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Slagboom TNA, Stenvers DJ, van de Giessen E, Roosendaal SD, de Win MML, Bot JCJ, Aronica E, Post R, Hoogmoed J, Drent ML, Pereira AM. Continuing Challenges in the Definitive Diagnosis of Cushing's Disease: A Structured Review Focusing on Molecular Imaging and a Proposal for Diagnostic Work-Up. J Clin Med 2023; 12:jcm12082919. [PMID: 37109254 PMCID: PMC10144206 DOI: 10.3390/jcm12082919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
The definitive diagnosis of Cushing's disease (CD) in the presence of pituitary microadenoma remains a continuous challenge. Novel available pituitary imaging techniques are emerging. This study aimed to provide a structured analysis of the diagnostic accuracy as well as the clinical use of molecular imaging in patients with ACTH-dependent Cushing's syndrome (CS). We also discuss the role of multidisciplinary counseling in decision making. Additionally, we propose a complementary diagnostic algorithm for both de novo and recurrent or persistent CD. A structured literature search was conducted and two illustrative CD cases discussed at our Pituitary Center are presented. A total of 14 CD (n = 201) and 30 ectopic CS (n = 301) articles were included. MRI was negative or inconclusive in a quarter of CD patients. 11C-Met showed higher pituitary adenoma detection than 18F-FDG PET-CT (87% versus 49%). Up to 100% detection rates were found for 18F-FET, 68Ga-DOTA-TATE, and 68Ga-DOTA-CRH, but were based on single studies. The use of molecular imaging modalities in the detection of pituitary microadenoma in ACTH-dependent CS is of added and complementary value, serving as one of the available tools in the diagnostic work-up. In selected CD cases, it seems justified to even refrain from IPSS.
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Affiliation(s)
- Tessa N A Slagboom
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Dirk Jan Stenvers
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Elsmarieke van de Giessen
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Stefan D Roosendaal
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Maartje M L de Win
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Joseph C J Bot
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Eleonora Aronica
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of (Neuro)Pathology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - René Post
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jantien Hoogmoed
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Madeleine L Drent
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Neuroscience, 1105 AZ Amsterdam, The Netherlands
| | - Alberto M Pereira
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Pituitary Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Doroudinia A, Emami H, Hosseini MS. 68Ga-DOTATATE Radioisotope scan to detect neuroendocrine tumors; A Cross-Sectional Study. ASIA OCEANIA JOURNAL OF NUCLEAR MEDICINE & BIOLOGY 2022; 10:14-19. [PMID: 35083345 PMCID: PMC8742856 DOI: 10.22038/aojnmb.2021.56971.1397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/30/2021] [Accepted: 08/16/2021] [Indexed: 12/13/2022]
Abstract
OBJEVTIVES Neuroendocrine tumors are a heterogeneous group of neoplasms that arise from the peptide-producing cells of the neuroendocrine system. Different functional imaging methods have been suggested to diagnose NETs. There is still not enough evidence to recommend 68Ga-DOTATATE as a standard diagnostic tool in NETs. Therefore, the aim of this study was to assess the value of 68Ga-DOTATATE scan in detecting NETs. METHODS This was a cross-sectional study. All patients with a pathologically confirmed NET tumor referred to Masih Daneshvari Hospital affiliated to Shahid Beheshti University of Medical Sciences entered the study. Patients underwent a 68Ga-DOTATATE PET/CT. All statistical analysis were performed by SPSS software version 18. RESULTS Forty patients with a mean age of 48.1±15.80 years entered the study. Twenty-one (52.5%) were male and 19 (47.5%) female. In the studied patients, neuroendocrine tumor was present in 19 cases (47.5%) in pancreas and gastrointestinal tract, 9 (22.5%) in lung, 3 (7.5%) in mediastinum and adrenal gland, 6 cases (5%) in liver and 3 other sites. There was no significant association between mean age and gender with primary location of the tumor. The mean SUVmax was 11.62±20.02 and the the mean tumor size was 38.25±31.35 mm. The mean size of the metastasis was 40.55±24.53 mm. The mean percentage of ki-67 was 12.54±18.40. There was no significant correlation between SUVmax of the lesion and age (r=0.063, P=0.701), tumor size (r=-0.63, P=0.067) or Ki-67 (r=0.011, P=0.960). In 20 cases, metastases were reported, of which 14 were (70%) in the liver, 3 in the lungs (15%), 2 in the gastrointestinal and cervical lymph nodes, and 1 in the bones and pancreas(%5). CONCLUSION 68Ga-DOTA-peptide PET/CT could find the primary or metastasis sites of NETs with good quality images. In general, this modality can enhance the management in patients with NETs.
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Affiliation(s)
| | | | - Mahsa Sadat Hosseini
- Chronic Respiratory Diseases Research Center, National research institute of tuberculosis and lung diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Liu Q, Zang J, Yang Y, Ling Q, Wu H, Wang P, Lu L, Zhu Z. Head-to-head comparison of 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT in localizing tumors with ectopic adrenocorticotropic hormone secretion: a prospective study. Eur J Nucl Med Mol Imaging 2021; 48:4386-4395. [PMID: 34146130 DOI: 10.1007/s00259-021-05370-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Localizing the source of ectopic adrenocorticotropic hormone secretion (EAS) is challenging. This study compared the diagnostic value of 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT in tumors with EAS. METHODS Thirty-six patients with a suspicion of EAS were enrolled to undergo both 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT within 4 weeks for comparison. Twenty-three underwent surgical resection or biopsy. Immunohistochemical staining for SSTR2 and Ki-67 was performed to correlate with 68Ga-DOTATATE uptake and 18F-FDG uptake, respectively. RESULTS EAS tumors were observed in 20/23 patients. Among the 20 patients with histologically proven EAS tumors, 68Ga-DOTATATE PET/CT correctly identified the tumor in 15 (75.0%), with an SUVmax ranging from 1.4 to 20.7 (6.7 ± 5.5). 18F-FDG PET/CT correctly identified the tumor in 12 (60.0%) patients, with an SUVmax ranging from 1.8 to 10.0 (4.0 ± 2.1). Moreover, 68Ga-DOTATATE PET/CT unmasked the sources of EAS in 6 patients with negative 18F-FDG uptake, and 18F-FDG PET/CT unmasked the sources in 3 patients with negative 68Ga-DOTATATE uptake, resulting in EAS tumors being identified in 18 (90%) patients by combining 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT. CONCLUSIONS 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT are complementary in localizing and discriminating the source of EAS. 68Ga-DOTATATE PET/CT combined with 18F-FDG PET/CT had higher detection rate than each alone. TRIAL REGISTRATION 68Ga-DOTATATE PET/CT in Neuroendocrine Tumors (NCT04041882) URL OF REGISTRY: https://clinicaltrials.gov/ct2/show/NCT04041882.
