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Bessiène L, Bonnet F, Tenenbaum F, Jozwiak M, Corchia A, Bertherat J, Groussin L. Rapid control of severe ectopic Cushing's syndrome by oral osilodrostat monotherapy. Eur J Endocrinol 2021; 184:L13-L15. [PMID: 33667191 DOI: 10.1530/eje-21-0147] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/02/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Laura Bessiène
- Department of Endocrinology, Polyclinic of Saint Côme, Compiegne, France
- Université de Paris, Paris, France
| | - Fidéline Bonnet
- Department of Hormonology, Polyclinic of Saint Côme, Compiegne, France
- INSERM Unité 1016, CNRS UMR 8104, Institut Cochin, Paris, France
- Université de Paris, Paris, France
| | - Florence Tenenbaum
- Department of Nuclear Medicine, Polyclinic of Saint Côme, Compiegne, France
| | - Mathieu Jozwiak
- Medical ICU, APHP, Cochin Hospital, Paris, France
- Université de Paris, Paris, France
| | - Anthony Corchia
- Department of Nephrology, Polyclinic of Saint Côme, Compiegne, France
| | - Jérôme Bertherat
- Department of Endocrinology, Polyclinic of Saint Côme, Compiegne, France
- INSERM Unité 1016, CNRS UMR 8104, Institut Cochin, Paris, France
- Université de Paris, Paris, France
| | - Lionel Groussin
- Department of Endocrinology, Polyclinic of Saint Côme, Compiegne, France
- INSERM Unité 1016, CNRS UMR 8104, Institut Cochin, Paris, France
- Université de Paris, Paris, France
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Chen K, Chen S, Lu L, Zhu H, Zhang X, Tong A, Pan H, Wang R, Lu Z. An Optimized Pathway for the Differential Diagnosis of ACTH-Dependent Cushing's Syndrome Based on Low-Dose Dexamethasone Suppression Test. Front Endocrinol (Lausanne) 2021; 12:720823. [PMID: 34539574 PMCID: PMC8445331 DOI: 10.3389/fendo.2021.720823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 06/05/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Traditionally, low-dose dexamethasone suppression test (LDDST) was used to confirm the diagnosis of Cushing's syndrome (CS), and high-dose dexamethasone suppression test (HDDST) was used to differentiate Cushing's disease (CD) and ectopic adrenocorticotropin (ACTH) syndrome (EAS), but some studies suggested that HDDST might be replaced by LDDST. For the differential diagnosis of CS, dexamethasone suppression test was usually combined with other tests such as bilateral petrosal sinus sampling (BIPSS) and pituitary magnetic resonance imaging, but the optimal pathway to incorporate these tests is still controversial. OBJECTIVES To develop an optimized pathway for the differential diagnosis of CD and EAS based on LDDST. DESIGN AND SETTING Single-center retrospective study (2011-2019). PATIENTS Two hundred sixty-nine CD and 29 EAS patients with pathological diagnosis who underwent consecutive low- and high-dose DST. RESULTS For the differential diagnosis of CD and EAS, the area under curve (AUC) of LDDST using urine free cortisol (0.881) was higher than that using serum cortisol (0.685) (p < 0.001) in head-to-head comparison among a subgroup of 108 CD and 10 EAS. The AUC of LDDST (0.883) was higher than that of HDDST (0.834) among all the included patients. With the cutoff of <26%, the sensitivity and specificity of LDDST were 39.4% and 100%. We designed a new pathway in which BIPSS was only reserved for those patients with unsuppressed LDDST and adenoma <6mm, yielding an overall sensitivity of 97.7% and specificity of 86.7%. CONCLUSION LDDST had similar value to HDDST in differentiating CD and EAS using the specific cutoff point. The pathway that combined LDDST and BIPSS could differentiate CD and EAS accurately.
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Affiliation(s)
- Kang Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shi Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Shi Chen, ; Lin Lu,
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Shi Chen, ; Lin Lu,
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaobo Zhang
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Anli Tong
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Pan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- 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
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhaolin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Cheng Y, Li J, Dou J, Ba J, Du J, Zhang S, Mu Y, Lv Z, Gu W. Case Report: Three Rare Cases of Ectopic ACTH Syndrome Caused by Adrenal Medullary Hyperplasia. Front Endocrinol (Lausanne) 2021; 12:687809. [PMID: 34276563 PMCID: PMC8281927 DOI: 10.3389/fendo.2021.687809] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/07/2021] [Indexed: 11/30/2022] Open
Abstract
Ectopic ACTH syndrome (EAS) accounts for 10-20% of endogenous Cushing's syndrome (CS). Hardly any cases of adrenal medullary hyperplasia have been reported to ectopically secrete adrenocorticotropic hormone (ACTH). Here we describe a series of three patients with hypercortisolism secondary to ectopic production of ACTH from adrenal medulla. Cushingoid features were absent in case 1 but evident in the other two cases. Marked hypokalemia was found in all three patients, but hyperglycemia and osteoporosis were present only in case 2. All three patients showed significantly elevated serum cortisol and 24-h urinary cortisol levels. The ACTH levels ranged from 19.8 to 103.0pmol/L, favoring ACTH-dependent Cushing's syndrome. Results of bilateral inferior petrosal sinus sampling (BIPSS) for case 1 and case 3 confirmed ectopic origin of ACTH. The extremely high level of ACTH and failure to suppress cortisol with high dose dexamethasone suppression test (HDDST) suggested EAS for patient 2. However, image studies failed to identify the source of ACTH secretion. Bilateral adrenalectomy was performed for rapid control of hypercortisolism. After surgery, cushingoid features gradually disappeared for case 2 and case 3. Blood pressure, blood glucose and potassium levels returned to normal ranges without medication for case 2. The level of serum potassium also normalized without any supplementation for case 1 and case 3. The ACTH levels of all three patients significantly decreased 3-6 months after surgery. Histopathology revealed bilateral adrenal medullary hyperplasia and immunostaining showed positive ACTH staining located in adrenal medulla cells. In summary, our case series reveals the adrenal medulla to be a site of ectopic ACTH secretion. Adrenal medulla-originated EAS makes the differential diagnosis of ACTH-dependent Cushing's syndrome much more difficult. Control of the hypercortisolism is mandatory for such patients.
