italy
| | - Yasir S Elhassan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B152TT, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B152TT, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B152GW, United Kingdom
| | - Valentina Pucino
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B152TT, United Kingdom
- The Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford OX37FY, United Kingdom
| | - Miriam Asia
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B152GW, United Kingdom
| | - Rowan Hardy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B152TT, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, Birmingham B152TT, United Kingdom
| | - Iacopo Chiodini
- Department of Biotechnology and Translational Medicine, University of Milan, Milan 20010, Italy
- Unit of Endocrinology, Ospedale Niguarda Cà Granda, Milan 20100, Italy
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B152TT, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B152TT, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B152GW, United Kingdom
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Lopes V, Marques O, De Sousa Lages A. Preventive strategies for hypercoagulation in Cushing's syndrome: when and how. Thromb J 2023; 21:72. [PMID: 37400845 DOI: 10.1186/s12959-023-00515-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023] Open
Abstract
PURPOSE The endogenous hypercortisolism that characterizes Cushing's syndrome (CS) is associated with a state of hypercoagulability that significantly increases the risk of thromboembolic disease, especially, venous events. Despite this certainty, there is no consensus on the best thromboprophylaxis strategy (TPS) for these patients. Our aim was to summarize the published data about different thromboprophylaxis strategies, and to review available clinical tools assisting thromboprophylaxis decision making. METHODS Narrative review of thromboprophylaxis strategies in patients with Cushing's syndrome. A search was carried out on PubMed, Scopus and EBSCO until November 14th, 2022, and articles were selected based on their relevance and excluded in case of redundant content. RESULTS Literature is scarce regarding thromboprophylaxis strategies to be adopted in the context of endogenous hypercortisolism, most often being a case-by-case decision according to the centre expertise. Only three retrospective studies, with a small number of patients enrolled, evaluated the use of hypocoagulation for the thromboprophylaxis of patients with CS in the post-operative period of transsphenoidal surgery and/or adrenalectomy, but all of them with favourable results. The use of low molecular weight heparin is the most frequent option as TPS in CS context. There are numerous venous thromboembolism risk assessment scores validated for different medical purposes, but just one specifically developed for CS, that must be validated to ensure solid recommendations in this context. The use of preoperative medical therapy is not routinely recommended to decrease the risk of postoperative venous thromboembolic events. The peak of venous thromboembolic events occurs in the first three months post-surgery. CONCLUSION The need to hypocoagulate CS patients, mainly in the post-operative period of a transsphenoidal surgery or an adrenalectomy, is undoubtable, especially in patients with an elevated risk of venous thromboembolic events, but the precise duration and the hypocoagulation regimen to institute is yet to be determined with prospective studies.
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Affiliation(s)
- Valentim Lopes
- Endocrinology Department of Hospital of Braga, Braga, Portugal.
| | - Olinda Marques
- Endocrinology Department of Hospital of Braga, Braga, Portugal
| | - Adriana De Sousa Lages
- Endocrinology Department of Hospital of Braga, Braga, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Lam-Chung CE, Cuevas-Ramos D. The promising role of risk scoring system for Cushing syndrome: Time to reconsider current screening recommendations. Front Endocrinol (Lausanne) 2022; 13:1075785. [PMID: 36482998 PMCID: PMC9725023 DOI: 10.3389/fendo.2022.1075785] [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: 10/20/2022] [Accepted: 11/01/2022] [Indexed: 11/24/2022] Open
Abstract
Despite the current screening approach for Cushing syndrome (CS), delayed diagnosis is common due to broad spectrum of presentation, poor discriminant symptoms featured in diabetes and obesity, and low clinical index of suspicion. Even if initial tests are recommended to screen CS, divergent results are not infrequent. As global prevalence of type 2 diabetes and obesity increases, CS may not be frequent enough to back routine screening to avoid false-positive results. This represents a greater challenge in countries with limited health resources. The development of indexes incorporates clinical features and biochemical data that are largely used to provide a tool to predict the presence of disease. In clinical endocrinology, indexes have been used in Graves' ophthalmology, hirsutism, and hypothyroidism. The use of clinical risk scoring system may assist clinicians in discriminating CS in the context of at-risk populations and, thus, may provide a potential intervention to decrease time to diagnosis. Development and validation of clinical model to estimate pre-test probability of CS in different geographic source population may help to establish regional prediction model for CS. Here, we review on the latest progress in clinical risk scoring system for CS and attempt to raise awareness for the use, validation, and/or development of clinical risk scores in CS.
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Affiliation(s)
- CE. Lam-Chung
- Department of Endocrinology and Metabolism, Complejo Hospitalario Dr. Manuel Amador Guerrero, Colón, Panama
| | - D. Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- *Correspondence: D. Cuevas-Ramos,
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