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Murakami M, Hirahata K, Fujimori N, Yamamoto T, Oda Y, Kozono S, Ueda K, Ito T, Nakamura M, Ogawa Y. Two cases of pancreatic neuroendocrine tumors with ectopic ACTH syndrome during their disease course. Clin J Gastroenterol 2024; 17:363-370. [PMID: 38244178 DOI: 10.1007/s12328-023-01908-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/08/2023] [Indexed: 01/22/2024]
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are rare malignant tumors that occur in the pancreas. They are divided into functioning and non-functioning tumors based on the presence or absence of their specific hormonal hyper-expression symptoms. Adrenocorticotropic hormone (ACTH)-producing PanNETs are rare, functional tumors, and their clinical characteristics and outcomes have not been well reported.Here, we report the cases of two patients with PanNETs who presented with ectopic ACTH syndrome (EAS) during the course of their disease. Case 1 involved a non-functioning PanNET at the time of surgery. During treatment for recurrent liver metastases, the patient presented with EAS and tumor-associated hypercalcemia, probably due to ACTH and parathyroid hormone-related peptide (PTHrP) production from the liver tumor. Case 2 was a gastrinoma, and similar to Case 1, this patient presented with EAS during the treatment of recurrent liver metastases.It is not uncommon for patients with PanNETs to have multiple hormones and develop secondary hormone secretion during their disease course, although tumor phenotypes differ between primary and metastatic sites. In patients with functioning PanNETs, symptom control with anti-hormonal therapy is essential, in addition to anti-tumor therapy, especially for EAS, which is an endocrine emergency disease that requires prompt diagnosis and treatment.
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Affiliation(s)
- Masatoshi Murakami
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keisuke Hirahata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Takeo Yamamoto
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shingo Kozono
- Department of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Keijiro Ueda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Testuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital, Fukuoka, Japan
- Department of Gastroenterology, Graduate School of Medical Sciences, International University of Health and Welfare, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Demir AN, Ayata D, Oz A, Sulu C, Kara Z, Sahin S, Ozaydin D, Korkmazer B, Arslan S, Kizilkilic O, Ciftci S, Celik O, Ozkaya HM, Tanriover N, Gazioglu N, Kadioglu P. Machine Learning May Be An Alternative To BIPSS In The Differential Diagnosis Of ACTH-Dependent Cushing's Syndrome. J Clin Endocrinol Metab 2024:dgae180. [PMID: 38501466 DOI: 10.1210/clinem/dgae180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/27/2024] [Accepted: 03/15/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE This study aimed to develop machine learning (ML) algorithms for the differential diagnosis of adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome (CS) based on biochemical and radiological features. METHODS Logistic regression algorithms were used for ML, and the area under the receiver operating characteristics curve (AUROC) was used to measure performance. We used Shapley Contributed Comments (SHAP) values, which help explain the results of the ML models to identify the meaning of each feature and facilitate interpretation. RESULTS A total of 106 patients, 80 with Cushing's disease (CD) and 26 with ectopic ACTH syndrome (EAS), were enrolled in the study. The ML task was created to classify patients with ACTH-dependent CS into CD and EAS. The average AUROC value obtained in the cross-validation of the logistic regression model created for the classification task was 0.850. The diagnostic accuracy of the algorithm was 86%. The SHAP values indicated that the most important determinants for the model were the 2-day 2-mg dexamethasone suppression test, the > 50% suppression in the 8-mg high-dose dexamethasone test, late-night salivary cortisol, and the diameter of the pituitary adenoma. We have also made our algorithm available to all clinicians via a user-friendly interface. CONCLUSION ML algorithms have the potential to serve as an alternative decision support tool to invasive procedures in the differential diagnosis of ACTH-dependent CS.
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Affiliation(s)
- Ahmet Numan Demir
- Istanbul University-Cerrahpasa, Department of Endocrinology, Metabolism, and Diabetes, Istanbul/Turkey
| | - Deger Ayata
- Istanbul University-Cerrahpasa, Department of Endocrinology, Metabolism, and Diabetes, Istanbul/Turkey
- Chief AI officer at AIATUS, Istanbul/Turkey
| | - Ahmet Oz
- Istanbul University-Cerrahpasa, Department of Radiology, Istanbul/Turkey
| | - Cem Sulu
- Istanbul University-Cerrahpasa, Department of Endocrinology, Metabolism, and Diabetes, Istanbul/Turkey
| | - Zehra Kara
- Istanbul University-Cerrahpasa, Department of Endocrinology, Metabolism, and Diabetes, Istanbul/Turkey
| | - Serdar Sahin
- Istanbul University-Cerrahpasa, Department of Endocrinology, Metabolism, and Diabetes, Istanbul/Turkey
| | - Dilan Ozaydin
- Health Sciences University, Kartal Dr. Lutfi Kirdar City Hospital, Department of Neurosurgery, Istanbul/Turkey
| | - Bora Korkmazer
- Istanbul University-Cerrahpasa, Department of Radiology, Istanbul/Turkey
| | - Serdar Arslan
- Istanbul University-Cerrahpasa, Department of Radiology, Istanbul/Turkey
| | - Osman Kizilkilic
- Istanbul University-Cerrahpasa, Department of Radiology, Istanbul/Turkey
- Istanbul University-Cerrahpasa, Pituitary Center, Istanbul/Turkey
| | - Sema Ciftci
- Health Sciences University, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Endocrinology and Metabolism, Istanbul/Turkey
| | - Ozlem Celik
- Mehmet Ali Aydinlar Acibadem University, Department of Endocrinology and Metabolism, Istanbul/Turkey
| | - Hande Mefkure Ozkaya
- Istanbul University-Cerrahpasa, Department of Endocrinology, Metabolism, and Diabetes, Istanbul/Turkey
- Istanbul University-Cerrahpasa, Pituitary Center, Istanbul/Turkey
| | - Necmettin Tanriover
- Istanbul University-Cerrahpasa, Pituitary Center, Istanbul/Turkey
- Istanbul University-Cerrahpasa, Department of Neurosurgery, Istanbul/Turkey
| | - Nurperi Gazioglu
- Istanbul University-Cerrahpasa, Pituitary Center, Istanbul/Turkey
- Istinye University, Department of Neurosurgery, Istanbul/Turkey
| | - Pinar Kadioglu
- Istanbul University-Cerrahpasa, Department of Endocrinology, Metabolism, and Diabetes, Istanbul/Turkey
- Istanbul University-Cerrahpasa, Pituitary Center, Istanbul/Turkey
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Cai Y, Zhao X, Ren L, Liu S, Liu X, Gang X, Wang G. Clinical features and risk factors for postoperative recurrence in patients with Cushing's syndrome of different etiologies. Sci Rep 2024; 14:4666. [PMID: 38409302 PMCID: PMC10897300 DOI: 10.1038/s41598-024-53913-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/06/2024] [Indexed: 02/28/2024] Open
Abstract
The clinical characteristics of Cushing's syndrome (CS) vary with etiology, and few studies have investigated the risk factors affecting CS recurrence after surgery. This retrospective study involved 202 patients diagnosed with CS between December 2012 and December 2022. The patients were divided into three groups according to etiology: Cushing's disease (CD), adrenocortical adenoma (ACA), and ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS). Of the patients with CS, 41.9% had hypokalemia and 15.0% had hypophosphatemia. The cortisol levels were negatively correlated with blood potassium, blood chlorine, and blood phosphorus. Moreover, 22.4% of patients had an abnormal heart structure, 11.2% had centripetal remodeling, 5.6% had centripetal hypertrophy, and 5.6% had centrifugal hypertrophy. The overall recurrence rate of CS caused by pituitary tumors and adrenal adenoma was 25.7%. The recurrence times were longer in the ACA group versus the CD group, in patients < 50 years of age versus in patients ≥ 50 years old group, and in patients with CD with tumors ≥ 1 cm versus tumors < 1 cm. Age, preoperative cortisol level, postoperative cortisol level, and absolute neutrophil value were closely related to postoperative recurrence, and etiology was an independent predictor of tumor recurrence in patients with CS. The results of this study showed that CS caused by different etiologies showed different clinical manifestations, blood electrolyte characteristics, and that CS could affect patient cardiac structure and function. Etiology is an independent predictor of tumor recurrence in patients with CS.
