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Abstract
While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.
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Affiliation(s)
| | - Sophie Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
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2
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Savas M, Mehta S, Agrawal N, van Rossum EFC, Feelders RA. Approach to the Patient: Diagnosis of Cushing Syndrome. J Clin Endocrinol Metab 2022; 107:3162-3174. [PMID: 36036941 PMCID: PMC9681610 DOI: 10.1210/clinem/dgac492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Indexed: 12/27/2022]
Abstract
Cushing syndrome results from supraphysiological exposure to glucocorticoids and is associated with significant morbidity and mortality. The pathogenesis includes administration of corticosteroids (exogenous Cushing syndrome) or autonomous cortisol overproduction, whether or not ACTH-dependent (endogenous Cushing syndrome). An early diagnosis of Cushing syndrome is warranted; however, in clinical practice, it is very challenging partly because of resemblance with other common conditions (ie, pseudo-Cushing syndrome). Initial workup should start with excluding local and systemic corticosteroid use. First-line screening tests including the 1-mg dexamethasone suppression test, 24-hour urinary free cortisol excretion, and late-night salivary cortisol measurement should be performed to screen for endogenous Cushing syndrome. Scalp-hair cortisol/cortisone analysis helps in the assessment of long-term glucocorticoid exposure as well as in detection of transient periods of hypercortisolism as observed in cyclical Cushing syndrome. Interpretation of results can be difficult because of individual patient characteristics and hence requires awareness of test limitations. Once endogenous Cushing syndrome is established, measurement of plasma ACTH concentrations differentiates between ACTH-dependent (80%-85%) or ACTH-independent (15%-20%) causes. Further assessment with different imaging modalities and dynamic biochemical testing including bilateral inferior petrosal sinus sampling helps further pinpoint the cause of Cushing's syndrome. In this issue of "Approach to the patient," the diagnostic workup of Cushing syndrome is discussed with answering the questions when to screen, how to screen, and how to differentiate the different causes. In this respect, the latest developments in biochemical and imaging techniques are discussed as well.
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Affiliation(s)
| | | | - Nidhi Agrawal
- Division of Endocrinology, NYU Langone Medical Center/ Bellevue Hospital Center, New York, NY
| | - Elisabeth F C van Rossum
- Correspondence: Elisabeth F.C. van Rossum, MD, PhD, Medicine, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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3
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Abstract
The hair cycle and hair follicle structure are highly affected by various hormones. Androgens—such as testosterone (T); dihydrotestosterone (DHT); and their prohormones, dehydroepiandrosterone sulfate (DHEAS) and androstendione (A)—are the key factors in terminal hair growth. They act on sex-specific areas of the body, converting small, straight, fair vellus hairs into larger darker terminal hairs. They bind to intracellular androgen receptors in the dermal papilla cells of the hair follicle. The majority of hair follicles also require the intracellular enzyme 5-alpha reductase to convert testosterone into DHT. Apart from androgens, the role of other hormones is also currently being researched—e.g., estradiol can significantly alter the hair follicle growth and cycle by binding to estrogen receptors and influencing aromatase activity, which is responsible for converting androgen into estrogen (E2). Progesterone, at the level of the hair follicle, decreases the conversion of testosterone into DHT. The influence of prolactin (PRL) on hair growth has also been intensively investigated, and PRL and PRL receptors were detected in human scalp skin. Our review includes results from many analyses and provides a comprehensive up-to-date understanding of the subject of the effects of hormonal changes on the hair follicle.
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4
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Capella CE, Chandrasekar T, Counsilman M, Sebastiano C, Lallas CD, Al-Kouatly HB. Robotic Adrenalectomy for Functional Adenoma in Second Trimester Treats Worsening Hypertension. Urology 2020; 151:67-71. [PMID: 32360626 DOI: 10.1016/j.urology.2020.04.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/29/2020] [Accepted: 04/19/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Courtney E Capella
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
| | - Thenappan Chandrasekar
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - MayJean Counsilman
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Christopher Sebastiano
- Department of Pathology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Costas D Lallas
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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5
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Manoharan M, Sinha P, Sibtain S. Adrenal disorders in pregnancy, labour and postpartum - an overview. J OBSTET GYNAECOL 2019; 40:749-758. [PMID: 31469031 DOI: 10.1080/01443615.2019.1648395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adrenal disorders may manifest during pregnancy for the first time, or present from before pregnancy as either undiagnosed or diagnosed and treated. They may present as hormonal hypofunction or hyperfunction, or with mass effects or other non-endocrine effects. Adrenal disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyper-aldosteronism and adreno-cortical carcinoma are rare in pregnancy. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal and renin-angiotensin-aldosterone axis as these undergoe major changes during pregnancy. Diagnosis is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. A timely diagnosis and treatment is critical as these disorders can cause maternal and foetal morbidity and mortality. A high index of suspicion must be maintained as they can go unrecognised and untreated. An early diagnosis and treatment often improves outcomes. The aim of this article is to review the patho-physiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.