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Affiliation(s)
- Qingxing Liu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Jie Zang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Yingying Yang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qing Ling
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Pengyan Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Zhaohui Zhu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China.
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Raj R, Taylor RK, Owen D. A Rapidly Progressive Case of Ectopic Adrenocorticotropic Hormone (ACTH) Syndrome. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e934437. [PMID: 34728594 PMCID: PMC8574168 DOI: 10.12659/ajcr.934437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patient: Female, 74-year-old
Final Diagnosis: ACTH-dependent Cushing’s syndrome • ectopic ACTH syndrome
Symptoms: Edema • general fatigue • recurrent mechanical fall
Medication: —
Clinical Procedure: —
Specialty: Critical Care Medicine • Endocrinology and Metabolic • Family Medicine • General and Internal Medicine • Nephrology • Oncology
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Affiliation(s)
- Rishi Raj
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Pikeville Medical Center, Pikeville, KY, USA
| | - Robb K Taylor
- Department of Family Medicine, Pikeville Medical Center, Pikeville, KY, USA
| | - Douglas Owen
- Department of Internal Medicine, University of Pikeville-Kentucky College of Osteopathic Medicine, Pikeville, KY, USA
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Shukla J, Vatsa R, Walia R, Chhabra A, Rana N, Singh H, Kumar R, Mittal BR. Development of Ga-68 DOTA-CRH for PET/CT Imaging of ACTH-Dependent Cushing's Disease: Initial Study. Cancer Biother Radiopharm 2021; 36:642-650. [PMID: 34191604 DOI: 10.1089/cbr.2020.4686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Adrenocorticotropic hormone (ACTH)-dependent Cushing's disease accounts for 75% cases of the endogenous Cushing's syndrome. The size of lesion is usually very small, which results in false-negative magnetic resonance imaging (MRI) even after biochemical confirmation of the disease. Corticotrophin-releasing hormone (CRH) the key controller of hypothalamus-pituitary--adrenal axis binds to CRH receptor R1 and R2. CRH R1 is overexpressed in pituitary adenomas. The present study aims to target these overexpressed receptors with Ga-68-DOTA-CRH for noninvasive imaging of ACTH-dependent pituitary adenomas. Materials and Methods: Custom-synthesized 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-CRH peptide was purified by high performance liquid chromatography (HPLC) and characterized by mass spectra. Postradiolabeling optimization with Ga-68, quality control tests were carried out to ensure the suitability of Ga-68 DOTA-CRH for intravenous administration. A pilot study consisting of 15 patients including 6 known cases of macroadenoma underwent Ga-68-DOTA-CRH regional brain positron emission tomography/computed tomography (PET/CT). The optimal imaging time and biodistribution studies were performed in five patients' whole-body and serial brain PET/CT imaging. Lesion activity was determined as SUVmax and correlated with CE-MRI and histopathology of excised tissue. Results: A retention time of 11.3 min and mass of 5145 Da was observed on HPLC and mass spectra. Radiolabeling yield of >98% was achieved under optimized conditions using 25-100 μg of conjugated peptide for 10-22 mCi of Ga-68. The quality control results were in agreement with acceptable criteria. Ga-68-DOTA-CRH was able to delineate ACTH secreting corticotropinoma in all 15 patients. Physiological uptake of radiotracer was observed in liver and spleen with diffused marrow activity. Excretion was noted by renal route. Imaging results were in correlation with CE-MRI and histopathology of excised tissue. Conclusion: Ga-68-DOTA-CRH PET/CT is a promising molecular imaging modality for detection of ACTH-dependent microadenoma.
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Affiliation(s)
- Jaya Shukla
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakhee Vatsa
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupriya Chhabra
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nivedita Rana
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmandeep Singh
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajender Kumar
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine and Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Novruzov F, Aliyev A, Wan MYS, Syed R, Mehdi E, Aliyeva I, Giammarile F, Bomanji JB, Kayani I. The value of [68Ga]Ga-DOTA-TATE PET/CT in diagnosis and management of suspected pituitary tumors. Eur J Hybrid Imaging 2021; 5:10. [PMID: 34181114 PMCID: PMC8218063 DOI: 10.1186/s41824-021-00104-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background Gallium 68-tetraazacyclododecane-tetraacetic acid-octreotate ([68Ga]Ga-DOTA-TATE) is a selective somatostatin analogue ligand, which shows increased affinity for somatostatin receptor subtype (SSTR) 2 and has been used routinely for imaging neuroendocrine tumors with PET/CT. We investigated the utility of [68Ga]Ga-DOTA-TATE positron emission tomography/computed tomography (PET/CT) in patients with suspected pituitary pathology. We reviewed imaging for twenty consecutive patients (8 men, 12 women, mean age of 48.2, range 14–78) with suspected pituitary pathology who were referred for [68Ga]Ga-DOTA-TATE PET/CT. Results Nine patients presented with recurrent Cushing’s syndrome following surgical resection of pituitary adenomas due to recurrent Cushing’s disease (seven patients) and ectopic ACTH secreting tumor (2 patients). All seven patients with recurrent Cushing’s disease showed positive pituitary [68Ga]Ga-DOTA-TATE uptake while both cases of ectopic hormonal secretion had absented pituitary uptake. In 1 of these 2 patients, [68Ga]Ga-DOTA-TATE was able to localize the source of ectopic ACTH tumor. Six patients presented de novo with Cushing’s due to ectopic ACTH secretion; [68Ga]Ga-DOTA-TATE PET/CT was able to localize ectopic tumors in six of eight patients (3 lungs, 2 pancreases, 1 mid-gut) There was high uptake [68Ga]Ga-DOTA-TATE in 3 cases of recurrent central hyperthyroidism (SUVmax 6.6–14.3) and 2 cases of prolactinoma (SUVmax 5.5 and 11.3). Conclusion Absent [68Ga]Ga-DOTA-TATE activity in the pituitary fossa is useful in excluding pituitary disease in recurrent Cushing’s. Recurrent pituitary thyrotropinomas and prolactinomas showed moderate to high pituitary activity. In addition, in Cushing’s syndrome, [68Ga]Ga-DOTA-TATE is useful for detection of ectopic sources of ACTH production, especially where anatomic imaging is negative.