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Affiliation(s)
- Yunjia Cai
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Xue Zhao
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Linan Ren
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Siyuan Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Xinming Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China.
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China.
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Attri B, Goyal A, Kalaivani M, Kandasamy D, Gupta Y, Agarwal S, Shamim SA, Damle N, Dhingra A, Jyotsna VP, Suri A, Tandon N. Clinical profile and treatment outcomes of patients with ectopic ACTH syndrome compared to Cushing disease: a single-center experience. Endocrine 2023; 80:408-418. [PMID: 36609908 DOI: 10.1007/s12020-022-03298-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE We aimed to evaluate and compare the clinical, biochemical and radiological profile and outcomes of patients with ectopic ACTH syndrome (EAS) and Cushing disease (CD) treated over a period of 10 years (2013-2022). METHODS In this ambispective observational study, we collected data for 146 patients with ACTH-dependent CS (EAS, n = 23; CD, n = 94; occult ACTH source, n = 29). Relevant details were filled in a predesigned proforma and outcomes were ascertained at the most recent visit. RESULTS EAS was more common in males (65.2 vs. 27.6%, p < 0.001). Patients with EAS had a shorter duration of symptoms [12 (6-12) vs. 31.5 (15-48) months, p < 0.001] and were more likely to have hypokalemia (82.6 vs. 21.0%, p = 0.001), pedal edema (65.2 vs. 34.2%, p = 0.015), weight loss (34.8 vs. 4.0%, p < 0.001) and systemic infection (30.4 vs. 6.5%, p = 0.006). They also had significantly higher 8 a.m. serum cortisol, midnight serum and salivary cortisol and 8 a.m. plasma ACTH levels. Bronchial carcinoid (n = 10, 43.5%) was the most common etiology of EAS. Bilateral adrenalectomy was performed in 11 (47.8%) patients with EAS. Eight patients (34.8%) with EAS died at the last follow-up, of whom 7 (87.5%) had metastatic disease. In CD group, overall remission rate was 69.4% (56.1%, early and 13.3%, delayed) and 26.3% of patients with an initial remission had recurrence. CONCLUSIONS Bronchial carcinoid was the most common cause of EAS in our cohort. Bilateral adrenalectomy was performed in approximately every 1 in 2 patients with EAS and approximately every 1 in 3 patients expired till the last follow-up.
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Affiliation(s)
- Bhawna Attri
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Alpesh Goyal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
| | - Mani Kalaivani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Yashdeep Gupta
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Shipra Agarwal
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Shamim A Shamim
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nishikant Damle
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Dhingra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Viveka P Jyotsna
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Abstract
The differential diagnosis of ACTH-dependent Cushing's syndrome is often a diagnostic challenge that has been debated in numerous studies. In this short article, we will discuss the performance and main drawbacks of the biochemical tests used for this diagnosis.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, 33604, Pessac, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, 33604, Pessac, France.
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de León-Castorena E, López-Sotomayor DM, Gaona-Garza LE, Treviño-Aguillón MA, Talamas-Mendoza A. Ectopic ACTH syndrome complicated by hypercortisolism-associated urolithiasis. A case report. Int J Surg Case Rep 2022; 97:107449. [PMID: 35905678 PMCID: PMC9403305 DOI: 10.1016/j.ijscr.2022.107449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 02/07/2023] Open
Abstract
Nephrolithiasis is a frequent and underestimated complication of Cushing’s syndrome (CS), prevalence soars up to 50 % in adult patients with active CS, and 25% in cured patients in whom certain abnormalities contribute to stone recurrence Ectopic ACTH secretion (EAS) is a less common cause of Cushing syndrome and is seen in 5 to 10% of cases with endogenous hypercortisolemia. Sudden and dramatic onset of CS often suggests an ectopic ACTH-secreting tumor. There is no information in any urological clinical practice guideline in relation to management of nephrolithiasis in Cushing’s syndrome, follow-up in glucocorticoid-induced nephrolithiasis should be tailored to each patient.
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Affiliation(s)
- Emilio de León-Castorena
- Tecnologico de Monterrey, TecSalud School of Medicine and Health Sciences, Monterrey, N.L., Mexico
| | | | | | - Mario Alberto Treviño-Aguillón
- Tecnologico de Monterrey, TecSalud School of Medicine and Health Sciences, Monterrey, N.L., Mexico,Corresponding author.
