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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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
Neoplasms that secrete ectopic adrenocorticotropin (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 (NETs) 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, and 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, New York , NY, USA
| | - Emily A Japp
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine at the University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gustavo Fernandez-Ranvier
- Division of Metabolic, Endocrine, and Minimally Invasive Surgery, Department of Surgery at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ketan Badani
- Division of Urology, Department of Surgery at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric Wilck
- Department of Diagnostic, Molecular and Interventional Radiology at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Munir Ghesani
- Department of Diagnostic, Molecular and Interventional Radiology at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrea Wolf
- Division of Thoracic Surgery, Department of Surgery at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - 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, New York, NY, USA
| | - Virginia Corbett
- Division of Hematology and Oncology, Department of Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Steinmetz
- Division of Metabolic, Endocrine, and Minimally Invasive Surgery, Department of Surgery at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria Skamagas
- The Adrenal Center, Division of Endocrine, Diabetes and Bone Diseases, Department of Medicine at the Icahn School of Medicine at Mount Sinai, New York , NY, USA
| | - 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, New York , NY, USA
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Fujiwara W, Haruki T, Kidokoro Y, Ohno T, Yurugi Y, Miwa K, Taniguchi Y, Nakamura H. Cushing's syndrome caused by ACTH-producing thymic typical carcinoid with local invasion and regional lymph node metastasis: a case report. Surg Case Rep 2018; 4:55. [PMID: 29892916 PMCID: PMC5995764 DOI: 10.1186/s40792-018-0459-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/31/2018] [Indexed: 11/17/2022] Open
Abstract
Background Ectopic ACTH-producing thymic carcinoid tumors are rare, but often behave aggressively with local invasion and distant metastasis. We herein report a case of ACTH-producing thymic typical carcinoid tumor with lymph node metastasis treated by surgery and postoperative radiation therapy. Case presentation A 61-year-old woman was admitted to be evaluated for hypoglycemia and hypokalemia. Laboratory data revealed elevation of serum cortisol and ACTH levels. Overnight administration of 8 mg dexamethasone did not suppress plasma ACTH. Chest CT demonstrated a tumor of 30 mm in diameter and enlargement of the lymph node at the anterior mediastinum. Ectopic ACTH syndrome was suspected and total thymectomy and lymph node dissection were performed. The histopathological examination indicated typical carcinoid tumor and mediastinal lymph node metastasis, and immunohistochemical staining was positive for ACTH. The plasma ACTH level decreased immediately after surgery. She received postoperative radiation therapy of 60 Gy. Conclusion Ectopic ACTH-producing thymic typical carcinoid tumors are rare, and it is important to consider this disease and perform appropriate treatment.
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Affiliation(s)
- Wakako Fujiwara
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan.
| | - Tomohiro Haruki
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan
| | - Yoshiteru Kidokoro
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan
| | - Takashi Ohno
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan
| | - Yohei Yurugi
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan
| | - Ken Miwa
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan
| | - Yuji Taniguchi
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan
| | - Hiroshige Nakamura
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, 36-1, Nishi-cho, Yonago, 683-8504, Japan
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Kim KJ, Yu JH, Kim NH, Kim YH, Kim YS, Seo JA. A Case of Pulmonary Carcinoid Tumor with a Superimposed Aspergilloma Presenting As a Covert Ectopic Adrenocorticotropic Hormone Syndrome. Front Endocrinol (Lausanne) 2017; 8:123. [PMID: 28642733 PMCID: PMC5462915 DOI: 10.3389/fendo.2017.00123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ectopic adrenocorticotropic hormone (ACTH) syndrome is a challenging diagnosis only responsible for approximately 10% of Cushing syndrome cases. It has been associated with a variety of benign and malignant tumors including a carcinoid tumor accompanied by aspergilloma in our case that was significantly difficult to be detected. We report a patient over 70 years old with uncontrolled hypertension and hypokalemia presenting with generalized edema. Laboratory results revealed ACTH-dependent Cushing syndrome, but imaging studies did not show any discrete lesions secreting ACTH. The petrosal to peripheral ACTH gradient resulted in no evidence of pituitary adenoma. As the only lesion suspicious for ectopic ACTH secretion was a right lower round cystic lesion that did not appear to be a carcinoid tumor on computed tomography scan of the chest, the patient underwent video-assisted thoracic surgical resection to provide a definitive diagnosis. The final diagnosis was a small ectopic ACTH-secreting carcinoid tumor with unusual superimposed aspergilloma in the periphery of the lung. Postoperatively, the abnormal endocrine levels were normalized, and all of the clinical symptoms and signs were ameliorated. This is an informative case of ectopic ACTH syndrome (EAS) that was the cause of hypokalemia, hypertension, metabolic alkalosis, and hypercortisolism despite its poorly specific cushingoid morphology and uncommon imaging findings. Therefore, we recommend that clinicians investigate any possible lesion as a potential source of EAS.
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Affiliation(s)
- Kyoung Jin Kim
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Ji Hee Yu
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Nan Hee Kim
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Young Hye Kim
- Department of Pathology, Gil Medical Center, Gachon University, Incheon, South Korea
| | - Young Sik Kim
- Department of Pathology, Korea University College of Medicine, Seoul, South Korea
| | - Ji A Seo
- Division of Endocrinology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
- *Correspondence: Ji A Seo,
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