[Differences of brain functional alterations between subtypes of Cushing's syndrome patients]

Objective: To compare the differences of brain functional damage of subtypes of patients with Cushing's syndrome (CS). Methods: A total of 11 adrenocorticotropic hormone (ACTH)-dependent CS patients and 29 ACTH-independent CS patients were recruited from Chinese PLA General Hospital between September 2015 and March 2017 with confirmed CS. The psychiatric scales and brain task functional magnetic resonance imaging (fMRI) were evaluated. Results: A total of 40 patients (34 females, 6 males) with a mean age of (39.20±12.10) years and a median education level of 12 (9, 16) years were enrolled. ACTH-dependent patients had significantly worse performance than the ACTH-independent patients in response to the depression evaluation (64.6±6.1 vs 56.2±12.8, P=0.008), positive emotion (17.8±4.2 vs 24.3±7.2, P=0.008) and CS life quality [31(29,33) vs 42(29,51), P=0.040]. In the reaction to positive target pictures, ACTH-dependent CS patients showed stronger activation in left superior temporal gyrus compared with patients in ACTH-independent group, while the activation degree of their bilateral dorsal anterior cingulate cortex, bilateralsuperior frontal gyrus and left middle frontal gyrus was much worse. In the reactions to negative target pictures, ACTH-dependent CS patients had weaker activation in bilateral cerebellum, left superior frontal gyrus, left middle frontal gyrus, left precuneus and right postcentral gyrus, compared with patients in the ACTH-independent CS group (P<0.01, AlphaSim corrected). The activation degree of some regions whose brain function was different between the two groups was correlated to the cortisol level, ACTH level, 24 h urinary free cortisol (UFC) level, depression evaluation and negative emotion assessment (all P<0.05). Conclusions: The severity of the depression and the life quality of patients in ACTH-dependent group are worse than ACTH-independent CS patients. The brain function of ACTH-dependent CS patients is much weaker.

[Clinical features and prognosis of 18 cases of primary lymphocytic hypophysitis]

Objective: To analyze clinical features, prognosis and treatment of lymphocytic hypophysitis (LYH). Methods: The clinical data, treatments and outcomes of 18 cases diagnosed as LYH at Chinese PLA General Hospital between January 2001 and July 2017 was respectively reviewed. Results: Eighteen patients with histology-proven LYH (13 females and 5 males ) were identified. All lymphocytic adenohypophysitis (LAH) were females(n=6), two of whom were associated with pregnancy. Eleven patients (6 females and 5 males) had lymphocytic panhypophysitis (LPH) and one(female) had hypothalamitis. Pre-treatment evaluation revealed that 11 patients presented with symptoms of intracranial space-occupying lesions, 12 patients had symptoms of anterior pituitary hormone deficiencies, and 12 patients had central diabetes insipidus (CDI). All patients had space-occupying lesions on magnetic resonance imaging (MRI), which were symmetrically enlarged and homogenously enhanced with or without pituitary stalk thickening. Before or after surgery, 11 patients received immunosuppressant therapy or radiotherapy to alleviate space-occupying effect. After 4-204 months follow-up, 5 patients had a relapse and received immunosuppressants, radiotherapy or surgery to achieve remission. Full recovery (both symptomatic and radiographic) was seen in 6 patients, and 11 patients maintained stable replacement therapy. Conclusions: LYH presents with acute space-occupying effects such as headache, visual disturbances, hypopituitarism, CDI and mild hyperprolactinemia, especially with characteristic radiographic manifestations. Usually, surgery reliably establishes diagnosis, and immunosuppressant therapy is a necessity. On the whole, LYH has a good prognosis.

[Diagnostic value of urinary free cortisol in the subclinical Cushing's syndrome in patients with adrenal incidentaloma]

Objective: To evaluate the efficacy of 24 h urinary free cortisol (24 h UFC) in the diagnosis of subclinical Cushing's syndrome (SCS), and explore the best diagnostic cut-off value. Methods: The clinical data of patients with adrenal incidentaloma in Chinese PLA General Hospital between January 2008 and December 2016 was retrospectively reviewed and analyzed. All SCS patients were diagnosed based on the current Cushing's syndrome (CS) guidelines and confirmed by histopathology and then treated as study group, and additional patients with non-functional adrenal adenoma (NFA) were enrolled as control group. ROC curve was used to evaluate efficacy of 24 h UFC and 24 h UFC to creatinine ratio (UFCCR), and explore their best cut-off values. Results: There were 161 patients with NFA, of which contained 84 males and 77 females, with a mean age of (51.02±10.49) years old. There were 88 patients with SCS, of which contained 26 males and 62 females, with a mean age of (51.74±10.29) years old. The 24 h UFC and UFCCR levels were significant higher in SCS group than those in NFA group[510 (363, 698) nmol vs 335 (209, 467) nmol for 24 h UFC, and 7.82(4.79, 12.13) ml vs 4.82(2.41, 6.57)ml for UFCCR, both P<0.05]. ROC analysis showed that the optimal cut-off for 24 h UFC was 480 nmol (AUC 0.716, 95% CI: 0.648-0.784, with a sensitivity of 58.0% and a specificity of 79.4%) and the optimal cut-off for UFCCR was 6.84 ml (AUC 0.729, 95% CI: 0.662-0.796, with a sensitivity of 59.1% and a specificity of 78.7%). Conclusions: The recommended cut-off points of 24 h UFC and UFCCR for diagnosing SCS in AI patients were 480 nmol and 6.84 ml, respectively.