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Affiliation(s)
- Fuad Novruzov
- Department of Nuclear Medicine, Azerbaijan National Centre of Oncology, M. Xiyabani street 137, AZ 1011, Baku, Azerbaijan. .,Institute of Nuclear Medicine, University College London Hospital, London, UK.
| | - Aziz Aliyev
- Department of Head and Neck Surgery, Azerbaijan National Centre of Oncology, Baku, Azerbaijan
| | - Ming Young S Wan
- Institute of Nuclear Medicine, University College London Hospital, London, UK
| | - Rizwan Syed
- Institute of Nuclear Medicine, University College London Hospital, London, UK
| | - Elnur Mehdi
- Department of Nuclear Medicine, Azerbaijan National Centre of Oncology, M. Xiyabani street 137, AZ 1011, Baku, Azerbaijan
| | - Irada Aliyeva
- Department of Internal Medicine, Azerbaijan Medical University, Baku, Azerbaijan
| | | | - Jamshed B Bomanji
- Institute of Nuclear Medicine, University College London Hospital, London, UK
| | - Irfan Kayani
- Institute of Nuclear Medicine, University College London Hospital, London, UK
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Prado VS, Leitao RCF, Silva F, Gano L, Santos IC, Marques FLN, Paulo A, Deflon VM. Gallium and indium complexes with new hexadentate bis(semicarbazone) and bis(thiosemicarbazone) chelators. Dalton Trans 2021; 50:1631-1640. [PMID: 33480908 DOI: 10.1039/d0dt04028b] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The synthesis of two new hexadentate potentially tetra-anionic acyclic chelators, an N2O4-donor bis(semicarbazone) (H4bsc) and an N2O2S2-donor bis(thiosemicarbazone) (H4btsc), is described. Coordination reactions of the ligands with gallium and indium precursors were investigated and yielded the complexes [Ga(Hbsc)] (1) and [In(Hbtsc)] (2), respectively. Ligands and complexes structures were confirmed by several techniques, including FTIR, NMR (1H, 13C, COSY, HSQC), ESI(+)-MS and single crystal X-ray diffraction analysis. The radioactive congeners [67Ga(Hbsc)] (1*) and [111In(Hbtsc)] (2*) were also synthesized and their radiolabeling yield and radiochemical purity were certified by HPLC and ITLC analyses. Biodistribution assays in groups of CD-1 mice showed a high uptake of both radiocomplexes in liver and intestine where 1* presented higher retention. In vitro and in vivo assays revealed higher stability of 1* compared with 2*, namely in the blood. The results suggest that radiocomplex 1* is a candidate for further investigation as it could be prepared in high yields (>95%), at low temperature (20-25 °C) and at fast reaction time (15 min), which are very desirable synthesis conditions for potential new radiopharmaceuticals.
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Affiliation(s)
- Viviana S Prado
- Instituto de Química de São Carlos, Universidade de São Paulo, CEP 13566-590 São Carlos, SP, Brazil.
| | - Renan C F Leitao
- Instituto de Química de São Carlos, Universidade de São Paulo, CEP 13566-590 São Carlos, SP, Brazil.
| | - Francisco Silva
- Centro de Ciências e Tecnologias Nucleares, Instituto Superior Técnico, Universidade de Lisboa, Estrada Nacional 10, 2695-066 Bobadela LRS, Portugal
| | - Lurdes Gano
- Centro de Ciências e Tecnologias Nucleares, Instituto Superior Técnico, Universidade de Lisboa, Estrada Nacional 10, 2695-066 Bobadela LRS, Portugal
| | - Isabel C Santos
- Centro de Ciências e Tecnologias Nucleares, Instituto Superior Técnico, Universidade de Lisboa, Estrada Nacional 10, 2695-066 Bobadela LRS, Portugal
| | - Fabio L N Marques
- Laboratório de Medicina Nuclear (LIM-43), Departamento de Radiologia e Oncologia, Faculdade de Medicina, Universidade de Sao Paulo, CEP 05403-911 Sao Paulo, SP, Brazil
| | - António Paulo
- Centro de Ciências e Tecnologias Nucleares, Instituto Superior Técnico, Universidade de Lisboa, Estrada Nacional 10, 2695-066 Bobadela LRS, Portugal
| | - Victor M Deflon
- Instituto de Química de São Carlos, Universidade de São Paulo, CEP 13566-590 São Carlos, SP, Brazil.
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Abstract
PURPOSE OF REVIEW Ectopic adrenocorticotropic hormone (ACTH)-secreting tumors are commonly small, yet they often lead to fulminant forms of Cushing syndrome. High-resolution functional imaging modalities, such as [Ga]-DOTATATE, have been recently introduced in clinical practice for the identification of neuroendocrine tumors. In this review, we focus on the performance of [Ga]-DOTATATE as a tool for localizing primary and metastatic sources of ectopic Cushing syndrome (ECS). RECENT FINDINGS Prompt surgical removal of ectopic ACTH-secreting tumors is the mainstay of therapy in patients with ECS. Detecting such tumors with conventional cross-sectional imaging is often unsuccessful, owing to their small size. [Ga]-DOTATATE has been approved in 2016 by the Federal Drug Administration for imaging well differentiated neuroendocrine tumors. Data regarding the performance of [Ga]-DOTATATE for detecting ectopic ACTH-secreting tumors remain limited, in part owing to the recent introduction of this imaging modality in clinical practice, and in part because of the low prevalence of ECS. Nevertheless, [Ga]-DOTATATE has been reported to be useful in identifying primary and metastatic ectopic ACTH-secreting lesions that were not apparent on other imaging studies, impacting the clinical care of many patients with ECS. SUMMARY [Ga]-DOTATATE-based imaging, which targets the somatostatin receptors abundantly expressed in neuroendocrine tumors, has generally high, although variable resolution in detecting the source(s) of ECS.
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Affiliation(s)
- Seda Grigoryan
- Department of Internal Medicine, Michigan State University, East Lasing
| | | | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
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Bélissant Benesty O, Nataf V, Ohnona J, Michaud L, Zhang-Yin J, Bertherat J, Chanson P, Reznik Y, Talbot JN, Montravers F. 68Ga-DOTATOC PET/CT in detecting neuroendocrine tumours responsible for initial or recurrent paraneoplastic Cushing's syndrome. Endocrine 2020; 67:708-717. [PMID: 31583575 DOI: 10.1007/s12020-019-02098-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Paraneoplastic Cushing's syndrome (PCS) is frequently caused by neuroendocrine tumours (NETs). Approximately 20% of tumours are still occult years later. Gallium-68 somatostatin receptor-PET/CT is promising for the detection of the causal primary NET, but its role in case of recurrent PCS is rarely reported. We report our experience with DOTATOC PET/CT in localising the causal NET in cases of initial but also recurrent PCS, and its clinical impact. METHODS A retrospective review of all DOTATOC PET/CTs performed in consecutive patients referred for PCS to our centre, between January 2011 and June 2017, was done. Nineteen patients underwent 26 PET/CTs, 13 for detection of a primary NET, seven for persistent or recurrent PCS after resection, and six for surveillance after resection of NETs previously detected on a DOTATOC PET/CT in our centre. RESULTS Among the 13 PET/CTs performed to search for primary NET, five were positive: four carcinoid lung tumours were confirmed after resection and one lung focus was not confirmed since surgery would have carried a high risk. Clinical impact was 23% (3/13). Among the seven PET/CTs performed for persistent or recurrent PCS, six were true-positive, with confirmation of metastatic lymph nodes after resection. Clinical impact was 57% (4/7). All PET/CTs performed for surveillance were true-negative. CONCLUSIONS DOTATOC PET/CT seems to be a valuable tool for detection of the NET responsible for persistent or recurrent PCS after surgery. In this context, DOTATOC PET/CT was more effective than for the detection of the causal tumour in initial PCS.
