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Ferri J, Martínez-Ibañez J, Terradez L, Savall E, Martínez-Hervás S, Oller MC, Lorente R, Ascaso JF, Real JT. Corticotroph cell hyperplasia as a rare cause of ACTH-dependent Cushing syndrome. ENDOCRINOL DIAB NUTR 2022; 69:694-701. [PMID: 36470644 DOI: 10.1016/j.endien.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/02/2021] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Our aim was to characterise a cohort of patients with Cushing's disease (CD) who did not present pituitary adenoma in magnetic resonance imaging (MRI), needing a catheterisation of the inferior petrosal sinus (CIPS), and to study the pathological findings of the pituitary gland in these subjects after transsphenoidal surgery in order to establish the aetiology of CD. Furthermore, we evaluated possible differences in the features of the diagnosis between hyperplasia and adenoma. SUBJECTS AND METHODS We included 16 subjects. 17 CIPS were done. Hormonal parameters were measured using standard methods. A microscopic histochemical study following standard procedures and immunohistochemical analysis was performed. The diagnostic criteria for adenoma and hyperplasia were based on the WHO classification. RESULTS One patient was excluded for presenting an ACTH-producing bronchial neuroendocrine tumour. The 15 subjects with CD have a positive CIPS test indicating hypophyseal ACTH production. After transsphenoidal surgery, 12 patients showed a microadenoma and three (20%) a corticotroph cell hyperplasia. We found four recurrences after the transsphenoidal surgery (26%), with a mean time for recurrence of 105 months. We found that recurrence was more frequent in subjects with hyperplasia, and in those subjects with lower right/left ACTH ratio. CONCLUSION Our study, which was focused on patients with CD with no pituitary adenoma detected by MRI and a positive CRH test after CIPS, has found that 20% showed corticotroph cell hyperplasia as the cause of CD. Right/left ACTH ratio after CIPS was useful to differentiate adenoma from hyperplasia. This finding may have important prognostic and treatment implications. More studies are necessary to confirm our result.
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Affiliation(s)
- Jordi Ferri
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Medicine, University of Valencia, Spain
| | - Juncal Martínez-Ibañez
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Liria Terradez
- Service of Pathology, Hospital Clínico Universitario de Valencia, Spain
| | - Ester Savall
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Sergio Martínez-Hervás
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Medicine, University of Valencia, Spain; CIBER de Diabetes y Enfermedades Metabólicas asociadas (CIBERDEM), Barcelona, Spain.
| | - María Cristina Oller
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Rosario Lorente
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Juan Francisco Ascaso
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Medicine, University of Valencia, Spain; CIBER de Diabetes y Enfermedades Metabólicas asociadas (CIBERDEM), Barcelona, Spain
| | - José Tomás Real
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Medicine, University of Valencia, Spain; CIBER de Diabetes y Enfermedades Metabólicas asociadas (CIBERDEM), Barcelona, Spain
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Abstract
Cushing disease is a disorder of hypercortisolemia caused by hypersecretion of adrenocorticotropic hormone by a pituitary adenoma and is a rare diagnosis. Cushing disease presents with characteristic clinical signs and symptoms associated with excess cortisol, but diagnosis is difficult and often relies on repeated and varied endocrinologic assays and neuroradiologic investigations. Gold standard treatment is surgical resection of adrenocorticotropic hormone-secreting pituitary adenoma, which is curative. Patients require close endocrinologic follow-up for maintenance of associated neuroendocrine deficiencies and surveillance for potential recurrence. Medications, radiation therapy, and bilateral adrenalectomy are alternative treatments for residual or recurrent disease.
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Ferri J, Martínez-Ibañez J, Terradez L, Savall E, Martínez-Hervás S, Oller MC, Lorente R, Ascaso JF, Real JT. Corticotroph cell hyperplasia as a rare cause of ACTH-dependent Cushing syndrome. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.11.007] [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: 11/30/2022]
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Takenouchi H, Anno T, Iwamoto H, Takahashi K, Iwamoto Y, Horiya M, Kimura Y, Kawasaki F, Kaku K, Tomoda K, Ono S, Kaneto H. Onset of Aortic Dissection Complicated with Cushing's Disease: A Case Report and Review of the Literature. Intern Med 2022; 61:2171-2177. [PMID: 35850988 PMCID: PMC9381334 DOI: 10.2169/internalmedicine.8665-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cushing's syndrome and Cushing's disease cause various metabolic disorders associated with high cortisol levels. Some reports have shown that Cushing's syndrome is complicated with dissecting aortic aneurysm and aortic dissection after long-term exposure to high cortisol levels. We herein report a rare case of aortic dissection complicated with Cushing's disease. Aortic dissection may occur even under relatively short periods of high cortisol conditions. This case suggests that hypercortisolemia should be treated as soon as possible in order to prevent aortic dissection in subjects with Cushing's disease.
