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Lemarcq L, De Vis M, Deweer S, Gutermuth J, Velkeniers B. Coexistence of Vitiligo and Hyperpigmentation: A Quiz. Acta Derm Venereol 2024; 104:adv35429. [PMID: 38380976 PMCID: PMC10910515 DOI: 10.2340/actadv.v104.35429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/22/2024] [Indexed: 02/22/2024] Open
Abstract
Abstract is missing (Quiz)
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Affiliation(s)
- Laure Lemarcq
- SKIN Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Dermatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.
| | - Maarten De Vis
- Department of Endocrinology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Sophie Deweer
- Department of Endocrinology and Diabetology, Algemeen Ziekenhuis Sint-Elisabeth Zottegem, Belgium
| | - Jan Gutermuth
- SKIN Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Dermatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Brigitte Velkeniers
- Department of Internal Medicine, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
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Jones K, Reis I, Levy MJ, Potdar N. Nelson syndrome and perinatal challenges: A case report and systematic review of the literature. Int J Gynaecol Obstet 2023; 163:89-95. [PMID: 37128819 DOI: 10.1002/ijgo.14791] [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: 02/14/2023] [Accepted: 03/29/2023] [Indexed: 05/03/2023]
Abstract
Nelson syndrome is a rare and potentially life-threatening complication of treatment with total bilateral adrenalectomy for women with Cushing disease. A successful term pregnancy following fertility treatment in a patient with Nelson syndrome is presented. Our study provides guidance in the prenatal and intrapartum management of this condition. A case report and a systematic review of 14 papers describing 50 pregnancies are presented. An electronic database search included Medline (1946 to September 2022), Embase (1980 to September 2022), Cochrane Library, and UKOSS. A small number of pregnancies in women with Nelson syndrome are reported in literature, but there are no guidelines. Some authors detail the prenatal care provided to their patients. Four studies report prenatal monitoring with visual field checks and two report monitoring with X-rays. Five studies report the use of parenteral hydrocortisone at the time of delivery. Where described, women delivered appropriately grown newborns at term, with timing and mode of delivery dictated by obstetric indications. Preconception counseling and optimization of maternal health status improve pregnancy outcomes in women with Nelson syndrome. Multidisciplinary review in a combined obstetric-endocrine prenatal clinic is ideal. Awareness about potential complications during pregnancy and the postnatal period is crucial in providing optimal care to the mother and baby.
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Affiliation(s)
- Kate Jones
- Women and Children CMG, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ines Reis
- Women and Children CMG, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Miles J Levy
- Department of Endocrinology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Neelam Potdar
- Women and Children CMG, University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
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Serioli S, Borghesi I, Regge Gianas N, Fontanella MM, Calbucci F, Draghi R. Petroclival Aggressive Pituitary Adenoma in Nelson's Syndrome: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e164. [PMID: 37222515 DOI: 10.1227/ons.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/29/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Ignazio Borghesi
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Nicolò Regge Gianas
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Fabio Calbucci
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Riccardo Draghi
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
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Desai PD, Kargutkar S, Nalla R. A Unique Presentation of Nelson Syndrome Due to Partial Adrenal Insufficiency Without Bilateral Adrenalectomy. Cureus 2023; 15:e43518. [PMID: 37719555 PMCID: PMC10501167 DOI: 10.7759/cureus.43518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/19/2023] Open
Abstract
Nelson syndrome is a rare disorder, characterized by clinical features arising from an adrenocorticotropic hormone (ACTH)-secreting pituitary macroadenoma after bilateral adrenalectomy. Common symptoms of Nelson syndrome include weight gain, vision problems, and skin hyperpigmentation, among many others. In this case report, a 58-year-old Asian female who displayed clinical features akin to Nelson syndrome despite not undergoing bilateral adrenalectomy is investigated. The patient has a past history of an ACTH-secreting pituitary macroadenoma, for which a transsphenoidal resection was performed along with radiation therapy. A year following this, she displayed severe facial and neck hyperpigmentation. According to the laboratory results obtained, the patient displayed initial high ACTH levels and low-normal AM cortisol levels, which are signs of partial adrenal insufficiency. A brain MRI was performed, which confirmed stable residual tumor tissue in the cavernous sinus. The results pointed to the adrenal glands as the cause of the hyperpigmentation, and the patient was diagnosed with primary adrenal insufficiency. To bring her ACTH levels and low-normal AM cortisol into the proper range, she was given low-dose hydrocortisone and monitored for five years. Over this time period, her hyperpigmentation improved significantly and eventually resolved entirely, and her ACTH levels were lowered, indicating that hydrocortisone was the appropriate treatment for normalizing ACTH levels. In this case, it was determined that unresponsive adrenal glands lead to high ACTH levels, which resulted in an atypical case of Nelson syndrome and the physical symptom of hyperpigmentation.
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Affiliation(s)
| | - Smita Kargutkar
- Endocrinology, Diabetes, and Metabolism, ACE Endocrinology Associates, Red Bank, USA
| | - Raveena Nalla
- Endocrinology, Diabetes, and Metabolism, Monmouth Medical Center, Long Branch, USA
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Torres-Ríos JA, Romero-Luna G, Meraz Soto JM, Zavala-Romero L, Aguirre Maqueda ML, Rodríguez Camacho A, Moreno Jiménez S. Nelson's Syndrome: A Narrative Review. Cureus 2023; 15:e39114. [PMID: 37332454 PMCID: PMC10272858 DOI: 10.7759/cureus.39114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Nelson's syndrome (NS) is an uncommon disease occurring as a complication of bilateral adrenalectomy (BLA) in patients with persistent Cushing's disease (CD) due to an adrenocorticotropin-producing pituitary tumor. The first reports of this syndrome were done in the 50s, although its pathophysiology is still not understood. Every year, between 1.8 and 2.6 cases are thought to occur per million people. It is characterized by hyperpigmentation, elevated adrenocorticotropic hormone (ACTH) plasma levels, and typical signs and symptoms related to pituitary adenomas, such as visual deficits due to optic pathway compression or decreased hormone production from the adenohypophysis. NS represents a challenge due to the lack of accepted diagnostic criteria and the complexity of its treatment. Moreover, the development of stereotactic radiosurgery (SRS) in the last few years has become an essential but controversial strategy for this syndrome. This review presents a comprehensive overview of NS.