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Affiliation(s)
| | - Valérie Nataf
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Jessica Ohnona
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Laure Michaud
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Jules Zhang-Yin
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
| | - Jérôme Bertherat
- Endocrinology, Hôpital Cochin APHP and Paris Descartes University, Paris, France
| | - Philippe Chanson
- Endocrinology, Hôpital Bicêtre APHP and Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Yves Reznik
- Endocrinology, Centre Hospitalo-Universitaire de Caen and Université de Caen Normandie, Caen, France
| | - Jean-Noël Talbot
- Nuclear Medicine, Hôpital Tenon APHP and Sorbonne University, Paris, France
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Varlamov E, Hinojosa-Amaya JM, Stack M, Fleseriu M. Diagnostic utility of Gallium-68-somatostatin receptor PET/CT in ectopic ACTH-secreting tumors: a systematic literature review and single-center clinical experience. Pituitary 2019; 22:445-455. [PMID: 31236798 DOI: 10.1007/s11102-019-00972-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Tumors causing ectopic Cushing's syndrome (ECS) are often not visible with conventional imaging. Gallium-68-DOTATATE, DOTATOC, and DOTANOC positron emission tomography/computed tomography (68Ga-SSTR PET/CT) reportedly exhibits greater sensitivity in identifying an ECS source, however, evidence is limited to mainly case reports and a few small retrospective studies. Previous systematic ECS imaging review has shown 68Ga-SSTR PET/CT sensitivity is similar to CT (81.8%) in histologically-proven cases and is 100% in covert-cases, however, the number of patients was small and no occult cases were reported. METHODS We performed a systematic literature review of 68Ga-SSTR PET/CT use in ECS patients. We also report 6 consecutive patients with confirmed active and occult ECS who underwent 68Ga-DOTATATE PET/CT and were followed at our institution between 2014 and 2019. RESULTS We identified 33 articles (23 case-reports, 4 case-series, 5 retrospective studies and 1 prospective study) detailing 68Ga-SSTR PET/CT in 69 ECS patients. Overall 68Ga-SSTR PET/CT sensitivity was 64.0%, while in histologically confirmed cases (67 lesions), sensitivity was 76.1%. There were two false-positives cases, both in the adrenal glands. In covert cases, 68Ga-SSTR PET/CT identified 50% of lesions. There were ten occult cases where all imaging failed to identify an adrenocorticotropic hormone source; source remains unknown. In our case series, 68Ga-DOTATATE PET/CT showed decreased uptake in pancreatic neuroendocrine tumor in one patient and did not help identify an ECS source in 5 patients. CONCLUSION Both this systematic literature review, the largest to date, and our single- center experience demonstrate a lower than previously reported 68Ga-SSTR PET/CT sensitivity for ECS, especially in occult lesions. We suggest that the data on 68Ga-SSTR PET/CT in ECS is subject to publication bias, and false-negatives are likely underreported; it's diagnostic value for ECS needs further study.
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Affiliation(s)
- Elena Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, L607, Portland, OR, USA
- Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, USA
| | - José Miguel Hinojosa-Amaya
- Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, USA
- Endocrinology Division, Department of Medicine, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - Madeleine Stack
- Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, USA
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, L607, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, USA.
- Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, USA.
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Wannachalee T, Turcu AF, Bancos I, Habra MA, Avram AM, Chuang HH, Waguespack SG, Auchus RJ. The Clinical Impact of [ 68 Ga]-DOTATATE PET/CT for the Diagnosis and Management of Ectopic Adrenocorticotropic Hormone - Secreting Tumours. Clin Endocrinol (Oxf) 2019; 91:288-294. [PMID: 31066920 PMCID: PMC6689243 DOI: 10.1111/cen.14008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/17/2019] [Accepted: 05/07/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Localization of ectopic ACTH-secreting tumours causing Cushing syndrome (ECS) is essential for clinical management, yet often difficult. [68 Ga]-DOTATATE PET/CT ([68 Ga]-DOTA-(Tyr3 )-octreotate)] is an FDA-approved high-resolution diagnostic tool for imaging neuroendocrine tumours. Data on the clinical utility of [68 Ga]-DOTATATE in patients with ECS, however, are scarce. The objectives of this study were to determine the efficacy for ECS localization and the clinical benefit of [68 Ga]-DOTATATE imaging. METHOD We conducted a retrospective review of all cases with ECS evaluated with [68 Ga]-DOTATATE from November 2016 through October 2018 at three referral centres. The clinical benefit of [68 Ga]-DOTATATE was based on detection of new tumours and resultant changes in management. RESULTS Over the study period, 28 patients with ECS underwent [68 Ga]-DOTATATE: 17 for identification of the primary tumour and 11 during follow-up. [68 Ga]-DOTATATE identified the suspected primary ECS in 11/17 patients (65%). Of these, nine patients underwent surgery: eight with confirmed ECS (5 bronchial, 1 thymic, 1 pancreatic and 1 metastatic neuroendocrine tumour of unknown primary origin) and one patient with a false-positive scan (adrenal gland). Of the 11 patients with ECS who underwent [68 Ga]-DOTATATE evaluation during follow-up, the study led to changes in clinical management in 7/11 (64%) patients. CONCLUSIONS [68 Ga]-DOTATATE is sensitive in detecting primary and metastatic ECS, often identifies occult tumours after conventional imaging, and impacts clinical care in the majority of patients.
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Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
- Division of Endocrinology and Metabolism, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Adina F. Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic Rochester, MN, USA
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anca M. Avram
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Hubert H. Chuang
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven G. Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard J. Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
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12
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Heat-Damaged Red Blood Cell Scintigraphy in Helping Interpretation of 68Ga-DOTATATE PET/CT. Clin Nucl Med 2019; 44:927-928. [PMID: 31306208 DOI: 10.1097/rlu.0000000000002730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ga-DOTATATE PET/CT was performed to determine the cause of endogenous Cushing syndrome in a 10-year-old boy whose MRI studies did not reveal pituitary or adrenal gland abnormality. The PET/CT images demonstrated an intense activity in a small soft tissue nodule in the left upper abdomen where splenules are commonly located. Heat-damaged Tc-labeled red blood cell imaging showed that this soft tissue nodule did not have increased red blood cell activity, which indicated that this lesion was a true somatostatin receptor-rich lesion. The pathology result following surgical resection of the lesion confirmed adrenocorticotropic hormone-producing neuroendocrine tumor.