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Chen X, Zhang Y, Lin J, Li H. An ACTH-secreting tumor hidden in a congenitally hypoplastic left lung. Interact Cardiovasc Thorac Surg 2022; 35:6586295. [PMID: 35575403 PMCID: PMC9419672 DOI: 10.1093/icvts/ivac130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/13/2022] [Indexed: 12/03/2022] Open
Abstract
Ectopic adrenocorticotrophic hormone (ACTH) syndrome has historically been a therapeutic challenge because of the difficulty localizing occult ACTH-secreting tumours. Here, we report a case of a 67-year-old woman with ectopic ACTH syndrome and had an ACTH-secreting tumour hidden within a congenitally hypoplastic left lung. A satisfactory therapeutic outcome was obtained after left pneumonectomy was performed on patient in this case.
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Affiliation(s)
- Xueyu Chen
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Huangpu District, Shanghai, (200025, ), P.R. China
| | - Yajie Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Huangpu District, Shanghai, (200025, ), P.R. China
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan Medical School, 2120TC/5344, 1500 E. Medical Center Drive, Ann Arbor, MI, 48105, USA
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Huangpu District, Shanghai, (200025, ), P.R. China
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Toivanen S, Leijon H, Arola A, Soinio M, Hämäläinen PO, Metso S, Knutar O, Koivikko M, Ebeling T, Moilanen L, Norvio L, Tamminen M, Rautiainen P, Vehkavaara S, Ryhänen E, Pekkarinen T, Matikainen N, Sane T, Schalin-Jäntti C. Characteristics and outcomes of the Finnish ectopic ACTH syndrome cohort. Endocrine 2021; 74:387-395. [PMID: 34036515 DOI: 10.1007/s12020-021-02768-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Ectopic ACTH syndrome (EAS) is rare. We established a national cohort to increase awareness and address unmet needs. METHODS The Finnish national EAS cohort includes 60 patients diagnosed in 1997-2016. We assessed clinical features, diagnostic work-ups, treatments, incidence, and outcomes of subgroups occult tumor (OT), well-differentiated neuroendocrine tumor G1/G2 (NETG1/G2) and NET G3/neuroendocrine carcinoma (NETG3/NEC). RESULTS The distribution of OT, NETG1/G2, and NETG3/NEC was 10 (17%), 20 (33%), and 30 (50%), respectively; and median follow-up 22 months (0-249). Annual incidence (0.20-0.93 per million inhabitants) and tumor subgroups (OT vs. NEC) varied across the country. The longest diagnostic delay from EAS onset to radiological tumor identification was 48 months. In NET/NEC, 6/50 (12%) were diagnosed 1-24 years before EAS onset. Osteoporotic fractures (32%) and severe infections (55%) were common. The CRH stimulation test accurately diagnosed EAS in 25/31 (81%). Metyrapone (≤6 g daily, prescribed in 88%) was well tolerated. In NETG1/G2, 13/20 (65%) underwent curative resection of the primary tumor; four experienced recurrence within 2-12 years. In OT, 70% underwent bilateral adrenalectomy. Five-year overall survival in OT, NETG1/G2, and NETG3/NEC was 90%, 55%, and 0%, respectively (P < 0.001). Morning cortisol, hypokalemia, infections, metastatic disease, and acute onset were negative, whereas resection of the primary tumor and bilateral adrenalectomy were positive predictors of survival. CONCLUSIONS NET/NEC may precede EAS onset by several years. In NETG1/G2, recurrences may occur > 10 years after successful primary surgery. Tumor subgroup (OT, NETG1/G2, NEC) was an independent predictor of survival.
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Affiliation(s)
- Sanna Toivanen
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Divison of Endocrinology, Helsinki University Hospital, Hyvinkää, Finland
| | - Helena Leijon
- Department of Pathology, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Aura Arola
- Department of Endocrinology, Turku University Hospital and University of Turku, Turku, Finland
| | - Minna Soinio
- Department of Endocrinology, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi O Hämäläinen
- Department of Internal Medicine and Tampere University, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere, Finland
| | - Saara Metso
- Department of Internal Medicine and Tampere University, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere, Finland
| | - Otto Knutar
- Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland
| | - Minna Koivikko
- Department of Internal Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tapani Ebeling
- Department of Internal Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Leena Moilanen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Leena Norvio
- Divison of Endocrinology, Helsinki University Hospital, Hyvinkää, Finland
| | - Marjo Tamminen
- Department of Internal Medicine, Central Hospital of Kymenlaakso, Kotka, Finland
| | - Päivi Rautiainen
- Department of Internal Medicine, Joint Muncipal Authority for North Karelia Social and Health Services (Siun sote), Joensuu, Finland
| | - Satu Vehkavaara
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eeva Ryhänen
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tuula Pekkarinen
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Niina Matikainen
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Sane
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Camilla Schalin-Jäntti
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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Abstract
BACKGROUND Manifestations of hypokalaemia in ectopic adrenocorticotropic hormonesyndrome(EAS) vary from mild muscle weakness to life-threatening arrhythmia. Herein, we present a rare case of EAS with concomitant rhabdomyolysis(RM) as a result of intractable hypokalaemia. CASE PRESENTATION A 64-year-old man was admitted for limb weakness and facial hyperpigmentation for 2 weeks. Lab tests revealed intractable hypokalaemia (lowest at 1.8 mmol/L) and metabolic alkalosis. The diagnosis of RM was based on a creatine kinase(CK)level of 5 times the upper limit. The elevated CK and myohemoglobin (Mb) levels returned to within the normal range after the alleviation of hypokalaemia. The patient was diagnosed with ACTH-dependent Cushing's syndrome (CS) based on unsuppressed serum cortisol after a low-dose dexamethasone suppression test(LDDST) and remarkably elevated ACTH levels. The diagnosis of EAS was made based on the results of a high-dose dexamethasone suppression test(HDDST) and bilateral inferior petrosal sinus sampling(BIPSS). Multiple lymph nodes in the left supraclavicular fossa, right root of neck, mediastinum and bilateral hili of the lung were found with abnormal uptake of 68Ga-DOTA-NOC. Mediastinoscopic lymph node biopsy was performed. The pathological diagnosis was small-cell and large-cell neuroendocrine carcinoma with positive ACTH staining. The patient was prescribed mifepristone and received one cycle of chemotherapy. The patient could not tolerate subsequent chemotherapy and died of dyscrasia. CONCLUSIONS RM is a rare complication of EAS with insidious onset and atypical clinical manifestations. Serum potassium levels should be vigilantly monitored to avoid RM in EAS.