[Surgery versus conservative management for subclinical Cushing's syndrome in adrenal incidentalomas]

Objective: To determine the effect of the surgical and conservative approaches on the metabolic profiles in patients with subclinical Cushing's syndrome (SCS) in adrenal incidentalomas (AI). Methods: A hundred and thirty AI patients with SCS in Department of Endocrinology, PLA General Hospital between January 2008 and December 2016 were studied, surgery was performed in 88 patients (surgical group), and the rest received conservative approach (conservative group). The improvement/worsening of blood pressure, blood glucose, lipid profiles and body weight after a duration of >18 months follow-up were analyzed, respectively. Results: Baseline demographics, clinical characteristics were similar between surgical and conservative groups. In the surgical group, blood pressure, blood glucose, lipid profiles and body weight improved more frequently than that in conservative group (29.69% vs 3.12%, P=0.003; 10.94% vs 3.12%, P=0.262; 7.81% vs 3.12%, P=0.660; 39.06% vs 9.38%, P=0.004, respectively). In conservative group, blood pressure, blood glucose, lipid profiles and body weight worsened more frequently than that in surgical group (28.13% vs 0, P<0.001; 25.0% vs 0, P<0.001; 18.75% vs 0, P=0.003; 40.62% vs 20.31%, P=0.051, respectively). Logistic regression analysis indicated surgical treatment was associated with improvement of blood pressure (OR=10.687, 95%CI: 1.279-89.299) and weight loss (OR=5.541, 95%CI: 1.404-21.872) independently of gender, age, duration of follow-up, serum cortisol level after 1 mg-dexamethasone suppression test and the mass size. Conclusion: In AI patients with SCS, surgery was beneficial in the aspect of metabolic profiles.

[Predictive value of sonographic features in preoperative evaluation of medullary thyroid carcinoma]

OBJECTIVE

To summarize ultrasound features associated with medullary thyroid carcinoma (MTC) and investigate the predictive value of ultrasonography in preoperative diagnosis of MTC.

METHODS

The sonographic and clinical data were studied in a series of nodules histologically proven as MTC collected from January 1993 to January 2013.

RESULTS

A total of 86 patients (92 nodules proven as MTC) were enrolled in the study with an average age of (47±12) years.Among the MTCs, 21.7%(20/92) were excluded because of missing data and the remained 78.3%(72/92) had complete data with the average diameter of (2.1±1.3) cm.The common US findings for MTC were solid, hypoechogenicity, regular sharp, well-defined margin, AP/ TR<1 and calcification (mostly microcalcification). Calcification and vascularization were more common in MTC nodules(48.6% vs 5.6%, P=0.001). Nodules with enlargement of cervical lymph node tended to be undergone FNAB(76.0% vs 55.3%, P=0.084), and ill-defined margin was more common in MTC nodules with cervical lymph node metastasis(36.4% vs 12.8%, P=0.009).

CONCLUSION

Despite having a few US features closely linked to the malignant nodules such as solid, hypoechogenicity and with microcalcification, the MTC nodules also have specific US imaging characteristics as regular sharp, well-defined margin and AP/ TR<1.

[Clinical features and outcomes of congenital adrenal hyperplasia with adenomatoid adrenal gland]

Objective: To analyze the clinical features and outcomes of congenital adrenal hyperplasia (CAH) with adenomatoid adrenal gland. Methods: Nineteen patients clinically confirmed as CAH with adenomatoid adrenal gland, from 2008 to 2015 in Deparment of Endocrinology of Chinese PLA General Hospital, were retrospectively analyzed, and the outcomes of the treatment were followed up. Results: Seventy-six patients were clinically confirmed as CAH, from 2008 to 2015 in PLA hospital. Nineteen of them have accompanied with adenomatoid adrenal gland. Of the 19 confirmed cases, 7 were male, and 12 were female. The mean age was (33.3±14.8) years old. Nineteen confirmed cases were consisted of 10 cases of 21-hydroxylase deficiency (OHD), 6 cases of 17α-OHD, and 3 cases of 11β-OHD. Of the 19 cases, 5 cases presented with adrenal hyperplasia with left side adenomatoid solid lesion, 2 cases presented with adrenal hyperplasia with right side adenomatoid solid lesion, and 8 cases presented with double side adenomatoid solid lesion. The proportion of adrenal hyperplasia with unilateral cystic or calcified changes was 21.1%. Nine of the 19 patients underwent operation or fine needle biopsy. The pathology showed 7 adenomas (21-OHD/17α-OHD 5/2) and 2 myelolipomas (21-OHD/17α-OHD 1/1). Four patients were admitted into hospital because of the incidentaloma, while others because of the clinical symptoms. The average follow-up time was 31 months. CT images were rechecked among 7 patients. After the treatment, 1 patient's tumor shrunk, 4 cases had no recurrence, 1 case's tumor disappeared, and the other one case had no change. Symtoms of eleven followed-up patients relieved. Conclusions: The image of adrenal of CAH with adenomatoid adrenal gland is various. It may occur in each type of CAH presented as unilateral or bilateral, adenoma or myelolipoma.