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Affiliation(s)
| | - Gerardo Romero-Luna
- Neurosurgery and Radiosurgery, National Institute of Neurology and Neurosurgery, Mexico City, MEX
| | - Juan Marcos Meraz Soto
- Neurosurgery and Radiosurgery, National Institute of Neurology and Neurosurgery, Mexico City, MEX
| | - Lilian Zavala-Romero
- Neurosurgery and Radiosurgery, National Institute of Neurology and Neurosurgery, Mexico City, MEX
| | - Monica L Aguirre Maqueda
- Neurosurgery and Radiosurgery, National Institute of Neurology and Neurosurgery, Mexico City, MEX
| | - Alejandro Rodríguez Camacho
- Radiosurgery, National Institute of Neurology and Neurosurgery, Mexico City, MEX
- Radioneurosurgery, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City, MEX
| | - Sergio Moreno Jiménez
- Neurology, ABC Medical Center, Mexico City, MEX
- Neurosurgery and Radiosurgery, National Institute of Neurology and Neurosurgery, Mexico City, MEX
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Schuppe K, Burke S, Cohoe B, Chang K, Lance RS, Mroch H. Atypical Nelson Syndrome Following Right Partial and Left Total Nephrectomy With Incidental Bilateral Total Adrenalectomy of Renal Cell Carcinoma: A Chat Generative Pre-Trained Transformer (ChatGPT)-Assisted Case Report and Literature Review. Cureus 2023; 15:e36042. [PMID: 37056551 PMCID: PMC10089233 DOI: 10.7759/cureus.36042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/14/2023] Open
Abstract
Nelson syndrome (NS) is a dangerous condition that can sometimes manifest after bilateral adrenalectomy (BA), typically in treating Cushing's disease. It is defined by the collection of systemic signs and symptoms that can arise in a state where there are chronically and massively elevated levels of adrenocorticotropic hormone (ACTH). Traditionally it may manifest from six months to 24 years following the loss of both adrenal glands, with the meantime of development being 15 years following BA. The diagnostic criteria are controversial, with historically many different methods being used, ranging from visual field defects and an enlarged pituitary corticotrophinoma to elevated plasma ACTH levels and skin hyperpigmentation. What remains consistent between criteria is that it is secondary to total BA, traditionally in treating refractory Cushing's disease. We describe here a rare case of a patient diagnosed with bilateral renal cell carcinoma (RCC) treated with right partial and left total nephrectomy, and incidental BA, presenting with the symptoms and signs of NS. Although NS classically presents following total BA for the treatment of Cushing disease, further research is required to look for etiologies of Nelson's-like pathology outside the context of Cushing's disease treatment, thereby necessitating a change to the traditional diagnostic criteria for the syndrome to identify cases that would otherwise go untreated. In addition, this case report's outlining, drafting, and conclusions were written in part by or with the support of Chat Generative Pre-Trained Transformer (ChatGPT), a large language transformer open-source artificial intelligence.
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Berkmann S, Roethlisberger M, Mueller B, Christ-Crain M, Mariani L, Nitzsche E, Juengling F. Selective resection of cushing microadenoma guided by preoperative hybrid 18-fluoroethyl-L-tyrosine and 11-C-methionine PET/MRI. Pituitary 2021; 24:878-886. [PMID: 34155554 DOI: 10.1007/s11102-021-01160-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE 11-C-methionine (MET)-positron emission tomography (PET) as an adjunct to magnetic resonance imaging (MRI) has been proposed as a suitable molecular imaging modality for localizing pituitary adenomas in Cushing's disease. 18-F-Fluoroethyl-L-tyrosine (FET)-PET, which is more widely available has not yet been reported in this context. METHODS Retrospective double-center cohort study on 15 patients who underwent transsphenoidal surgery for biochemically proven Cushing's disease between 2011 and 2019. Preoperative MET-PET/MRI and/or FET-PET/MRI were compared with intraoperative and histopathological examinations using the Mann Whitney U test and the Fisher's Exact test, along with positive predictive value calculations. RESULTS Fifteen patients were included, with a mean age of 47.2 (18-69) years. Six patients received either a MET-PET/MRI or a FET-PET/MRI and 3 patients both exams, respectively. 67% of the tumors were detected by MRI (MET-PET-group [56%]; FET-PET-group [78%]). All tumors were microadenomas with a mean adenoma volume of 0.19 cm3 (0.02-0.78), all of which displayed a circumscribed pathological FET- and/or MET-uptake. FET-PET/MRI results positively correlated with the localization of the tumor confirmed intraoperatively and histopathologically in all cases, resulting in a sensitivity and specificity of FET-PET/MRI for tumor localization of 100% (95% CI 66.37-100%). One MET-PET/MRI suggested a localization contralateral to the expected spot. The sensitivity and specificity of MET-PET for tumor localization hence was 89% (95% CI 51.75-99.72%). CONCLUSIONS Preoperative hybrid FET-PET/MRI and MET-PET/MRI have a high predictive value in localizing corticotroph adenoma for selective adenomectomy in Cushing's disease.
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Affiliation(s)
- Sven Berkmann
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, CH, Switzerland.