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Affiliation(s)
- Wei Qiang
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
| | - Sucai Song
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
- Department of Endocrinology, The First Affiliated Hospital of Zhengzhou University, 450052 Zhengzhou, People’s Republic of China
| | - Tianjun Chen
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Zhe Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jun Feng
- Department of Vascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Jiaojiao Zhang
- Department of Pathology, The First Affiliated Hospital of Xi’an Jiaotong University, 710061 Xi’an, People’s Republic of China
| | - Hui Guo
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Xi’an Jiaotong University, No.277 West Yanta Road, 710061 Xi’an, People’s Republic of China
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Rahmani F, Tohidi M, Dehghani M, Broumand B, Hadaegh F. Recurrence of a neuroendocrine tumor of adrenal origin: a case report with more than a decade follow-up. BMC Endocr Disord 2021; 21:9. [PMID: 33413271 PMCID: PMC7791754 DOI: 10.1186/s12902-020-00673-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neuroendocrine tumor (NET) with adrenocorticotropic hormone (ACTH) secretion are very rare. To our knowledge, no follow-up study is published for ACTH-secreting NET, regardless of the primary site, to show second occurrence of tumor after a long follow-up, following resection of primary tumor. CASE PRESENTATION Here, we describe a 49-year-old-man with cushingoid feature, drowsiness and quadriparesis came to emergency department at December 2005. Laboratory tests revealed hyperglycemia, metabolic alkalosis, severe hypokalemia, and chemical evidence of an ACTH-dependent hypercortisolism as morning serum cortisol of 57 μg /dL without suppression after 8 mg dexamethasone suppression test, serum ACTH level of 256 pg/mL, and urine free cortisol of > 1000 μg /24 h. Imaging showed only bilateral adrenal hyperplasia, without evidence of pituitary adenoma or ectopic ACTH producing tumors. Importantly, other diagnostic tests for differentiating Cushing disease (CD) from ectopic ACTH producing tumor, such as inferior petrosal sinus sampling (IPSS), corticotropin releasing hormone (CRH) stimulation test, octreotide scan or fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan were not available in our country at that time. Therefore, bilateral adrenalectomy was performed that led to clinical and biochemical remission of hypercortisolism and decreased ACTH level to < 50 pg/mL, findings suggestive of a primary focus of NET in adrenal glands. After 11 years uncomplicated follow up, the ACTH level elevated up to 341 pg/mL and re-evaluation showed a 2 cm nodule in the middle lobe of the right lung. Surgical excision of the pulmonary nodule yielded a carcinoid tumor with positive immunostaining for ACTH; leading to decrease in serum ACTH level to 98 pg/mL. Subsequently after 7 months, serum ACHT levels rose again. More investigation showed multiple lung nodules with metastatic bone lesions accompanied by high serum chromogranin level (2062 ng/mL), and the patient managed as a metastatic NET, with bisphosphonate and somatostatin receptor analogues. CONCLUSION This case of surgically-treated NET showing a secondary focus of carcinoid tumor after one decade of disease-free follow-up emphasizes on the importance of long-term follow-up of ACTH-secreting adrenal NET.
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Affiliation(s)
- Fatemeh Rahmani
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran
| | - Maryam Tohidi
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran
| | - Maryam Dehghani
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran
| | - Behrooz Broumand
- Emeritus Professor of Medicine, Iran University of Medical Sciences, Pars Advanced and Minimally Invasive Manners Research Center, Pars General Hospital, Keshavarz Blvd, Tehran, Iran
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran.
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Stachowska B, Kuliczkowska-Płaksej J, Kałużny M, Grzegrzółka J, Jończyk M, Bolanowski M. Etiology, baseline clinical profile and comorbidities of patients with Cushing's syndrome at a single endocrinological center. Endocrine 2020; 70:616-628. [PMID: 32880849 PMCID: PMC7674323 DOI: 10.1007/s12020-020-02468-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/19/2020] [Indexed: 12/02/2022]
Abstract
PURPOSE The aim of this study was to compare phenotype of patients with pituitary, adrenal and ectopic CS and identify the differences regarding biochemical parameters, clinical presentations, and comorbidities in CS patients who were diagnosed at the single endocrinological center in Wroclaw. METHODS The study population involved 64 patients with CS (53 women and 11 men) diagnosed in Department of Endocrinology, Diabetes and Isotope Therapy in 2000-2018. Patients were divided into three etiologic groups: pituitary dependent-CS (P-CS) (64%), adrenal dependent CS (A-CS) (25%), and CS from an ectopic source (E-CS) (11%). RESULTS Percentage of men in the A-CS group was significantly higher than in the other etiologic groups. ACTH, UFC, and cortisol in DST were significantly higher in E-CS group compare to P-CS and A-CS (p < 0.05). Mean potassium level in E-CS group was significantly lower than in P-CS and A-CS (p < 0.05). Median of time elapsed to diagnosis was significantly lower in the E-CS group compared with either the P-CS and the A-CS group (p < 0.01). The most frequently symptoms in CS patients were skin alterations (82.8%), weight gain (81.2%), and hypertension (81.2%). CONCLUSIONS The epidemiology of CS is changing toward a growing proportion of A-CS. All patients with E-CS presented a profound hypokalemia. Salient hypokalemia could be a biochemical marker more suggestive for E-CS rather than P-CS. The incidence of diabetes is more frequent in E-CS group than in P-CS and A-CS groups.
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Affiliation(s)
- Barbara Stachowska
- Department and Clinic of Endocrinology, Diabetes, and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland.
| | - Justyna Kuliczkowska-Płaksej
- Department and Clinic of Endocrinology, Diabetes, and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Kałużny
- Department and Clinic of Endocrinology, Diabetes, and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Jędrzej Grzegrzółka
- Department and Clinic of Endocrinology, Diabetes, and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Maja Jończyk
- Department and Clinic of Endocrinology, Diabetes, and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Bolanowski
- Department and Clinic of Endocrinology, Diabetes, and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
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12
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Saxena R, Pathak M, Shukla R, Sinha A, Elhence P, Bharti JN, Khera P. Bronchial Carcinoid Tumour as a Rare Cause of Cushing’s Syndrome in Children: A Case Report and Review of Literature. J Clin Res Pediatr Endocrinol 2020; 12:340-346. [PMID: 31898446 PMCID: PMC7711641 DOI: 10.4274/jcrpe.galenos.2019.2019.0156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Cushing’s syndrome (CS) is rare in childhood and adolescence. The most common paediatric cause of CS is exogenous administration of glucocorticoids; either topical, inhaled or oral corticosteroids. Endogenous causes can be classified into adrenocorticotropic hormone (ACTH) independent and ACTH dependent causes. Herein, we report our experience of managing a 12 year old girl who presented with features of CS and was found to have an ectopic, ACTH-secreting bronchial carcinoid tumour, which was resected surgically. Our patient was managed successfully by multidisciplinary approach and has recovered from hypertension and Cushing’s habitus. The English language literature was searched from 2019 back, using PubMed, Google and Google Scholar. Keywords used for the search were; “Ectopic ACTH syndrome (EAS) in children”, “bronchial carcinoid in children” and “Cushing’s Syndrome in children”. Children with bronchial carcinoid tumours causing EAS were identified. Case variables such as age, sex, type of carcinoid, investigations, surgery, recurrences and outcome were reviewed. Fourteen cases of paediatric bronchial carcinoid producing ACTH were found with a mean age of 15.8 years and female preponderance. Most of the patients had a right lung lesion and histological appearance was typical of carcinoid tumour. Bronchial carcinoid is extremely rare in children and only 4% are associated with CS. The postoperative treatment of CS is challenging with a high prevalence of hypertension, increased body mass index and visceral fat mass, impaired cognitive function and decreased quality of life. A careful follow up is indispensable for monitoring recurrence of carcinoid and complete remission of CS.