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Affiliation(s)
- Haruka Takenouchi
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Hideyuki Iwamoto
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Kaio Takahashi
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Yuichiro Iwamoto
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Megumi Horiya
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Yukiko Kimura
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, Japan
| | - Shigeki Ono
- Department of Neurosurgery 2, Kawasaki Medical School, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
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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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Pedro J, Belo S, Guerreiro V, Ferreira MJ, Salazar D, Costa C, Esteves C, Pereira J, Freitas P, Carvalho D. Cushing's syndrome: Consequences of late diagnosis after bariatric surgery. Clin Case Rep 2020; 8:559-562. [PMID: 32185059 PMCID: PMC7069850 DOI: 10.1002/ccr3.2694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/06/2019] [Accepted: 01/07/2020] [Indexed: 11/11/2022] Open
Abstract
Prior to bariatric surgery, endocrine causes of obesity must be excluded. The diagnosis of osteoporosis in a male requires the study of secondary causes of this condition. The diagnostic delay of Cushing's syndrome may have irreversible consequences.
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Affiliation(s)
- Jorge Pedro
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversidade do PortoPortoPortugal
- Instituto de Investigação e Inovação em Saúde (i3S)Universidade do PortoPortoPortugal
| | - Sandra Belo
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Vanessa Guerreiro
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversidade do PortoPortoPortugal
- Instituto de Investigação e Inovação em Saúde (i3S)Universidade do PortoPortoPortugal
| | - Maria João Ferreira
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversidade do PortoPortoPortugal
- Instituto de Investigação e Inovação em Saúde (i3S)Universidade do PortoPortoPortugal
| | - Daniela Salazar
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversidade do PortoPortoPortugal
- Instituto de Investigação e Inovação em Saúde (i3S)Universidade do PortoPortoPortugal
| | - Cláudia Costa
- Department of EndocrinologyInstituto Português de Oncologia do PortoPortoPortugal
| | - César Esteves
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Josué Pereira
- Department of NeurosurgeryCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Paula Freitas
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversidade do PortoPortoPortugal
- Instituto de Investigação e Inovação em Saúde (i3S)Universidade do PortoPortoPortugal
| | - Davide Carvalho
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversidade do PortoPortoPortugal
- Instituto de Investigação e Inovação em Saúde (i3S)Universidade do PortoPortoPortugal
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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: 34] [Impact Index Per Article: 6.8] [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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Fuertes M, Tkatch J, Rosmino J, Nieto L, Guitelman MA, Arzt E. New Insights in Cushing Disease Treatment With Focus on a Derivative of Vitamin A. Front Endocrinol (Lausanne) 2018; 9:262. [PMID: 29881371 PMCID: PMC5976796 DOI: 10.3389/fendo.2018.00262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/07/2018] [Indexed: 12/19/2022] Open
Abstract
Cushing's disease (CD) is an endocrine disorder originated by a corticotroph tumor. It is linked with high mortality and morbidity due to chronic hypercortisolism. Treatment goals are to control cortisol excess and achieve long-term remission, therefore, reducing both complications and patient's mortality. First-line of treatment for CD is pituitary's surgery. However, 30% of patients who undergo surgery experience recurrence in long-term follow-up. Persistent or recurrent CD demands second-line treatments, such as pituitary radiotherapy, adrenal surgery, and/or pharmacological therapy. The latter plays a key role in cortisol excess control. Its targets are inhibition of adrenocorticotropic hormone (ACTH) production, inhibition of adrenal steroidogenesis, or antagonism of cortisol action at its peripheral receptor. Retinoic acid (RA) is a metabolic product of vitamin A (retinol) and has been studied for its antiproliferative effects on corticotroph tumor cells. It has been shown that this drug regulates the expression of pro-opiomelanocortin (POMC), ACTH secretion, and tumor growth in corticotroph tumor mouse cell lines and in the nude mice experimental model, via inhibition of POMC transcription. It has been shown to result in tumor reduction, normalization of cortisol levels and clinical improvement in dogs treated with RA for 6 months. The orphan nuclear receptor COUP-TFI is expressed in normal corticotroph cells, but not in corticotroph tumoral cells, and inhibits RA pathways. A first clinical human study demonstrated clinical and biochemical effectiveness in 5/7 patients treated with RA for a period of up to 12 months. In a recent second clinical trial, 25% of 16 patients achieved eucortisolemia, and all achieved a cortisol reduction after 6- to 12-month treatment. The goal of this review is to discuss in the context of the available and future pharmacological treatments of CD, RA mechanisms of action on corticotroph tumor cells, and future perspectives, focusing on potential clinical implementation.