| | | | - Beat Mueller
- Division of Endocrinology, Diabetology and Metabolism, Univ. Department of Medicine, Kantonsspital Aarau, Aarau, CH, Switzerland
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetology and Metabolism, Univ. Department of Medicine, Universitaetsspital Basel, Basel, CH, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, Universitaetsspital Basel, Basel, CH, Switzerland
| | - Egbert Nitzsche
- Department of Nuclear Medicine, Kantonsspital Aarau, Aarau, CH, Switzerland
| | - Freimut Juengling
- Department of Nuclear Medicine, St. Claraspital, Basel, CH, Switzerland
- Medical Faculty, University Bern, Bern, CH, Switzerland
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Papakokkinou E, Piasecka M, Carlsen HK, Chantzichristos D, Olsson DS, Dahlqvist P, Petersson M, Berinder K, Bensing S, Höybye C, Engström BE, Burman P, Follin C, Petranek D, Erfurth EM, Wahlberg J, Ekman B, Åkerman AK, Schwarcz E, Johannsson G, Falhammar H, Ragnarsson O. Prevalence of Nelson's syndrome after bilateral adrenalectomy in patients with cushing's disease: a systematic review and meta-analysis. Pituitary 2021; 24:797-809. [PMID: 34036460 PMCID: PMC8416875 DOI: 10.1007/s11102-021-01158-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Bilateral adrenalectomy (BA) still plays an important role in the management of Cushing's disease (CD). Nelson's syndrome (NS) is a severe complication of BA, but conflicting data on its prevalence and predicting factors have been reported. The aim of this study was to determine the prevalence of NS, and identify factors associated with its development. DATA SOURCES Systematic literature search in four databases. STUDY SELECTION Observational studies reporting the prevalence of NS after BA in adult patients with CD. DATA EXTRACTION Data extraction and risk of bias assessment were performed by three independent investigators. DATA SYNTHESIS Thirty-six studies, with a total of 1316 CD patients treated with BA, were included for the primary outcome. Pooled prevalence of NS was 26% (95% CI 22-31%), with moderate to high heterogeneity (I2 67%, P < 0.01). The time from BA to NS varied from 2 months to 39 years. The prevalence of NS in the most recently published studies, where magnet resonance imaging was used, was 38% (95% CI 27-50%). The prevalence of treatment for NS was 21% (95% CI 18-26%). Relative risk for NS was not significantly affected by prior pituitary radiotherapy [0.9 (95% CI 0.5-1.6)] or pituitary surgery [0.6 (95% CI 0.4-1.0)]. CONCLUSIONS Every fourth patient with CD treated with BA develops NS, and every fifth patient requires pituitary-specific treatment. The risk of NS may persist for up to four decades after BA. Life-long follow-up is essential for early detection and adequate treatment of NS.
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Affiliation(s)
- Eleni Papakokkinou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden
| | - Marta Piasecka
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden
| | - Hanne Krage Carlsen
- Department of Environmental and Occupational Health School of Public Health and Community Medicine, University of Gothenburg, 4053, Gothenburg, Sweden
| | - Dimitrios Chantzichristos
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden
| | - Daniel S Olsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Maria Petersson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Katarina Berinder
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Britt Edén Engström
- Department of Endocrinology and Diabetes, Uppsala University Hospital, and Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University, 751 85, Uppsala, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, University of Lund, 205 02, Malmö, Sweden
| | - Cecilia Follin
- Department of Endocrinology, Skåne University Hospital, 222 42, Lund, Sweden
| | - David Petranek
- Department of Endocrinology, Skåne University Hospital, 222 42, Lund, Sweden
| | - Eva Marie Erfurth
- Department of Endocrinology, Skåne University Hospital, 222 42, Lund, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology and Department of Medical and Health Sciences, Linköping University, 581 83, Linköping, Sweden
- Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, 702 81, Örebro, SE, Sweden
| | - Bertil Ekman
- Department of Endocrinology and Department of Medical and Health Sciences, Linköping University, 581 83, Linköping, Sweden
| | - Anna-Karin Åkerman
- Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, 702 81, Örebro, SE, Sweden
| | - Erik Schwarcz
- Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, 702 81, Örebro, SE, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.
- The Department of Endocrinology, Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden.
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Losa M, Detomas M, Bailo M, Barzaghi LR, Albano L, Piloni M, Pagnano A, Pedone E, Mortini P. Gamma knife radiosurgery in patients with Nelson's syndrome. J Endocrinol Invest 2021; 44:2243-2251. [PMID: 33611756 DOI: 10.1007/s40618-021-01531-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Nelson's syndrome (NS) is a long-term complication of bilateral adrenalectomy in patients with Cushing's disease. The best therapeutic strategy in NS has not been well defined. Gamma knife radiosurgery (GKRS) is very effective to stop the growth of the pituitary adenoma, which is the main goal of the treatment of patients with NS. We report the largest series of patients with NS treated by GKRS at a single center. METHODS The study was an observational, retrospective analysis of 28 consecutive patients with NS treated by GKRS in our department between 1995 and 2019. All patients had a growing ACTH-secreting pituitary adenoma. The main outcome of the study was to assess by the Kaplan-Meier method the risk of tumor progression after GKRS. RESULTS The median follow-up after GKRS treatment was 98 months (IQR 61-155 months, range 7-250 months). Two patients (7.1%) had a recurrence of disease during follow-up. The 10-year progression-free survival was 91.7% (95% CI 80.5-100%). No patient had deterioration of visual function or oculomotor function after GKRS. New onset of hypogonadism and hypothyroidism occurred in 18.8% and 14.3% of the patients at risk. CONCLUSION Our study confirms that GKRS may stop the tumor growth in the majority of patients with NS, even though very aggressive adenomas may ultimately escape this treatment. Safety of GKRS was good in our experience, but due attention must be paid to planning the distribution of radiation to critical structures, especially in patients previously treated by radiation.
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Affiliation(s)
- M Losa
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
| | - M Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - M Bailo
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - L R Barzaghi
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - L Albano
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - M Piloni
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - A Pagnano
- Vita-Salute San Raffaele University, Milan, Italy
| | - E Pedone
- Vita-Salute San Raffaele University, Milan, Italy
| | - P Mortini
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
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Shahrestani S, Strickland BA, Carmichael J, Zada G. Multivariable analysis of 63 contemporary patients diagnosed with nelson's syndrome: A nationwide readmission database study. J Clin Neurosci 2021; 92:45-48. [PMID: 34509260 DOI: 10.1016/j.jocn.2021.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 06/14/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Nelson's syndrome (NS) is a rare complication involving enlargement of an adrenocorticotropic hormone (ACTH) producing tumor in the pituitary following bilateral adrenalectomy in Cushing's syndrome. Here, we explore the epidemiology, complication profiles, and readmission statistics of 63 patients diagnosed with NS. METHODS The Nationwide Readmission Database was retrospectively queried for all patients diagnosed with NS (n = 63) or receiving total bilateral adrenalectomy (TBA) surgery (n = 275) between 2016 and 2017. Complications, demographics, and predictive factors were queried for all patients involved. Statistical analysis used Mann-Whitney U nonparametric testing was to compare basic demographics and gaussian-fitted multivariable regression analysis with post hoc odds ratios to compare patient predictors of development of NS and complication rates between the two cohorts. RESULTS We report the largest contemporary patient series of NS through a nationally-representative inpatient database and explore the clinical characteristics of modern NS patients. Modeling revealed that the absence of primary hypertension served as a significant predictor for NS when compared to the TBA control cohort (OR = 0.88; 95%CI = 0.79-0.99; p = 0.037). In addition, analysis of complications between NS and TBA cohortsrevealed that NS patients have significantly higher rates of hypoosmolarity/hyponatremia (OR = 1.42; 95%CI = 1.19-1.71; p = 0.00021), hypopituitarism (OR = 1.94; 95%CI = 1.60-2.36; p < 0.0001), and sepsis (OR = 1.51; 95%CI = 1.14-2.00; p = 0.0046). CONCLUSION Contemporary NS is a rare complication of TBA, and modern cases of NS may differ significantly from cases of NS reported in the mid-1900s. As such, a thorough understanding of patient complications and predictive factors for NS are necessary to fully guide patient management in the modern era.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA.