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Affiliation(s)
- Rahul Saxena
- All India Institute of Medical Sciences, Department of Pediatric Surgery, Jodhpur, India,* Address for Correspondence: All India Institute of Medical Sciences, Department of Pediatric Surgery, Jodhpur, India Phone: +9587326200 E-mail:
| | - Manish Pathak
- All India Institute of Medical Sciences, Department of Pediatric Surgery, Jodhpur, India
| | - Ravindra Shukla
- All India Institute of Medical Sciences, Department of Endocrinology, Jodhpur, India
| | - Arvind Sinha
- All India Institute of Medical Sciences, Department of Pediatric Surgery, Jodhpur, India
| | - Poonam Elhence
- All India Institute of Medical Sciences, Department of Pathology, Jodhpur, India
| | - Jyotsna N. Bharti
- All India Institute of Medical Sciences, Department of Pathology, Jodhpur, India
| | - Pushpinder Khera
- All India Institute of Medical Sciences, Department of Diagnostic and Interventional Radiology, Jodhpur, India
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13
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Decaestecker K, Wijtvliet V, Coremans P, Van Doninck N. Olfactory neuroblastoma (esthesioneuroblastoma) presenting as ectopic ACTH syndrome: always follow your nose. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190093. [PMID: 31627184 DOI: 10.1530/edm-19-0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/25/2019] [Indexed: 11/08/2022] Open
Abstract
SUMMARY ACTH-dependent hypercortisolism is caused by an ectopic ACTH syndrome (EAS) in 20% of cases. We report a rare cause of EAS in a 41-year-old woman, presenting with clinical features of Cushing's syndrome which developed over several months. Biochemical tests revealed hypokalemic metabolic alkalosis and high morning cortisol and ACTH levels. Further testing, including 24-hour urine analysis, late-night saliva and low-dose dexamethasone suppression test, confirmed hypercortisolism. An MRI of the pituitary gland was normal. Inferior petrosal sinus sampling (IPSS) revealed inconsistent results, with a raised basal gradient but no rise after CRH stimulation. Additional PET-CT showed intense metabolic activity in the left nasal vault. Biopsy of this lesion revealed an unsuspected cause of Cushing's syndrome: an olfactory neuroblastoma (ONB) with positive immunostaining for ACTH. Our patient underwent transnasal resection of the tumour mass, followed by adjuvant radiotherapy. Normalisation of cortisol and ACTH levels was seen immediately after surgery. Hydrocortisone substitution was started to prevent withdrawal symptoms. As the hypothalamic-pituitary-axis slowly recovered, daily hydrocortisone doses were tapered and stopped 4 months after surgery. Clinical Cushing's stigmata improved gradually. LEARNING POINTS Ectopic ACTH syndrome can originate from tumours outside the thoracoabdominal region, like the sinonasal cavity. The diagnostic accuracy of IPSS is not 100%: both false positives and false negatives may occur and might be due to a sinonasal tumour with ectopic ACTH secretion. Olfactory neuroblastoma (syn. esthesioneuroblastoma), named because of its sensory (olfactory) and neuroectodermal origin in the upper nasal cavity, is a rare malignant neoplasm. It should not be confused with neuroblastoma, a tumour of the sympathetic nervous system typically occurring in children. If one criticises MRI of the pituitary gland because of ACTH-dependent hypercortisolism, one should take a close look at the sinonasal field as well.
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Affiliation(s)
- Karen Decaestecker
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Veerle Wijtvliet
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Peter Coremans
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Nike Van Doninck
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
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Abstract
Ectopia of nodular adrenocortical tissue is very frequently found in the periadrenal region. It corresponds to accessory adrenal tissue and is a normal variant. Ectopia in more distant regions are found in inner male or female genitalia. Strong long-lasting hyperstimultions induce hyperplasia and simulate true tumors ("adrenal rest tumors"). Real autonomic tumors from ectopic adrenal tissue with or without hyperfunction are rare. Ectopia of adrenomedullary tissue are nearly exclusively found in the surroundings of normal medulla. Ectopia in the adrenals corresponds almost exclusively with thyroid tissue. Ectopic secretion of hormones, mostly ACTH, can be found in pheochromocytomas and induces hyperfunction (Cushing's syndrome).
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15
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Takeuchi M, Sato J, Manaka K, Tanaka M, Matsui H, Sato Y, Kume H, Fukayama M, Iiri T, Nangaku M, Makita N. Molecular analysis and literature-based hypothesis of an immunonegative prostate small cell carcinoma causing ectopic ACTH syndrome. Endocr J 2019; 66:547-554. [PMID: 30918166 DOI: 10.1507/endocrj.ej18-0563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ectopic ACTH syndrome (EAS) due to a prostate small cell carcinoma (SCC) is very rare with only 26 cases reported to date and has a poor prognosis. We here describe another case of this disorder that was clinically typical based on prior reports as it showed hypercortisolemia and severe hypokalemia with multiple metastasis. However, our current case of prostate SCC causing EAS is the first to display negative immunostaining for ACTH despite detectable POMC mRNA expression in the primary lesion. ACTH immunonegativity is thought to be associated with a more aggressive disease course and a poorer prognosis although there are few studies of the underlying mechanisms. We explored two possibilities for this finding in our current patient: aberrant POMC processing prevented immunodetection with an anti-ACTH antibody; and the ACTH content per cell was below the threshold for immunodetection due to its rapid secretion or low synthesis. The aberrant processing theory was thought to be less likely because of immunonegative findings even using anti-POMC/ACTH antibodies. As the plasma ACTH levels in our patient were comparable with those reported for previous immunopositive prostate EAS cases, we speculated that the depletion of ACTH may be caused not only by rapid secretion but also by low production levels as a sign of de-differentiation. De-differentiation may therefore explain the mechanism underlying the negative correlation between immunoreactivity for ACTH in EAS and disease aggressiveness. We believe that our present findings will be of use in future prospective studies aimed at confirming the mechanism of immunonegativity.