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13
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Abstract
BACKGROUND Two types of ectopic Cushing syndrome (ECS) are described: ECS associated with aggressive neoplasms, and ECS with indolent and occult tumors, however, there is a lack of studies that thoroughly review their characteristics. METHODS A systematic review was carried out on PUBMED of all the papers about the ECS, in order to better define the types of this subcategory of Cushing's syndrome, highlighting the differential aspects between these subgroups. RESULTS It was found that in 50% of cases the prototypic "aggressive" ECS is caused by small cell lung carcinomas (SCLC). In these cases, the clinical presentation may be atypical, predominating the signs and symptoms derived from the protein catabolism. Cortisol and ACTH levels are extremely high, the clinical presentation is abrupt (< 3-6 months) and the tumor is usually advanced, being impossible a curative treatment. On the other hand, "indolent" ECS is mainly represented by carcinoid tumors (CT). In these cases the clinical presentation overlaps enormously with that of Cushing's disease (CD). Cortisol and ACTH levels are slightly elevated, the clinical presentation is progressive (> 6 months) and the prognosis is usually good, and a curative treatment is possible in about 75% of the cases. CONCLUSION Although there is no absolute differentiation between the two extremes of ECS, a classification could be established in two groups, guided by its clinical and biochemical characteristics, and mainly by the type and stage of the ACTH-secreting tumor. However, a small percentage of tumors do not fit in this simple grouping, and may present both phenotypes or an intermediate one.
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Affiliation(s)
- Marta Araujo Castro
- Department Endocrinology, Hospital Universitario de la Princesa, Madrid, Spain.
- Department Endocrinology, Hospital Universitario Rey Juan Carlos, Madrid, Spain.
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14
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Gabriel S, Garrigue P, Dahan L, Castinetti F, Sebag F, Baumstark K, Archange C, Jha A, Pacak K, Guillet B, Taïeb D. Prospective evaluation of 68 Ga-DOTATATE PET/CT in limited disease neuroendocrine tumours and/or elevated serum neuroendocrine biomarkers. Clin Endocrinol (Oxf) 2018; 89:155-163. [PMID: 29788534 PMCID: PMC7450718 DOI: 10.1111/cen.13745] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/10/2018] [Accepted: 05/17/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT The 68 Ga-labelled somatostatin analogues (68 Ga-DOTA-SSAs) is becoming popular as an important diagnostic tool in neuroendocrine tumours as evidenced by a growing number of reports detailing institutional experience with various DOTA peptides. However, only few prospective studies have compared 68 Ga-DOTA-SSAs and somatostatin receptor scintigraphy (SRS) in gastroenteropancreatic neuroendocrine tumours (GEP-NETs) and pulmonary neuroendocrine tumours. OBJECTIVE The aim of our prospective study was to perform head-to-head comparison between 68 Ga-DOTATATE PET/CT and standard imaging work-up (SI) that included multiphasic CT, liver MRI and SRS using single photon emission computed tomography. DESIGN In this prospective study, the patients were enrolled only if they met any of the following inclusion criteria: (i) initial staging of a NETs without distant metastases on SI or neuroendocrine tumour with unknown primary on SI; (ii) restaging of NETs that could be treated by focused therapeutic interventions; (iii) elevated serum neuroendocrine hormones or peptides. The exclusion criteria was grade 3 GEP-NETs. RESULTS Thirty-two patients were enrolled in the study. Eleven patients (6 pancreas, 4 ileum, 1 duodenal) were included for initial evaluation and staging of NETs, 8 patients (5 pancreas, 1 ileal, 1 lung, 1 duodenal gastrinoma) for restaging, and 13 patients for elevated serum neuroendocrine biomarkers (5 ectopic Cushing's syndrome, 5 organic hypoglycaemia, 1 patient each with elevated vasoactive inhibitory peptide, chromogranin A and neuron-specific enolase). 68 Ga-DOTATATE PET/CT detected more primary tumours than SRS (15/18 vs 10/18: P = .074). The missed tumours on 68 Ga-DOTATATE PET/CT were located in the lung in two cases and duodenum in one case. For other anatomical regions (nodal and distant metastasis), no statistical difference was observed between imaging modalities using 68 Ga-DOTATATE PET/CT and SRS. Overall, 68 Ga-DOTATATE PET/CT+CT+MRI detected 31/33 of the involved regions (including primaries) (29 and 22 for 68 Ga-DOTATATE and SRS, respectively). CONCLUSION Our study shows that 68 Ga-DOTATATE PET/CT detected similar number of sites than combination of SRS, liver MRI and thoraco-abdominopelvic CT on region-based analysis. 68 Ga-DOTATATE PET/CT missed half of primary lung carcinoids with ectopic Cushing's syndrome.
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Affiliation(s)
- Sophie Gabriel
- Department of Nuclear Medicine, La Timone & North University Hospital, Aix-Marseille University, Marseille, France
- European Center for Research in Medical Imaging, Aix-Marseille University, Marseille, France
| | - Philippe Garrigue
- European Center for Research in Medical Imaging, Aix-Marseille University, Marseille, France
- Department of Radiopharmacy, La Timone & North University Hospital, Aix-Marseille University, Marseille, France
| | - Laetitia Dahan
- Digestive Oncology Unit, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Frédéric Castinetti
- Department of Endocrinology, Conception Hospital, Aix-Marseille University, Marseille, France
| | - Frédéric Sebag
- Department of Endocrine Surgery, Conception Hospital, Aix-Marseille University, Marseille, France
| | - Karine Baumstark
- Department of Public Health, Aix-Marseille University, Marseille, France
| | - Cendrine Archange
- Department of Nuclear Medicine, La Timone & North University Hospital, Aix-Marseille University, Marseille, France
- European Center for Research in Medical Imaging, Aix-Marseille University, Marseille, France
| | - Abhishek Jha
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health, Bethesda, MD, USA
| | - Karel Pacak
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health, Bethesda, MD, USA
| | - Benjamin Guillet
- European Center for Research in Medical Imaging, Aix-Marseille University, Marseille, France
- Department of Radiopharmacy, La Timone & North University Hospital, Aix-Marseille University, Marseille, France
| | - David Taïeb
- Department of Nuclear Medicine, La Timone & North University Hospital, Aix-Marseille University, Marseille, France
- European Center for Research in Medical Imaging, Aix-Marseille University, Marseille, France
- Inserm UMR1068 Marseille Cancerology Research Center, Institut Paoli-Calmettes, Marseille, France
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Białkowska AM, Morawski K, Florczak T. Extremophilic proteases as novel and efficient tools in short peptide synthesis. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s10295-017-1961-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Abstract
The objective of this review is to outline the crucial role that peptides play in various sectors, including medicine. Different ways of producing these compounds are discussed with an emphasis on the benefits offered by industrial enzyme biotechnology. This paper describes mechanisms of peptide bond formation using a range of proteases with different active site structures. Importantly, these enzymes may be further improved chemically and/or genetically to make them better suited for their various applications and process conditions. The focus is on extremophilic proteases, whose potential does not seem to have been fully appreciated to date. The structure of these proteins is somewhat different from that of the common commercially available enzymes, making them effective at high salinity and high or low temperatures, which are often favorable to peptide synthesis. Examples of such enzymes include halophilic, thermophilic, and psychrophilic proteases; this paper also mentions some promising catalytic proteins which require further study in this respect.