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John Carmichael
- Department of Endocrinology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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11
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Bunevicius A, Lavezzo K, Smith PW, Vance ML, Sheehan J. Stereotactic radiosurgery before bilateral adrenalectomy is associated with lowered risk of Nelson's syndrome in refractory Cushing's disease patients. Acta Neurochir (Wien) 2021; 163:1949-1956. [PMID: 33759014 DOI: 10.1007/s00701-021-04823-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Nelson's syndrome is a rare but challenging sequelae of Cushing's disease (CD) after bilateral adrenalectomy (BLA). We sought to determine if stereotactic radiosurgery (SRS) of residual pituitary adenoma performed before BLA can decrease the risk of Nelson's syndrome. METHODS Consecutive patients with CD who underwent BLA after non-curative resection of ACTH secreting pituitary adenoma and had at least one follow-up visit after BLA were studied. Nelson's syndrome was diagnosed based on the combination of rising ACTH levels, increasing volume of the pituitary adenoma and/or hyperpigmentation. RESULTS Fifty patients underwent BLA for refractory CD, and 43 patients (7 men and 36 women) had at least one follow-up visit after BAL. Median endocrine, imaging, and clinical follow-up were 66 months, 69 months, and 80 months, respectively. Nine patients (22%) were diagnosed with the Nelson's syndrome at median time after BLA at 24 months (range: 0.6-119.4 months). SRS before BLA was associated with reduced risk of the Nelson's syndrome (HR = 0.126; 95%CI [0.022-0.714], p=0.019), while elevated ACTH level within 6 months after BLA was associated with increased risk for the Nelson's syndrome (HR = 9.053; 95%CI [2.076-39.472], p=0.003). CONCLUSIONS SRS before BLA can reduce the risk for the Nelson's syndrome in refractory CD patients requiring BLA and should be considered before proceeding to BLA. Elevated ACTH concentration within 6 months after BLA is associated with greater risk of the Nelsons' syndrome. When no prior SRS is administered, those with a high ACTH level shortly after BLA may benefit from early SRS.
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Esparza-Salazar FJ, Hernández-González JA, Lezama-Toledo AR, Incontri-Abraham D, Corral A, Armenta-Moreno JI, Vargas-Abonce VP, Cuevas-Ramos D, Gómez-Pérez FJ, Gómez-Sámano MA. Nelson Syndrome: A Case Report and Literature Review. AACE Clin Case Rep 2020; 7:141-144. [PMID: 34095473 PMCID: PMC8053620 DOI: 10.1016/j.aace.2020.11.034] [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] [Indexed: 11/04/2022] Open
Abstract
Objective Nelson syndrome (NS) is a rare clinical disorder that can occur after total bilateral adrenalectomy (TBA), performed as a treatment for Cushing disease. NS is defined as the accelerated growth of an adrenocorticotropic hormone-producing pituitary adenoma. Our objective is to describe a case of NS and discuss it based on existing knowledge of this syndrome. Methods We describe the case of a woman diagnosed with NS at our facility in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran and review published cases of NS. Results The patient, a 35-year-old woman with Cushing disease, had been diagnosed in 2006 at the endocrinology department in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. In 2007, a laparoscopic TBA was performed, and 2 years later, she presented with hyperpigmentation and adrenocorticotropic hormone levels of up to 11 846 pg/mL. NS was suspected, and as magnetic resonance imaging showed macroadenoma, transsphenoidal surgery was performed. The patient remained asymptomatic until 2012, when she presented with a right hemicranial headache, photophobia, and phonophobia. A fresh magnetic resonance imaging was performed, which documented tumor growth. She was referred to the Instituto Nacional de Neurologia y Neurocirugia, where she underwent surgery. Conclusion NS develops as a complication of TBA, which is used as a treatment of Cushing disease. The main treatment is surgery and radiotherapy.
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Affiliation(s)
| | | | | | | | - Armando Corral
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | | | - Valerie P Vargas-Abonce
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | - Daniel Cuevas-Ramos
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | - Francisco J Gómez-Pérez
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | - Miguel A Gómez-Sámano
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
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13
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Lin AL, Donoghue MTA, Wardlaw SL, Yang TJ, Bodei L, Tabar V, Geer EB. Approach to the Treatment of a Patient with an Aggressive Pituitary Tumor. J Clin Endocrinol Metab 2020; 105:5905925. [PMID: 32930787 PMCID: PMC7566322 DOI: 10.1210/clinem/dgaa649] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022]
Abstract
A small subset of pituitary adenomas grows despite maximal treatment with standard therapies; namely, surgery and radiotherapy. These aggressive tumors demonstrate 2 patterns of growth: they may be locally aggressive or metastasize distantly, either hematogenously or through the spinal fluid. Further surgery and radiotherapy may be helpful for palliation of symptoms, but they are rarely definitive in the management of these malignant tumors. The only chemotherapy with established activity in the treatment of pituitary tumors is the alkylating agent temozolomide. At most, 50% of patients exhibit an objective response to temozolomide and the median time to progression is short; thus, there remains a significant unmet need for effective treatments within this patient population. Several targeted agents have reported activity in this tumor type-including small molecule inhibitors, checkpoint inhibitors, and other biologics-but remain investigational at this time.