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Affiliation(s)
- Maki Takeuchi
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Junichiro Sato
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Katsunori Manaka
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Mariko Tanaka
- Department of Pathology, The University of Tokyo, Tokyo, Japan
| | - Hotaka Matsui
- Department of Urology, The University of Tokyo, Tokyo, Japan
| | - Yusuke Sato
- Department of Urology, The University of Tokyo, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, The University of Tokyo, Tokyo, Japan
| | | | - Taroh Iiri
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
- Department of Pharmacology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Noriko Makita
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
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16
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Lawrence L, Zhang P, Choi H, Ahmad U, Arrossi V, Purysko A, Makin V. A unique case of ectopic Cushing's syndrome from a thymic neuroendocrine carcinoma. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190002. [PMID: 30802210 PMCID: PMC6391898 DOI: 10.1530/edm-19-0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 11/26/2022] Open
Abstract
Ectopic adrenocorticotropic hormone (ACTH) production leading to ectopic ACTH syndrome accounts for a small proportion of all Cushing's syndrome (CS) cases. Thymic neuroendocrine tumors are rare neoplasms that may secrete ACTH leading to rapid development of hypercortisolism causing electrolyte and metabolic abnormalities, uncontrolled hypertension and an increased risk for opportunistic infections. We present a unique case of a patient who presented with a mediastinal mass, revealed to be an ACTH-secreting thymic neuroendocrine tumor (NET) causing ectopic CS. As the diagnosis of CS from ectopic ACTH syndrome (EAS) remains challenging, we emphasize the necessity for high clinical suspicion in the appropriate setting, concordance between biochemical, imaging and pathology findings, along with continued vigilant monitoring for recurrence after definitive treatment. Learning points: Functional thymic neuroendocrine tumors are exceedingly rare. Ectopic Cushing's syndrome secondary to thymic neuroendocrine tumors secreting ACTH present with features of hypercortisolism including electrolyte and metabolic abnormalities, uncontrolled hypertension and hyperglycemia, and opportunistic infections. The ability to undergo surgery and completeness of resection are the strongest prognostic factors for improved overall survival; however, the recurrence rate remains high. A high degree of initial clinical suspicion followed by vigilant monitoring is required for patients with this challenging disease.
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Affiliation(s)
- Lima Lawrence
- Departments of Endocrinology, Diabetes & Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peng Zhang
- Departments of Pulmonary Medicine & Critical Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Humberto Choi
- Departments of Pulmonary Medicine & Critical Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Usman Ahmad
- Departments of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Valeria Arrossi
- Departments of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrei Purysko
- Departments of Diagnostic Radiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vinni Makin
- Departments of Endocrinology, Diabetes & Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
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Kadoya M, Kurajoh M, Miyoshi A, Shoji T, Terada T, Nakamoto Y, Tsukamoto Y, Moriwaki Y, Hirota S, Koyama H. Ectopic adrenocorticotropic hormone syndrome associated with olfactory neuroblastoma: acquirement of adrenocorticotropic hormone expression during disease course as shown by serial immunohistochemistry examinations. J Int Med Res 2019; 46:4760-4768. [PMID: 30392451 PMCID: PMC6259372 DOI: 10.1177/0300060517754026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS) is a condition of endogenous hypercortisolism sustained by an extrapituitary ACTH-secreting tumor. Olfactory neuroblastoma (ONB) is a rare malignant neoplasm of the sinonasal tract and is derived from the olfactory epithelium. Because the paranasal sinus is not a common site of EAS, the development of ONB in patients with EAS is rare. We herein report the first known case of ONB with acquirement of ACTH production during the clinical course as proven by immunohistochemistry. A 50-year-old man diagnosed with ONB was referred to our department in July 2015 because of hypokalemia, hyperglycemia, decreased eosinophil and granulocyte counts, and elevated serum levels of ACTH and cortisol. Although two previous ONB biopsy specimens (2011 and 2014) showed no ACTH immunoreactivity, a newly obtained specimen in August 2015 clearly showed ACTH immunoreactivity. This is the first case of ectopic ACTH syndrome associated with an ONB that acquired the ability to express ACTH during its clinical course as shown by serial immunohistochemical examinations.
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Affiliation(s)
- Manabu Kadoya
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Masafumi Kurajoh
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Akio Miyoshi
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Takuhito Shoji
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Tomonori Terada
- Department of Otorhinolaryngology-Head and Neck Surgery, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Yoshitane Tsukamoto
- Department of Surgical Pathology, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Yuji Moriwaki
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Seiichi Hirota
- Department of Surgical Pathology, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Hidenori Koyama
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
- Hidenori Koyama, Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan.
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18
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Yamamuro T, Inoue K, Nagai Y, Azuma D, Yamamoto A, Hara K, Kohara M, Iwata T, Nakatsuka S, Morii E, Yamamoto T. A case of ectopic ACTH syndrome due to DDAVP-sensitive but V1b receptor-negative bronchial typical carcinoid with lymphatic metastasis and plasma ProGRP elevation. Endocr J 2018; 65:1161-1169. [PMID: 30232300 DOI: 10.1507/endocrj.ej18-0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ectopic ACTH syndrome (EAS) is a potentially fatal endocrine disease that results from a variety of neuroendocrine tumors (NETs), such as small cell lung cancer (SCLC) and bronchial typical carcinoid. Typical carcinoid is usually slow growing, not associated with plasma progastrin releasing peptide (ProGRP) elevation. Here, we report a 47-year-old female smoker with progressive typical carcinoid and plasma ProGRP elevation. Several types of Cushingoid features were found on physical examination. In addition, laboratory examination showed elevated plasma ACTH and serum cortisol levels. These findings indicated ACTH-dependent Cushing's syndrome. Moreover, the serum cortisol level was not suppressed by overnight high-dose dexamethasone treatment, suggesting the presence of an extra-pituitary tumor. Contrast-enhanced brain MRI revealed no pituitary adenoma, which also supported the idea that EAS occurred in the present case. Strikingly, chest computed tomographic (CT) scan showed a single 18-mm peripheral nodule in the right middle lobe of the lung. Tumor marker analysis revealed an elevation in plasma ProGRP. These data suggested a possibility that SCLC secreted ACTH and caused EAS in this patient. Of note, the plasma ACTH level was increased (1.7 fold) in l-desamino-8-D-arginine vasopressin (DDAVP) test, also suggesting the specific clinical feature in this case. After additional imaging examinations, we performed surgical resection with the suspicion of limited SCLC. As a result, pathological examination revealed a vasopressin receptor Ib (V1b) receptor-negative bronchial typical carcinoid with ACTH production and mediastinal lymphatic metastasis. In summary, we present a case of EAS caused by progressive bronchial typical carcinoid with plasma ProGRP elevation. We propose a novel subtype of lung typical carcinoid.