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Affiliation(s)
- Mariana Fuertes
- Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) – CONICET – Partner Institute of the Max Planck Society, Buenos Aires, Argentina
| | - Julieta Tkatch
- División Endocrinología, Hospital General de Agudos “Carlos G. Durand”, Buenos Aires, Argentina
| | - Josefina Rosmino
- División Endocrinología, Hospital General de Agudos “Carlos G. Durand”, Buenos Aires, Argentina
| | - Leandro Nieto
- Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) – CONICET – Partner Institute of the Max Planck Society, Buenos Aires, Argentina
| | | | - Eduardo Arzt
- Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) – CONICET – Partner Institute of the Max Planck Society, Buenos Aires, Argentina
- Departamento de Fisiología y Biología Molecular y Celular, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
- *Correspondence: Eduardo Arzt,
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Smith TR, Hulou MM, Huang KT, Nery B, de Moura SM, Cote DJ, Laws ER. Complications after transsphenoidal surgery for patients with Cushing's disease and silent corticotroph adenomas. Neurosurg Focus 2015; 38:E12. [PMID: 25639314 DOI: 10.3171/2014.10.focus14705] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to describe complications associated with the endonasal, transsphenoidal approach for the treatment of adrenocorticotropic hormone (ACTH)-positive staining tumors (Cushing's disease [CD] and silent corticotroph adenomas [SCAs]) performed by 1 surgeon at a high-volume academic medical center. METHODS Medical records from Brigham and Women's Hospital were retrospectively reviewed. Selected for study were 82 patients with CD who during April 2008-April 2014 had consecutively undergone transsphenoidal resection or who had subsequent pathological confirmation of ACTH-positive tumor staining. In addition to demographic, patient, tumor, and surgery characteristics, complications were evaluated. Complications of interest included syndrome of inappropriate antidiuretic hormone secretion, diabetes insipidus (DI), CSF leakage, carotid artery injury, epistaxis, meningitis, and vision changes. RESULTS Of the 82 patients, 68 (82.9%) had CD and 14 (17.1%) had SCAs; 55 patients were female and 27 were male. Most common (n = 62 patients, 82.7%) were microadenomas, followed by macroadenomas (n = 13, 14.7%). A total of 31 (37.8%) patients underwent reoperation. Median follow-up time was 12.0 months (range 3-69 months). The most common diagnosis was ACTH-secreting (n = 68, 82.9%), followed by silent tumors/adenomas (n = 14, 17.1%). ACTH hyperplasia was found in 8 patients (9.8%). Of the 74 patients who had verified tumors, 12 (16.2%) had tumors with atypical features. The overall (CD and SCA) rate of minor complications was 35.4%; the rate of major complications was 8.5% (n = 7). All permanent morbidity was associated with DI (n = 5, 6.1%). In 16 CD patients (23.5%), transient DI developed. Transient DI was more likely to develop in CD patients who had undergone a second operation (37.9%) than in those who had undergone a first operation only (12.8%, p < 0.05). Permanent DI developed in 4 CD patients (5.9%) and 1 SCA patient (7.1%). For 1 CD patient, intraoperative carotid artery injury required endovascular sacrifice of the injured artery, but the patient remained neurologically intact. For another CD patient, aseptic meningitis developed and was treated effectively with corticosteroids. One CD patient experienced major postoperative epistaxis requiring another operative procedure to achieve hemostasis. For 2 CD patients, development of sinus mucoceles was managed conservatively. For 1 SCA patient, an abdominal wound dehisced at the fat graft site. No patients experienced postoperative CSF leakage, visual impairment, or deep vein thrombosis. CONCLUSIONS Transsphenoidal surgery is the treatment of choice for patients with CD and other ACTH-positive staining tumors. Recent advances in endoscopic technology and increasing surgeon comfort with this technology are making transsphenoidal procedures safer, faster, and more effective. Serious complications are uncommon and can be managed successfully.
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Affiliation(s)
- Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
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