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Affiliation(s)
- Andrew L Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Correspondence and Reprint Requests: Andrew Lin, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA. E-mail:
| | - Mark T A Donoghue
- Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sharon L Wardlaw
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Bodei
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Program in Cell Biology and Genetics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eliza B Geer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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14
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Cheng X, D'Orsogna MR, Chou T. Mathematical modeling of depressive disorders: Circadian driving, bistability and dynamical transitions. Comput Struct Biotechnol J 2020; 19:664-690. [PMID: 33510869 PMCID: PMC7815682 DOI: 10.1016/j.csbj.2020.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022] Open
Abstract
The hypothalamus-pituitary-adrenal (HPA) axis is a key neuroendocrine system implicated in stress response, major depression disorder, and post-traumatic stress disorder. We present a new, compact dynamical systems model for the response of the HPA axis to external stimuli, representing stressors or therapeutic intervention, in the presence of a circadian input. Our work builds upon previous HPA axis models where hormonal dynamics are separated into slow and fast components. Several simplifications allow us to derive an effective model of two equations, similar to a multiplicative-input FitzHugh-Nagumo system, where two stable states, a healthy and a diseased one, arise. We analyze the effective model in the context of state transitions driven by external shocks to the hypothalamus, but also modulated by circadian rhythms. Our analyses provide mechanistic insight into the effects of the circadian cycle on input driven transitions of the HPA axis and suggest a circadian influence on exposure or cognitive behavioral therapy in depression, or post-traumatic stress disorder treatment.
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Affiliation(s)
- Xiaoou Cheng
- School of Mathematical Sciences, Peking University, Haidian District, Beijing 100871, China
| | - Maria R D'Orsogna
- Dept. of Mathematics, California State University, Northridge, CA 91330, United States
- Dept. of Computational Medicine, UCLA, Los Angeles, CA 90095, United States
| | - Tom Chou
- Dept. of Computational Medicine, UCLA, Los Angeles, CA 90095, United States
- Dept. of Mathematics, UCLA, Los Angeles, CA 90095, United States
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15
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Fill SM, Popp KH, Stalla GK, Athanasoulia-Kaspar AP. Exceptional Response of Nelson's Syndrome to Pasireotide LAR in the Long-Term Follow-up of 9 Years. Exp Clin Endocrinol Diabetes 2020; 129:776-778. [PMID: 33184804 DOI: 10.1055/a-1158-9214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Sandra M Fill
- Urological Clinic und Poliklinik für Urologie, Munich
| | - Kathrin H Popp
- Medicover Neuroendocrinology Prof. Stalla and Colleagues, Munich
| | - Günter K Stalla
- Medicover Neuroendocrinology Prof. Stalla and Colleagues, Munich.,Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians Universität München, Munich
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16
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He X, Spencer-Segal JL. Rapid response of Nelson's syndrome to pasireotide in radiotherapy-naive patient. Clin Diabetes Endocrinol 2020; 6:22. [PMID: 33292741 PMCID: PMC7648374 DOI: 10.1186/s40842-020-00110-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nelson's syndrome is a well-described complication following bilateral adrenalectomy for management of Cushing's disease. There is no consensus on optimal management of Nelson's syndrome, characterized by the triad of pituitary corticotroph adenoma growth, elevated serum adrenocorticotropic hormone, and skin hyperpigmentation. Medical therapy with a variety of drug classes have been studied. One potentially promising drug already approved for Cushing's disease is pasireotide, a somatostatin analog with affinity for multiple somatostatin receptors, including subtype 5, the most highly expressed receptor on corticotroph tumors. CASE PRESENTATION A 24-year-old female was diagnosed with Cushing's disease with initial ACTH levels around 700-800 pg/mL. She underwent transsphenoidal surgery without remission, followed by bilateral adrenalectomy. Over the subsequent 3 years, the patient developed skin hyperpigmentation, recurrent elevations of ACTH, and tumor recurrence requiring two additional transsphenoidal surgeries. After her third transsphenoidal resection, ACTH normalized, no residual tumor was seen on radiology, and the patient's skin hyperpigmentation improved. She then had an uncomplicated full-term pregnancy, during which ACTH levels remained within normal limits. One month after delivery, ACTH levels began rising to a peak at 5,935 pg/mL. Imaging revealed two new bilateral pituitary adenomas, measuring 14 mm on the left, and 7 mm on the right. She was then started on pasireotide. After two months of therapy, ACTH decreased to 609 pg/mL, and repeat pituitary MRI showed interval decrease in size of both pituitary adenomas to 13 mm on the left and 6 mm on the right. CONCLUSION We report the protracted course of a young female with several recurrences of Nelson's syndrome following bilateral adrenalectomy and multiple transsphenoidal surgeries, who ultimately responded to pasireotide. Unique features of her case not described previously are the response to pasireotide in a radiotherapy-naive patient, as well as the rapid radiologic response to therapy. Her history illustrates the unresolved challenges of Nelson's syndrome and the continued need for additional studies to identify optimal management.
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Affiliation(s)
- Xin He
- Department of Internal Medicine, Division of Metabolism, Endocrinology & Diabetes, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Joanna L Spencer-Segal
- Department of Internal Medicine, Division of Metabolism, Endocrinology & Diabetes, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA. .,Michigan Neuroscience Institute, University of Michigan, 205 Zina Pitcher Pl, Ann Arbor, MI, 48109, USA.
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17
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Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
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Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
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18
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Abstract
Nelson's syndrome (NS) is a condition which may develop in patients with Cushing's disease after bilateral adrenalectomy. Although there is no formal consensus on what defines NS, corticotroph tumor growth and/or gradually increasing ACTH levels are important diagnostic elements. Pathogenesis is unclear and well-established predictive factors are lacking; high ACTH during the first year after bilateral adrenalectomy is the most consistently reported predictive parameter. Management is individualized and includes surgery, with or without radiotherapy, radiotherapy alone, and observation; medical treatments have shown inconsistent results. A subset of tumors demonstrates aggressive behavior with challenging management, malignant transformation and poor prognosis.