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Affiliation(s)
- Tadashi Yamamuro
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Kana Inoue
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Yasuki Nagai
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Daisuke Azuma
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Aya Yamamoto
- Department of Thoracic and Cardiovascular Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Kantaro Hara
- Department of Thoracic and Cardiovascular Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Masaharu Kohara
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Iwata
- Department of Thoracic and Cardiovascular Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | | | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsunehiko Yamamoto
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
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Inoue M, Okamura K, Kitaoka C, Kinoshita F, Namitome R, Nakamura U, Shiota M, Goto K, Ohtsubo T, Matsumura K, Oda Y, Eto M, Kitazono T. Metyrapone-responsive ectopic ACTH-secreting pheochromocytoma with a vicious cycle via a glucocorticoid-driven positive-feedback mechanism. Endocr J 2018; 65:755-767. [PMID: 29760304 DOI: 10.1507/endocrj.ej18-0025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In ectopic ACTH-secreting pheochromocytoma, combined ACTH-driven hypercortisolemia and hypercatecholaminemia are serious conditions, which can be fatal if not diagnosed and managed appropriately, especially when glucocorticoid-driven positive feedback is suggested with a high ACTH/cortisol ratio. A 46-year-old man presented with headache, rapid weight loss, hyperhidrosis, severe hypertension and hyperglycemia without typical Cushingoid appearance. Endocrinological examinations demonstrated elevated plasma and urine catecholamines, serum cortisol and plasma ACTH. Moreover, his ACTH/cortisol ratio and catecholamine levels were extremely high, suggesting catecholamine-dominant ACTH-secreting pheochromocytoma. Computed tomography revealed a large right adrenal tumor. 18F-FDG positron emission tomography showed uptake in the area of the adrenal tumor, while 123I-metaiodobenzylguanidine scintigraphy showed no accumulation. His plasma ACTH level paradoxically became elevated after a dexamethasone suppression test. After metyrapone administration, not only serum cortisol but also plasma ACTH levels were exponentially decreased almost in parallel, suggesting a glucocorticoid-driven positive-feedback regulation in this rapidly exacerbated ectopic ACTH-producing pheochromocytoma. Interestingly enough, plasma catecholamine levels were also decreased by metyrapone, although they remained extremely high. He became severely dehydrated due to hypoadrenalism requiring hydrocortisone supplementation. His clinical signs and symptoms were improved, and right adrenalectomy was performed uneventfully, resulting in complete remission of pheochromocytoma and Cushing's syndrome. A glucocorticoid-driven positive-feedback regulation in this ectopic ACTH-secreting pheochromocytoma created a vicious cycle with rapid exacerbation of both hypercortisolemia and hypercatecholaminemia with extremely elevated plasma ACTH level. Metyrapone was clinically effective to stop this vicious cycle; nonetheless, great care must be taken to avoid hypoadrenalism especially when hypercatecholaminemia remained.
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Affiliation(s)
- Minako Inoue
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Okamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Chie Kitaoka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Fumio Kinoshita
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryo Namitome
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Udai Nakamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaki Shiota
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichi Goto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshio Ohtsubo
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kiyoshi Matsumura
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatoshi Eto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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20
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Abstract
A thirty-eight year old patient presented with a gradual increase in weight and Cushingoid facies of two years duration. He also had orbital congestion, with puffy eyelids and corkscrew conjunctival vessels, associated with painful eye movements. An endocrine evaluation revealed raised cortisol and ACTH. Head imaging was performed which showed an enhancing tumour arising from the sphenoid sinus, with osseous erosion of the sphenoid sinus, extending to the nasopharynx, sellar and a small amount extending intracranially. He underwent an endoscopic endonasal resection of the tumour and histology revealed a low-grade carcinoid tumour with ACTH staining. The patient also underwent radiotherapy for the intracranial extension. He is currently in his fourth year of follow-up and imaging has showed a small, stable intracranial remnant. His anterior pituitary hormonal profile remains normal.
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21
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Zhou X, Hang J, Che J, Chen Z, Qiu W, Ren J, Yang X, Xiang J, Li H. Surgical treatment of ectopic adrenocorticotropic hormone syndrome with intra-thoracic tumor. J Thorac Dis 2016; 8:888-93. [PMID: 27162663 DOI: 10.21037/jtd.2016.03.54] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The study was to review the clinical manifestations and laboratory examinations of ectopic adrenocorticotropic hormone (ACTH) syndrome, and to analyze the efficacy of surgical treatment. METHODS The clinical data, surgical therapy, and outcome of 23 cases of ectopic ACTH syndrome accompanied by intra-thoracic tumors were reviewed. The tumors were removed from all the patients according to the principles of radical resection. RESULTS The tumors were confirmed as associated with ectopic ACTH secretion in 19 cases. Hyperglycemia and hypokalemia were recovered, while plasma cortisol, plasma ACTH and 24-hour urinary free cortisol (UFC) levels were significantly reduced after surgery in these 19 cases. Recurrences of the disease were found in six cases during following-up, and five of them died. CONCLUSIONS The thoracic cavity should be a focus in routine examinations of patients with symptoms of Cushing's syndrome (CS), because ectopic ACTH-producing tumors are commonly found in bronchus/lung and mediastinum. Despite the incidence of the pulmonary nodule secondary to opportunistic infection in some cases, surgery is still the first choice if the tumor is localized. The surgical procedure should be performed according to the principles in resection of lung cancer and mediastinal tumor. The surgical efficacy is significant for short-term periods; however, the recurrence of the disease in long-term periods is in great part related to distal metastasis or relapse of the tumor.