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Affiliation(s)
- Aneta M Białkowska
- 0000 0004 0620 0652 grid.412284.9 Institute of Technical Biochemistry Lodz University of Technology Stefanowskiego Street 4/10 90-924 Lodz Poland
| | - Krzysztof Morawski
- 0000 0004 0620 0652 grid.412284.9 Institute of Technical Biochemistry Lodz University of Technology Stefanowskiego Street 4/10 90-924 Lodz Poland
| | - Tomasz Florczak
- 0000 0004 0620 0652 grid.412284.9 Institute of Technical Biochemistry Lodz University of Technology Stefanowskiego Street 4/10 90-924 Lodz Poland
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16
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Ectopic Corticotropin-Producing Neuroendocrine Tumor of the Pancreas Treated With 177Lu DOTATATE Induction and Maintenance Peptide Receptor Radionuclide Therapy. Clin Nucl Med 2016; 41:50-2. [PMID: 26359569 DOI: 10.1097/rlu.0000000000000971] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 57-year-old woman diagnosed with ectopic Cushing syndrome was found to have a 111In-octreotide-avid corticotropin-producing pancreatic neuroendocrine tumor with liver metastases. She was treated with 4 induction and 4 maintenance cycles of 177Lu-DOTATATE, which normalized her serum corticotropin levels and dramatically reduced the size of the pancreatic primary and liver metastases.
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17
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Goroshi MR, Jadhav SS, Lila AR, Kasaliwal R, Khare S, Yerawar CG, Hira P, Phadke U, Shah H, Lele VR, Malhotra G, Bandgar T, Shah NS. Comparison of 68Ga-DOTANOC PET/CT and contrast-enhanced CT in localisation of tumours in ectopic ACTH syndrome. Endocr Connect 2016; 5:83-91. [PMID: 27006371 PMCID: PMC5002954 DOI: 10.1530/ec-16-0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/22/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Localising ectopic adrenocorticotrophic hormone (ACTH) syndrome (EAS) tumour source is challenging. Somatostatin receptor-based PET imaging has shown promising results, but the data is limited to case reports and small case series. We reviewed here the performance of (68)Ga-DOTANOC positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) in our cohort of 12 consecutive EAS patients. MATERIALS AND METHODS Retrospective data analysis of 12 consecutive patients of EAS presenting to a single tertiary care centre in a period between January 2013 and December 2014 was done. CECT and (68)Ga-DOTANOC PET/CT were reported (blinded) by an experienced radiologist and a nuclear medicine physician, respectively. The performance of CECT and (68)Ga-DOTANOC PET/CT was compared. RESULTS Tumours could be localised in 11 out of 12 patients at initial presentation (overt cases), whereas in one patient, tumour remained occult. Thirteen lesions were identified in 11 patients as EAS source (true positives). CECT localised 12 out of these 13 lesions (sensitivity 92.3%) and identified five false-positive lesions (positive predictive value (PPV) 70.5%). Compared with false-positive lesions, true-positive lesions had greater mean contrast enhancement at 60s (33.2 vs 5.6 Hounsfield units (HU)). (68)Ga-DOTANOC PET/CT was able to identify 9 out of 13 lesions (sensitivity 69.2%) and reported no false-positive lesions (PPV 100%). CONCLUSION CECT remains the first-line investigation in localisation of EAS. The contrast enhancement pattern on CECT can further aid in characterisation of the lesions. (68)Ga-DOTANOC PET/CT can be added to CECT, to enhance positive prediction of the suggestive lesions.
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Affiliation(s)
- Majunath R Goroshi
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Swati S Jadhav
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Anurag R Lila
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rajeev Kasaliwal
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shruti Khare
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Chaitanya G Yerawar
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Priya Hira
- Department of RadiologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Hina Shah
- Department of Nuclear Medicine and Positron Emission Tomography/Computed TomographyJaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Vikram R Lele
- Department of Nuclear Medicine and Positron Emission Tomography/Computed TomographyJaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Gaurav Malhotra
- Radiation Medicine CentreBhabha Atomic Research Centre, Tata Memorial Centre, Annexe, Parel, Mumbai, Maharashtra, India
| | - Tushar Bandgar
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini S Shah
- Department of EndocrinologySeth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Mifepristone Improves Octreotide Efficacy in Resistant Ectopic Cushing's Syndrome. Case Rep Endocrinol 2016; 2016:8453801. [PMID: 26989527 PMCID: PMC4773543 DOI: 10.1155/2016/8453801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 01/26/2016] [Indexed: 12/18/2022] Open
Abstract
A 30-year-old Caucasian man presented with severe Cushing's syndrome (CS) resulting from ectopic adrenocorticotropin syndrome (EAS) from a metastatic pancreatic neuroendocrine tumor. The patient remained hypercortisolemic despite treatment with steroidogenesis inhibitors, chemotherapy, and octreotide long-acting release (LAR) and was enrolled in a 24-week, phase 3 clinical trial of mifepristone for inoperable hypercortisolemia. After mifepristone was added to ongoing octreotide LAR treatment, EAS symptoms essentially resolved. Cortisol decreased dramatically, despite mifepristone's competitive glucocorticoid receptor antagonist effects. The clinical and biochemical effects reversed upon mifepristone discontinuation despite the continued use of octreotide LAR therapy. Substantial improvement in octreotide LAR efficacy with mifepristone use was noted in this patient with ectopic CS, consistent with upregulation of somatostatin receptors previously downregulated by hypercortisolemia.