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Affiliation(s)
- Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
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19
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Fountas A, Lim ES, Drake WM, Powlson AS, Gurnell M, Martin NM, Seejore K, Murray RD, MacFarlane J, Ahluwalia R, Swords F, Ashraf M, Pal A, Chong Z, Freel M, Balafshan T, Purewal TS, Speak RG, Newell-Price J, Higham CE, Hussein Z, Baldeweg SE, Dales J, Reddy N, Levy MJ, Karavitaki N. Outcomes of Patients with Nelson's Syndrome after Primary Treatment: A Multicenter Study from 13 UK Pituitary Centers. J Clin Endocrinol Metab 2020; 105:5628028. [PMID: 31735971 DOI: 10.1210/clinem/dgz200] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023]
Abstract
CONTEXT Long-term outcomes of patients with Nelson's syndrome (NS) have been poorly explored, especially in the modern era. OBJECTIVE To elucidate tumor control rates, effectiveness of various treatments, and markers of prognostic relevance in patients with NS. PATIENTS, DESIGN, AND SETTING Retrospective cohort study of 68 patients from 13 UK pituitary centers with median imaging follow-up of 13 years (range 1-45) since NS diagnosis. RESULTS Management of Cushing's disease (CD) prior to NS diagnosis included surgery+adrenalectomy (n = 30; eight patients had 2 and one had 3 pituitary operations), surgery+radiotherapy+adrenalectomy (n = 17; two received >1 courses of irradiation, two had ≥2 pituitary surgeries), radiotherapy+adrenalectomy (n = 2), and adrenalectomy (n = 19). Primary management of NS mainly included surgery, radiotherapy, surgery+radiotherapy, and observation; 10-year tumor progression-free survival was 62% (surgery 80%, radiotherapy 52%, surgery+radiotherapy 81%, observation 51%). Sex, age at CD or NS diagnosis, size of adenoma (micro-/macroadenoma) at CD diagnosis, presence of pituitary tumor on imaging prior adrenalectomy, and mode of NS primary management were not predictors of tumor progression. Mode of management of CD before NS diagnosis was a significant factor predicting progression, with the group treated by surgery+radiotherapy+adrenalectomy for their CD showing the highest risk (hazard ratio 4.6; 95% confidence interval, 1.6-13.5). During follow-up, 3% of patients had malignant transformation with spinal metastases and 4% died of aggressively enlarging tumor. CONCLUSIONS At 10 years follow-up, 38% of the patients diagnosed with NS showed progression of their corticotroph tumor. Complexity of treatments for the CD prior to NS diagnosis, possibly reflecting corticotroph adenoma aggressiveness, predicts long-term tumor prognosis.
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Affiliation(s)
- Athanasios Fountas
- 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
| | - Eugenie S Lim
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - William M Drake
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Andrew S Powlson
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Niamh M Martin
- Section of Endocrinology and Investigative Medicine, Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Khyatisha Seejore
- Department of Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Robert D Murray
- Department of Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James MacFarlane
- Department of Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Rupa Ahluwalia
- Department of Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Francesca Swords
- Department of Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Muhammad Ashraf
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Aparna Pal
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Zhuomin Chong
- Department of Endocrinology, Queen Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Marie Freel
- Department of Endocrinology, Queen Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Tala Balafshan
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Tejpal S Purewal
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Rowena G Speak
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ziad Hussein
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephanie E Baldeweg
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jolyon Dales
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Narendra Reddy
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Miles J Levy
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - 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
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Abstract
According to the Endocrine Society Clinical Practice Guidelines, the goal of treating overt Cushing's syndrome is to control cortisol levels or more importantly its actions at its receptor in order to eliminate the end organ effects and treat comorbidities associated with hypercortisolism. This chapter will review the surgical management of hypercortisolism. It will be subdivided into two main sections: the management of: (I) ACTH-dependent; and (II) ACTH-independent (adrenal) hypercortisolism. The perioperative factors that surgeons should consider after the diagnosis has been made will also be discussed. Lastly, the utilization of robotic surgery for adrenalectomy and the perceived benefits and potential pitfalls of this approach when treating patients with hypercortisolism will be reviewed.
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21
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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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22
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Surgical and radiosurgical treatment strategies for Cushing’s disease. J Neurooncol 2019; 145:403-413. [DOI: 10.1007/s11060-019-03325-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/26/2019] [Indexed: 12/11/2022]
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23
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Cordeiro D, Xu Z, Li CE, Iorio-Morin C, Mathieu D, Sisterson ND, Kano H, Attuati L, Picozzi P, Sheehan KA, Lee CC, Liscak R, Jezkova J, Lunsford LD, Sheehan J. Gamma Knife radiosurgery for the treatment of Nelson's syndrome: a multicenter, international study. J Neurosurg 2019; 133:336-341. [PMID: 31299652 DOI: 10.3171/2019.4.jns19273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nelson's syndrome is a rare and challenging neuroendocrine disorder, and it is associated with elevated adrenocorticotrophic hormone (ACTH) level, skin hyperpigmentation, and pituitary adenoma growth. Management options including resection and medical therapy are traditional approaches. Ionizing radiation in the form of Gamma Knife radiosurgery (GKRS) is also being utilized to treat Nelson's syndrome. In the current study the authors sought to better define the therapeutic role of stereotactic radiosurgery (SRS) in Nelson's syndrome. METHODS Study patients with Nelson's syndrome were treated with single-fraction GKRS (median margin dose of 25 Gy) at 6 different centers as part of an International Radiosurgery Research Foundation (IRRF) investigation. Data including neurological function, endocrine response, and radiological tumor response were collected and sent to the study-coordinating center for review. Fifty-one patients with median endocrine and radiological follow-ups of 91 and 80.5 months from GKRS, respectively, were analyzed for endocrine remission, tumor control, and neurological outcome. Statistical methods were used to identify prognostic factors for these endpoints. RESULTS At last follow-up, radiological tumor control was achieved in 92.15% of patients. Endocrine remission off medical management and reduction in pre-SRS ACTH level were achieved in 29.4% and 62.7% of patients, respectively. Improved remission rates were associated with a shorter time interval between resection and GKRS (p = 0.039). Hypopituitarism was seen in 21.6% and new visual deficits were demonstrated in 15.7% of patients. CONCLUSIONS GKRS affords a high rate of pituitary adenoma control and improvement in ACTH level for the majority of Nelson's syndrome patients. Hypopituitarism is the most common adverse effect from GKRS in Nelson's syndrome patients and warrants longitudinal follow-up for detection and endocrine replacement.