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Affiliation(s)
| | - Prabha Sinha
- Department of Obstetrics and Gynaecology, Oman Medical College, Muscat, Oman
| | - Shabnum Sibtain
- Department of Obstetrics and Gynaecology, Azra Naheed Medical College, Lahore, Pakistan
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6
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Jolly K, Darr A, Arlt W, Ahmed S, Karavitaki N. Surgery for Cushing's disease in pregnancy: our experience and a literature review. Ann R Coll Surg Engl 2019; 101:e26-e31. [PMID: 30286651 PMCID: PMC6303815 DOI: 10.1308/rcsann.2018.0175] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 12/23/2022] Open
Abstract
Cushing's syndrome in pregnancy is a rare phenomenon and there is limited literature on its management. Cushing's disease in pregnancy is even less common and there is little guidance to help in the treatment for this patient group. Diagnosis of Cushing's syndrome in pregnancy is often delayed due to overlap of symptoms. In addition, there are no validated diagnostic tests or parameters documented. We present a case of a 30-year-old woman presenting to the antenatal clinic at 13 weeks of pregnancy with high suspicion of Cushing's disease. Her 21-week fetal scan showed a congenital diaphragmatic hernia and she underwent pituitary magnetic resonance imaging, which confirm Cushing's disease. She successfully underwent transsphenoidal adenomectomy with histology confirming a corticotroph adenoma. Tests following transsphenoidal surgery confirmed remission of Cushing's disease and she underwent an emergency caesarean section at 38 weeks. Unfortunately, her baby died from complications associated with the congenital abnormality 36 hours after birth. The patient remains in remission following delivery. To date, there have been no reported cases of congenital diaphragmatic hernia associated with Cushing's disease in pregnancy. In addition, we believe that this is only the eighth reported patient to have undergone successful transsphenoidal surgery for Cushing's disease in pregnancy.
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Affiliation(s)
- K Jolly
- Ear, Nose and Throat Department, University Hospital Birmingham, Birmingham, UK
| | - A Darr
- Ear, Nose and Throat Department, University Hospital Birmingham, Birmingham, UK
| | - W Arlt
- Department of Endocrinology, University Hospital Birmingham, Birmingham, UK
| | - S Ahmed
- Ear, Nose and Throat Department, University Hospital Birmingham, Birmingham, UK
| | - N Karavitaki
- Department of Endocrinology, University Hospital Birmingham, Birmingham, UK
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7
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Pourali L, Vatanchi AM, Hamidi A. A Case of Cushing's Syndrome in Pregnancy. IRANIAN JOURNAL OF MEDICAL SCIENCES 2017; 42:607-610. [PMID: 29184271 PMCID: PMC5684384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cushing's syndrome (CS) occurs rarely during pregnancy. CS can be caused by prolonged abnormal exposure to excess glucocorticoids leading to special and significant signs and symptoms. It is often difficult to diagnose pathological hypercortisolism in pregnant women since some symptoms of the disease might be due to a complicated pregnancy, including preeclampsia or gestational diabetes. In this study, we report the case of a 29-year-old female who referred to our institution with hypertension, weakness, steria, and truncal obesity. Physical examination revealed cushingoid characteristic. She was also found to be 27 weeks pregnant. CS was diagnosed on the basis of abnormal serum cortisol and adrenocorticotropin hormone (ACTH) levels, as well as radiologic findings. She eventually gave birth to a preterm infant via vaginal delivery. A right adrenal adenoma was diagnosed and was subsequently treated with surgical resection. The patient's condition remained stable after the surgery.
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Affiliation(s)
- Leila Pourali
- Department of Obstetrics and Gynecology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atiyeh Mohammadzade Vatanchi
- Department of Obstetrics and Gynecology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran,Correspondence: Atiyeh Mohammadzade Vatanchi, MD; Department of Obstetrics and Gynecology, Ghaem Hospital, Ahmadabad St., P. O. Box: 91766-99199, Mashhad, Iran Tel/Fax: +98 51 38430569 (345)
| | - Anahita Hamidi
- Department of Obstetrics and Gynecology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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8
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Paduraru DN, Nica A, Carsote M, Valea A. Adrenalectomy for Cushing's syndrome: do's and don'ts. J Med Life 2016; 9:334-341. [PMID: 27928434 PMCID: PMC5141390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aim. To present specific aspects of adrenalectomy for Cushing’s syndrome (CS) by introducing well established aspects (“do’s”) and less known aspects (“don’ts”). Material and Method. This is a narrative review. Results. The “do’s” for laparoscopic adrenalectomy (LA) are the following: it represents the “gold standard” for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients’ selection and the surgeon’s skills. The “don’ts” are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The “don’ts” are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the “do’s” are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing’s disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing’s syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA. Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women. Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing’s disease, CS = Cushing’s syndrome, ECS = Ectopic Cushing’s syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing’ syndrome
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Affiliation(s)
- D N Paduraru
- Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Department of Surgery, University Emergency Hospital, Bucharest, Romania
| | - A Nica
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesiology, University Emergency Hospital, Bucharest, Romania
| | - M Carsote
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Department of Endocrinology, "C. I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - A Valea
- "I. Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Endocrinology, Clinical County Hospital, Cluj-Napoca, Romania
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