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Abstract
Cushing syndrome due to endogenous hypercortisolism may cause significant morbidity and mortality. The source of excess cortisol may be adrenal, pituitary, or ectopic. Ectopic Cushing syndrome is sometimes difficult to localize on conventional imaging like CT and MRI. After performing a multilevel thoracoabdominal imaging with CT, the evidence regarding the use of radiotracers for PET imaging is unclear due to significant molecular and etiological heterogeneity of potential causes of ectopic Cushing's syndrome. In our systematic review of literature, it appears that GalLium-based (Ga68) somatostatin receptor analogs have better sensitivity in diagnosis of bronchial carcinoids causing Cushing syndrome and FDG PET appears superior for small-cell lung cancers and other aggressive tumors. Further large-scale studies are needed to identify the best PET tracer for this condition.
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Affiliation(s)
- Prasanna Santhanam
- Section of Endocrinology, Department of Internal Medicine, Joan C Edwards School of Medicine, Marshall University, Huntington, WV, 25701, USA.
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France.
- Marseille Cancerology Research Center, Institut Paoli-Calmettes, Marseille, France.
| | - Luca Giovanella
- Nuclear Medicine and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, Switzerland.
| | - Giorgio Treglia
- Nuclear Medicine and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, Switzerland.
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20
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Koulouri O, Steuwe A, Gillett D, Hoole AC, Powlson AS, Donnelly NA, Burnet NG, Antoun NM, Cheow H, Mannion RJ, Pickard JD, Gurnell M. A role for 11C-methionine PET imaging in ACTH-dependent Cushing's syndrome. Eur J Endocrinol 2015; 173:M107-20. [PMID: 26245763 DOI: 10.1530/eje-15-0616] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/05/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We report our experience of functional imaging with (11)C-methionine positron emission tomography-computed tomography (PET-CT) co-registered with 3D gradient echo (spoiled gradient recalled (SPGR)) magnetic resonance imaging (MRI) in the investigation of ACTH-dependent Cushing's syndrome. DESIGN Twenty patients with i) de novo Cushing's disease (CD, n=10), ii) residual or recurrent hypercortisolism following first pituitary surgery (±radiotherapy; n=8) or iii) ectopic Cushing's syndrome (n=2) were referred to our centre for functional imaging studies between 2010 and 2015. Six of the patients with de novo CD and five of those with persistent/relapsed disease had a suspected abnormality on conventional MRI. METHODS All patients underwent (11)C-methionine PET-CT. For pituitary imaging, co-registration of PET-CT images with contemporaneous SPGR MRI (1 mm slice thickness) was performed, followed by detailed mapping of (11)C-methionine uptake across the sella in three planes (coronal, sagittal and axial). This allowed us to determine whether suspected adenomas seen on structural imaging exhibited focal tracer uptake on functional imaging. RESULTS In seven of ten patients with de novo CD, asymmetric (11)C-methionine uptake was observed within the sella, which co-localized with the suspected site of a corticotroph microadenoma visualised on SPGR MRI (and which was subsequently confirmed histologically following successful transsphenoidal surgery (TSS)). Focal (11)C-methionine uptake that correlated with a suspected abnormality on pituitary MRI was seen in five of eight patients with residual or recurrent Cushing's syndrome following first TSS (and pituitary radiotherapy in two cases). Two patients elected to undergo repeat TSS with histology confirming a corticotroph tumour in each case. In two patients with the ectopic ACTH syndrome, (11)C-methionine was concentrated in sites of distant metastases, with minimal uptake in the sellar region. CONCLUSIONS (11)C-methionine PET-CT can aid the detection of ACTH-secreting tumours in Cushing's syndrome and facilitate targeted therapy.
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Affiliation(s)
- Olympia Koulouri
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Andrea Steuwe
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Daniel Gillett
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Andrew C Hoole
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Andrew S Powlson
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Neil A Donnelly
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Neil G Burnet
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Nagui M Antoun
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Heok Cheow
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Richard J Mannion
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - John D Pickard
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Mark Gurnell
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
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Isidori AM, Sbardella E, Zatelli MC, Boschetti M, Vitale G, Colao A, Pivonello R. Conventional and Nuclear Medicine Imaging in Ectopic Cushing's Syndrome: A Systematic Review. J Clin Endocrinol Metab 2015; 100:3231-44. [PMID: 26158607 PMCID: PMC4570166 DOI: 10.1210/jc.2015-1589] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
CONTEXT Ectopic Cushing's Syndrome (ECS) can be a diagnostic challenge with the hormonal source difficult to find. This study analyzes the accuracy of imaging studies in ECS localization. EVIDENCE ACQUISITION Systematic review of medical literature for ECS case series providing individual patient data on at least one conventional imaging technique (computed tomography [CT]/magnetic resonance imaging) and one of the following: 111In-pentetreotide (OCT), 131I/123I-metaiodobenzylguanidine, 18Ffluoro-2-deoxyglucose-positron emission tomography (FDG-PET), 18F-fluorodopa-PET (F-DOPA-PET), 68Ga- DOTATATE-PET/CT or 68Ga-DOTATOC-PET/CT scan (68Gallium-SSTR-PET/CT). EVIDENCE SUMMARY The analysis comprised 231 patients (females, 50.2%; age, 42.617 y). Overall, 52.4%(121/231) had "overt" ECS,18.6% had "occult" ECS, and 29% had "covert" ECS. Tumors were located in the lung (55.3%), mediastinum-thymus (7.9%), pancreas (8.5%), adrenal glands (6.4%), gastrointestinal tract (5.4%), thyroid (3.7%), and other sites (12.8%), and primary tumors were mostly bronchial neuroendocrine tumors (NETs) (54.8%), pancreatic NETs (8%), mediastinum-thymus NETs (6.9%), gastrointestinal NETs (5.3%), pheochromocytoma (6.4%), neuroblastoma (3.2%), and medullary thyroid carcinoma (3.2%). Tumors were localized byCTin66.2%(137/207), magnetic resonance imaging in 51.5% (53/103), OCT in 48.9% (84/172), FDG-PET in 51.7% (46/89), F-DOPAPET in 57.1% (12/21), 131/123I-metaiodobenzylguanidine in 30.8% (4/13), and 68Gallium-SSTRPET/CT in 81.8% (18/22) of cases. Molecular imaging discovered 79.1% (53/67) of tumors unidentified by conventional radiology, with OCT the most commonly used, revealing the tumor in 64%, followed by FDG-PET in 59.4%. F-DOPA-PET was used in only seven covert cases (sensitivity, 85.7%). Notably, 68Gallium-SSTR-PET/CT had 100% sensitivity among covert cases. CONCLUSIONS Nuclear medicine improves the sensitivity of conventional radiology when tumor site identification is problematic. OCT offers a good availability/reliability ratio, and FDG-PET was proven useful. 68Gallium-SSTR-PET/CT use was infrequent, despite offering the highest sensitivity.