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Affiliation(s)
- Xiang Zhou
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Junbiao Hang
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Jiaming Che
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Zhongyuan Chen
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Weicheng Qiu
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Jian Ren
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Xiaoqing Yang
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Jie Xiang
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
| | - Hecheng Li
- Department of Thoracic Surgery, Shanghai Jiaotong University Medical School affiliated Ruijin Hospital, Shanghai 200025, China
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22
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Abstract
BACKGROUND Neuroendocrine tumor originates from the diffuse neuroendocrine system. Intracranial originating is lower to 0.74 %. CASE PRESENTATION We present two cases of primary intracranial neuroendocrine tumor A 39-year-old woman was admitted with headache, fever, polydipsia and polyuria. Biochemical and endocrinological results showed hyponatremia, hypothyroidism and hypopituitarism. MRI scans demonstrated an obviouslyenhancing lesion in seller and superseller area. Then a gross removal of tumor was achieved during the single nostril transsphenoidal approach surgery. Pathological diagnosis was high-grade small-cell neuroendocrine tumor. A 40-year-old woman presented with multiple symptoms and neurological deficit. Neuroimaging results demonstrated a huge obviously-enhancing tumor in anterior cranial fossa. Biochemical and hormone findings revealed hypokalemia, high glucose and hypercortisolemia. The intracranial surgery achieved a gross removal through a right frontal craniotomy. Pathological diagnosis was low-grade small-cell neuroendocrine tumor with immuno-negativity for ACTH. CONCLUSION The mechanism, diagnosis, and treatment of neuroendocrine tumor are still challenging.
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Affiliation(s)
- Hailong Liu
- Department of Neurosurgery, Sanbo Brain Hospital Capital Medical University, No. 50 Xiang Shan Yi-Ke-Song, Haidian District, Beijing, 100093, People's Republic of China
| | - Haoran Wang
- Department of Neurosurgery, Sanbo Brain Hospital Capital Medical University, No. 50 Xiang Shan Yi-Ke-Song, Haidian District, Beijing, 100093, People's Republic of China
| | - Xueling Qi
- Department of Neurosurgery, Sanbo Brain Hospital Capital Medical University, No. 50 Xiang Shan Yi-Ke-Song, Haidian District, Beijing, 100093, People's Republic of China
| | - Chunjiang Yu
- Department of Neurosurgery, Sanbo Brain Hospital Capital Medical University, No. 50 Xiang Shan Yi-Ke-Song, Haidian District, Beijing, 100093, People's Republic of China.
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23
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Sarma A, Shyn PB, Vivian MA, Ng JM, Tuncali K, Lorch JH, Zaheer SN, Gordon MS, Silverman SG. Single-Session CT-Guided Percutaneous Microwave Ablation of Bilateral Adrenal Gland Hyperplasia Due to Ectopic ACTH Syndrome. Cardiovasc Intervent Radiol 2015; 38:1335-8. [PMID: 25762486 DOI: 10.1007/s00270-015-1056-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 01/05/2015] [Indexed: 10/23/2022]
Abstract
Bilateral adrenalectomy is currently the only available treatment for adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome (ectopic ACTH syndrome) that is refractory to pharmacologic therapy. We describe two patients with refractory ectopic ACTH syndrome who were treated with CT-guided percutaneous microwave ablation of both hyperplastic adrenal glands in a single session: O ne was not a surgical candidate, and the other had undergone unsuccessful surgery. Following the procedure, both patients achieved substantial decreases in serum cortisol, symptomatic improvement, and decreased anti-hypertensive medication requirements.
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24
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Kikuchi H, Yoshimoto T, Tanaka H, Tsujimoto K, Yamamura C, Arai Y, Hirasawa S, Aki S, Inaba N, Aoyagi M, Ogawa Y, Tamura T. Periodic hypokalemia associated with cyclic Cushing's syndrome. CEN Case Rep 2013; 3:80-85. [PMID: 28509248 DOI: 10.1007/s13730-013-0090-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 07/08/2013] [Indexed: 11/26/2022] Open
Abstract
A 69-year-old woman presented with periodic hypertension, edema, and hypokalemia that occurred within an interval of a few weeks. Her laboratory test values showed autonomously elevated plasma adrenocorticotropic hormone (ACTH) and cortisol concentrations. The patient's Cushingoid features were not evident on first admission. Several weeks later, in spite of constant oral potassium supplementation, severe hypokalemia recurred with Cushingoid features and worsening symptoms of leg edema and pigmentation, which spontaneously disappeared within a few days. Her periodic symptoms occurred in parallel with fluctuations of plasma ACTH and cortisol concentrations. A series of endocrinological and pituitary imaging findings led to a tentative diagnosis of cyclic Cushing's syndrome caused by ectopic ACTH secretion. However, chest and abdominal computed tomography did not reveal any candidate lesion. The patient's periodic hypercortisolemia and symptoms were well controlled after treatment with metyrapone plus dexamethasone. This is a very rare case of periodic hypokalemia and hypertension caused by cyclic Cushing's syndrome.
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Affiliation(s)
- Hiroaki Kikuchi
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan.
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Tanaka
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Kazutaka Tsujimoto
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Chisato Yamamura
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Yohei Arai
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Suguru Hirasawa
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Shota Aki
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Naoto Inaba
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Makoto Aoyagi
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Yoshihiro Ogawa
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Teiichi Tamura
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
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25
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Abstract
A 48-year-old man presented with symptoms consistent with Cushing's syndrome. Subsequent laboratory studies revealed markedly elevated adrenocorticotropic (ACTH) and cortisol levels, as well as a hypoklemic metabolic alkalosis. A pituitary MRI was performed, which revealed a normal pituitary; however, a large mass was seen centered in the ethmoid and paranasal sinuses with a significant amount of extension into surrounding structures. A biopsy was performed and pathology of the specimen was consistent with esthesioneuroblastoma. Immunohistochemical staining further defined the tumor as an ACTH-secreting esthesioneuroblastoma. After total resection of the mass and further treatment with adjuvant radiation therapy, the patient's symtoms completely resolved and the ACTH and cortisol levels were also greatly reduced. This case demonstrates the successful diagnosis and treatment of a rare neoplasm. Ectopic ACTH syndrome due to esthesioneuroblastoma is extremely uncommon with only five other cases being discussed in the literature.
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Affiliation(s)
- Lydia Josephs
- University of Michigan Medical School, Ann Arbor, MI
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