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Affiliation(s)
- Diogo Cordeiro
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chelsea E Li
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christian Iorio-Morin
- 2Department of Surgery, Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - David Mathieu
- 2Department of Surgery, Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | | | - Hideyuki Kano
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Luca Attuati
- 4Neurosurgery and Gamma Knife Radiosurgery, Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Piero Picozzi
- 4Neurosurgery and Gamma Knife Radiosurgery, Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Kimball A Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 5Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, People's Republic of China; and
| | - Roman Liscak
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jana Jezkova
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - L Dade Lunsford
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Jason Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Renner U, Ciato D, Stalla GK. Recent advances in understanding corticotroph pituitary tumor initiation and progression. F1000Res 2018; 7. [PMID: 30228864 PMCID: PMC6117851 DOI: 10.12688/f1000research.14789.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2018] [Indexed: 11/20/2022] Open
Abstract
Cushing’s disease is the most frequent form of hypercortisolism and is caused by hypophyseal corticotroph adenomas secreting excessive amounts of adrenocorticotropic hormone. Most of the tumors develop sporadically and only a limited number of corticotroph adenomas have been found to be associated with different neuroendocrine syndromes or with familial isolated pituitary adenomas. The pathogenic mechanisms of corticotroph adenomas are largely unknown, but the discovered aberrant chaperoning activity of heat shock protein 90 on the one hand and the presence of ubiquitin-specific protease 8 mutations on the other hand partially explained the causes of their development. Corticotroph tumors arise initially as benign microadenomas but with time form invasively growing aggressive macroadenomas which can switch to corticotroph carcinomas in extremely rare cases. The mechanisms through which corticotroph tumors escape from glucocorticoid negative feedback are still poorly understood, as are the processes that trigger the progression of benign corticotroph adenomas toward aggressive and malignant phenotypes. This review summarizes recent findings regarding initiation and progression of corticotroph pituitary tumors.
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Affiliation(s)
- Ulrich Renner
- Max Planck Institute of Psychiatry, Clinical Neuroendocrinology Group, Munich, Germany
| | - Denis Ciato
- Max Planck Institute of Psychiatry, Clinical Neuroendocrinology Group, Munich, Germany
| | - Günter K Stalla
- Max Planck Institute of Psychiatry, Clinical Neuroendocrinology Group, Munich, Germany
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Caruso JP, Patibandla MR, Xu Z, Vance ML, Sheehan JP. A Long-Term Study of the Treatment of Nelson's Syndrome With Gamma Knife Radiosurgery. Neurosurgery 2017; 83:430-436. [DOI: 10.1093/neuros/nyx426] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/18/2017] [Indexed: 12/16/2022] Open
Abstract
Abstract
BACKGROUND
Nelson's syndrome may be a devastating complication for patients with Cushing's disease who underwent a bilateral adrenalectomy. Previous studies have demonstrated that stereotactic radiosurgery (SRS) can be used to treat patients with Nelson's syndrome.
OBJECTIVE
To report a retrospective study of patients with Nelson's syndrome treated with Gamma Knife radiosurgery to evaluate the effect of SRS on endocrine remission and tumor control.
METHODS
Twenty-seven patients with Nelson's syndrome treated with Gamma Knife radiosurgery after bilateral adrenalectomy were included in this study. After radiosurgery, patients were followed with serial adrenocorticotropic hormone (ACTH) levels and MRI sequences to assess for endocrine remission and tumor control. Cox proportional hazards regression analysis was used to evaluate the relationship between the time to remission and potential prognostic factors.
RESULTS
In 21 patients with elevated ACTH prior to SRS and endocrine follow-up data, 14 (67%) had decreased or stable ACTH levels, and 7 achieved a normal ACTH level at a median of 115 mo (range 7-272) post-SRS. Tumor volume was stable or reduced after SRS in 92.5% of patients (25/27) with radiological follow-up. Time to remission was not significantly associated with the ACTH prior to SRS (P = .252) or with the margin dose (P = .3). However, a shorter duration between the patient's immediate prior transsphenoidal resection and SRS was significantly associated with a shorter time to remission (P = .045).
CONCLUSION
This retrospective analysis suggests that SRS is an effective means of achieving endocrine remission and tumor control in patients with Nelson's syndrome.
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Affiliation(s)
- James P Caruso
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mohana Rao Patibandla
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mary Lee Vance
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
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26
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Graffeo CS, Perry A, Carlstrom LP, Meyer FB, Atkinson JLD, Erickson D, Nippoldt TB, Young WF, Pollock BE, Van Gompel JJ. Characterizing and predicting the Nelson-Salassa syndrome. J Neurosurg 2017; 127:1277-1287. [PMID: 28084914 DOI: 10.3171/2016.9.jns161163] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nelson-Salassa syndrome (NSS) is a rare consequence of bilateral adrenalectomy (ADX) for refractory hypercortisolism due to Cushing disease (CD). Although classically defined by rapid growth of a large, invasive, adrenocorticotropin hormone (ACTH)-secreting pituitary tumor after bilateral ADX that causes cutaneous hyperpigmentation, visual disturbance, and high levels of ACTH, clinical experience suggests more variability. METHODS The authors conducted a retrospective chart review of all patients 18 years and older with a history of bilateral ADX for CD, adequate pituitary MRI, and at least 2 years of clinical follow-up. Statistical tests included Student's t-test, chi-square test, Fisher's exact test, multivariate analysis, and derived receiver operating characteristic curves. RESULTS Between 1956 and 2015, 302 patients underwent bilateral ADX for the treatment of hypercortisolism caused by CD; 88 had requisite imaging and follow-up (mean 16 years). Forty-seven patients (53%) had radiographic progression of pituitary disease and were diagnosed with NSS. Compared with patients who did not experience progression, those who developed NSS were significantly younger at the time of CD diagnosis (33 vs 44 years, p = 0.007) and at the time of bilateral ADX (35 vs 49 years, p = 0.007), had larger tumors at the time of CD diagnosis (6 mm vs 1 mm, p = 0.03), and were more likely to have undergone external-beam radiation therapy (EBRT, 43% vs 12%, p = 0.005). Among NSS patients, the mean tumor growth was 7 mm/yr (SE 6 mm/yr); the median tumor growth was 3 mm/yr. Prevalence of pathognomonic symptoms was low; the classic triad occurred in 9%, while hyperpigmentation without visual field deficit was observed in 23%, and 68% remained asymptomatic despite radiographic disease progression. NSS required treatment in 14 patients (30%). CONCLUSIONS NSS is a prevalent sequela of CD after bilateral ADX and affects more than 50% of patients. However, although radiological evidence of NSS is common, it is most often clinically indolent, with only a small minority of patients developing the more aggressive disease phenotype characterized by clinically meaningful symptoms and indications for treatment. Young age at the time of CD diagnosis or treatment with bilateral ADX, large tumor size at CD diagnosis, and EBRT are associated with progression to NSS and may be markers of aggressiveness.