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Mendoza CF, Ontiveros P, Xibillé DX, Rivera HM. Ectopic ACTH secretion (EAS) associated to a well-differentiated peritoneal mesothelioma: case report. BMC Endocr Disord 2015; 15:40. [PMID: 26253127 PMCID: PMC4528349 DOI: 10.1186/s12902-015-0031-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/12/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The association between mesotheliomas and ectopic ACTH secretion has been rarely reported; we present the first case of ectopic ACTH secretion (EAS) associated with a well-differentiated peritoneal mesothelioma in whom the high dose dexamethasone suppression test (HDDST) results and plasmatic ACTH levels were similar to those found in Cushing's disease (CD). CASE PRESENTATION A 43-year-old hispanic woman with a 20 year history of treatment resistant diabetes mellitus and arterial hypertension. She had a full moon face, a buffalo hump, increased volume in both supraclavicular regions, purple striae in her arms and abdomen, truncal obesity, polymenorrhea and umbilical hernia. A cortisol suppression test with low dose dexamethasone (LDDST) with a result of 16.6 μg/dL and ACTH plasma levels were measured at 32.6 pg/mL. The high dose dexamethasone test suppression percentage was 84.8% and magnetic resonance imaging (MRI) showed no evidence of pituitary alterations, computed tomography (CT) showed images suggestive of uterine fibroid and an intra-abdominal tumor that correlated with an umbilical hernia, which reinforcement after contrast. Surgery was performed, finding uterine fibroids and paracolic tumor implants as well as on the omentum, bladder, bowel, ovaries and appendix. Pathology reported a well-differentiated peritoneal mesothelioma with positive immunohistochemistry for ACTH. CONCLUSIONS Although most cases of ectopic secretion of ACTH derive from rapidly-developing lung tumors, with very high plasma ACTH levels and cortisol suppression percentages with high doses of dexamethasone under 60%, there is a small percentage of slow-developing, chronic tumors that are biochemically undistinguishable from Cushing's disease. Following the expert recommendations regarding imaging techniques it is possible to identify the associated tumor in most cases.
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Affiliation(s)
- Carmen F Mendoza
- Endocrinology Department, Universidad Autónoma del Estado de Morelos and Hospital General de Cuernavaca, Iztaccihuatl Esq. Leñeros S/N, Los Volcanes, 62350, Cuernavaca, Morelos, Mexico.
| | | | - Daniel X Xibillé
- Universidad Autónoma del Estado de Morelos and Hospital General de Cuernavaca, Morelos, Mexico.
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Rombolá CA, Genovés-Crespo M, López-Jiménez L, Martín-Ordoñez F, León-Atance P. Radioguided intraoperative detection of ectopic adrenocorticotropic hormone-producing carcinoid tumor. Cir Esp 2015; 94:361-2. [PMID: 26159237 DOI: 10.1016/j.ciresp.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 05/08/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Carlos A Rombolá
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España.
| | - Marta Genovés-Crespo
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - Luz López-Jiménez
- Servicio de Endocrinología, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | - Pablo León-Atance
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
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Abstract
A 37-year-old woman with clinical and biochemical features of ectopic adrenocorticotropic hormone (ACTH) syndrome underwent 68Ga DOTANOC PET/CT to localize the source of ectopic ACTH secretion. The images showed 35 × 45-mm retroperitoneal mass with significantly increased tracer uptake. Plasma-free metanephrines and serum chromogranin levels were normal. Whole-body 131I-MIBG scan including the retroperitoneal mass did not show any abnormal uptake. On excision, histopathology of this paravertebral abdominal mass revealed carcinoid tumor. We suggest the use of 68Ga DOTANOC PET/CT as a first-line imaging modality for localization of source of ACTH secretion in ectopic ACTH syndrome.
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Vaduganathan M, Nagarur A, Kerr DA, Lauter KB, Padmanabhan A, Raghavan S, Pallais JC, Fenves AZ. Metastatic pancreatic neuroendocrine tumor with ectopic adrenocorticotropic hormone production. Proc (Bayl Univ Med Cent) 2015; 28:46-9. [PMID: 25552797 DOI: 10.1080/08998280.2015.11929184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We describe a 71-year-old man who presented with abdominal pain, lower-extremity edema, recent unintentional weight loss, hypertension, hyperglycemia, hypokalemia, and metabolic alkalosis. Serum cortisol levels remained elevated after overnight high-dose dexamethasone suppression. Magnetic resonance imaging revealed a small mass in the head of the pancreas with scattered liver metastases. Both endoscopic ultrasound-guided pancreatic biopsy and liver biopsy revealed a well-differentiated neuroendocrine tumor. These lesions did not show significant uptake on octreotide scan. Medical management and hepatic artery chemoembolization were attempted. Ultimately, the patient underwent bilateral adrenalectomy, but died within 4 months of symptom onset secondary to postoperative complications.
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Affiliation(s)
- Muthiah Vaduganathan
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amulya Nagarur
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Darcy A Kerr
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kelly B Lauter
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arun Padmanabhan
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Srivatsan Raghavan
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Juan C Pallais
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Z Fenves
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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A challenging case of an ectopic cushing syndrome. Case Rep Med 2014; 2014:413136. [PMID: 25431598 PMCID: PMC4241739 DOI: 10.1155/2014/413136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/15/2014] [Accepted: 10/21/2014] [Indexed: 11/25/2022] Open
Abstract
Bronchopulmonary carcinoids are rare pulmonary neoplasms although they account for most cases of ectopic ACTH syndromes. When feasible, the mainstay treatment is surgical resection of the tumor. We report the case of a 52-year-old woman with signs and symptoms suggestive of hypercortisolism for 12 months, admitted to our department because of community acquired pneumonia. Blood hormone analysis showed increased levels of ACTH and urinary free cortisol and nonsuppressibility to high- and low-dose dexamethasone tests. Pituitary MRI showed no lesion and no central-to-peripheral ACTH gradient was present in bilateral inferior petrosal sinus sampling. CRH stimulation test suggested an ectopic ACTH source. Thoracic CT scan revealed a nodular region measuring 12 mm located in the inferior lingular lobule of the left superior lung with negative uptake by 18-FDG-PET scan and negative SRS. The patient was successfully treated with an atypical lung resection and histology revealed an atypical bronchial carcinoid tumor with positive ACTH immunoreactivity. This was an interesting case because the patient was admitted due to pneumonia that may have been associated with her untreated and chronic hypercortisolism and a challenging case of ectopic ACTH syndrome due to conflicting results on the diagnostic exams.
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