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Affiliation(s)
| | | | | | | | | | - Dana Erickson
- 2Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Todd B Nippoldt
- 2Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - William F Young
- 2Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
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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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Lonser RR, Nieman L, Oldfield EH. Cushing's disease: pathobiology, diagnosis, and management. J Neurosurg 2016; 126:404-417. [PMID: 27104844 DOI: 10.3171/2016.1.jns152119] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cushing's disease (CD) is the result of excess secretion of adrenocorticotropic hormone (ACTH) by a benign monoclonal pituitary adenoma. The excessive secretion of ACTH stimulates secretion of cortisol by the adrenal glands, resulting in supraphysiological levels of circulating cortisol. The pathophysiological levels of cortisol are associated with hypertension, diabetes, obesity, and early death. Successful resection of the CD-associated ACTH-secreting pituitary adenoma is the treatment of choice and results in immediate biochemical remission with preservation of pituitary function. Accurate and early identification of CD is critical for effective surgical management and optimal prognosis. The authors review the current pathophysiological principles, diagnostic methods, and management of CD.
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Affiliation(s)
- Russell R Lonser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lynnette Nieman
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; and
| | - Edward H Oldfield
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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29
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Lin AL, Sum MW, DeAngelis LM. Is there a role for early chemotherapy in the management of pituitary adenomas? Neuro Oncol 2016; 18:1350-6. [PMID: 27106409 DOI: 10.1093/neuonc/now059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/16/2016] [Indexed: 12/25/2022] Open
Abstract
Pituitary adenomas are benign intracranial neoplasms that are frequently well-controlled with standard treatments that include surgical resection, radiotherapy, and agents that modulate hormonal excess. Unfortunately, a subset of patients remains uncontrolled or develops complications from these interventions. For these patients, chemotherapy is an additional treatment option that could improve outcomes. Temozolomide is an oral chemotherapy with a favorable side-effect profile that has shown activity against pituitary adenomas. Its non-overlapping toxicity and ability to induce rapid tumor regression renders it a potentially important adjunctive treatment. In patients with tumors that cannot be optimally addressed with standard treatments, there may be a role for early initiation of temozolomide.
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Affiliation(s)
- Andrew L Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
| | - Melissa W Sum
- Division of Endocrinology, Columbia University Medical Center, New York, New York (M.W.S.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
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30
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Creemers SG, Hofland LJ, Lamberts SWJ, Feelders RA. Cushing's syndrome: an update on current pharmacotherapy and future directions. Expert Opin Pharmacother 2015; 16:1829-44. [PMID: 26133755 DOI: 10.1517/14656566.2015.1061995] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Endogenous Cushing's syndrome (CS) is characterized by chronic overproduction of cortisol and is associated with increased mortality and morbidity. It can be caused by a pituitary adenoma, ectopic adrenocorticotropic hormone (ACTH) production or primary adrenal disease. Successful tumor-directed surgery is the keystone treatment. When surgery is unsuccessful, contraindicated or in case of acute disease, pharmacotherapy is indicated to treat hypercortisolism. AREAS COVERED In this review, pharmacotherapeutic options for CS will be covered discussing the different possible targets, that is: i) inhibition of ACTH secretion; ii) suppression of steroidogenesis; and iii) blockade of cortisol effects at tissue level. Preclinical and clinical studies will be discussed considering mono- and combination therapy, taking into account efficacy, toxicity and mechanism of action. Per CS entity, future directions of pharmacotherapies will be addressed. EXPERT OPINION The number of medical treatment options for CS has increased in the past years. In contrast to decades ago, prospective trials are now being performed focusing on pituitary-directed drugs like pasireotide, the glucocorticoid receptor blocker mifepristone and 'new generation' steroid synthesis inhibitors. Future studies will focus on tumor-shrinking effects of neuromodulatory drugs, the optimal order and combination of pharmacotherapy, long-term efficacy and safety and new targets for medical treatment of CS.
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Affiliation(s)
- Sara G Creemers
- Erasmus Medical Center, Department of Internal Medicine, Division of Endocrinology , Dr. Molewaterplein 50, 3015GE Rotterdam , The Netherlands +31 10 7040704 ; +31 10 7044862 ;
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31
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Temozolomide-Induced Shrinkage of Invasive Pituitary Adenoma in Patient with Nelson's Syndrome: A Case Report and Review of the Literature. Case Rep Endocrinol 2015. [PMID: 26221547 PMCID: PMC4499620 DOI: 10.1155/2015/623092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction. Invasive tumours in Nelson's syndrome need aggressive therapy. Recent reports have documented the efficacy of temozolomide (TMZ) in the treatment of adenomas resistant to conventional management. Objective. The review of the literature concerning TMZ treatment of atypical corticotroph adenomas and a case study of 56-year-old woman who developed Nelson's syndrome. Treatment Proceeding. The patient with Cushing's disease underwent transsphenoidal adenomectomy followed by a 27-month-long period of remission. Due to a regrowth of the tumor, she underwent two reoperations followed by stereotactic radiotherapy. Because of treatment failures, bilateral adrenalectomy was performed. Then she developed Nelson's syndrome. A fourth transsphenoidal adenomectomy was performed, but there was a rapid recurrence. Five months later, she underwent a right frontotemporal craniotomy. Due to a rapid regrowth of the tumour, the patient did not receive gamma-knife therapy and was treated with cabergoline and somatostatin analogue for some time. Only TMZ therapy resulted in marked clinical, biochemical, and radiological improvement. To date, this is the first case of invasive corticotroph adenoma in Nelson's syndrome treated with temozolomide in Poland. Conclusion. In our opinion, temozolomide can be an effective treatment option of invasive adenomas in Nelson's syndrome.
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