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Affiliation(s)
- Yu Cheng
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Jie Li
- Department of Pathology, Chinese PLA General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Jianming Ba
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Saichun Zhang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Zhaohui Lv, ; Weijun Gu,
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Zhaohui Lv, ; Weijun Gu,
| | - Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Zhaohui Lv, ; Weijun Gu,
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Serban AL, Rosso L, Mendogni P, Cremaschi A, Indirli R, Mantovani B, Rumi M, Castellani M, Chiti A, Croci GA, Mantovani G, Nosotti M, Ferrante E, Arosio M. Case Report: A Challenging Localization of a Pulmonary Ectopic ACTH-Secreting Tumor in a Patient With Severe Cushing's Syndrome. Front Endocrinol (Lausanne) 2021; 12:687539. [PMID: 34305814 PMCID: PMC8299119 DOI: 10.3389/fendo.2021.687539] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/18/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Ectopic adrenocorticotropic syndrome (EAS) is a rare cause of endogenous ACTH-dependent Cushing's syndrome, usually associated with severe hypercortisolism as well as comorbidities. Tumor detection is still a challenge and often requires several imaging procedures. In this report, we describe a case of an ectopic ACTH secretion with a misleading localization of the responsible tumor due to a concomitant rectal carcinoma. CASE PRESENTATION A 49-year-old man was referred to our Endocrinology Unit due to suspicion of Cushing's syndrome. His medical history included metastatic rectal adenocarcinoma, diagnosed 5 years ago and treated with adjuvant chemotherapy, radiotherapy and surgical resection. During follow-up, a thoracic computed tomography scan revealed two pulmonary nodules located in the superior and middle lobes of the right lung with a diameter of 5 and 10 mm, respectively. However, these nodules remained radiologically stable thereafter and were not considered relevant. All biochemical tests were suggestive of EAS (basal ACTH levels: 88.2 ng/L, nv 0-46; basal cortisol levels: 44.2 µg/dl, nv 4.8-19.5; negative response to CRH test and high dose dexamethasone suppression test) and radiological localization of the ectopic ACTH-secreting tumor was scheduled. The CT scan revealed a dimensional increase of the right superior lung nodule (from 5 to 12 mm). [68Ga]-DOTA-TOC PET/CT scan was negative, while [18F]-FDG-PET/CT showed a tracer accumulation in the superior nodule. After a multidisciplinary consultation, the patient underwent thoracic surgery that started with two atypical wedge resections of nodules. Frozen section analyses showed a neuroendocrine tumor on the right middle lobe nodule and a metastatic colorectal adenocarcinoma on the superior lesion. Then, a right superior nodulectomy and a right middle lobectomy with mediastinal lymphadenectomy were performed. The final histopathological examination confirmed a typical carcinoid tumor, strongly positive for ACTH. A post-surgical follow-up showed a persistent remission of Cushing's syndrome. CONCLUSIONS The present report describes a case of severe hypercortisolism due to EAS not detected by functional imaging methods, in which the localization of ACTH ectopic origin was puzzled by a concomitant metastatic rectal carcinoma. The multidisciplinary approach was crucial for the management of this rare disease.
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Affiliation(s)
- Andreea Liliana Serban
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paolo Mendogni
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Arianna Cremaschi
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rita Indirli
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Beatrice Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mariagrazia Rumi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Hepatology Unit, Ospedale San Giuseppe Multimedica Milan, Milan, Italy
| | - Massimo Castellani
- Department of Nuclear Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giorgio Alberto Croci
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Division of Pathology, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- *Correspondence: Emanuele Ferrante,
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Paleń-Tytko JE, Przybylik-Mazurek EM, Rzepka EJ, Pach DM, Sowa-Staszczak AS, Gilis-Januszewska A, Hubalewska-Dydejczyk AB. Ectopic ACTH syndrome of different origin-Diagnostic approach and clinical outcome. Experience of one Clinical Centre. PLoS One 2020; 15:e0242679. [PMID: 33237923 PMCID: PMC7688153 DOI: 10.1371/journal.pone.0242679] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 11/08/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose Ectopic Cushing Syndrome (EAS) is a rare condition responsible for about 5–20% of all Cushing syndrome cases. It increases the mortality of affected patients thus finding and removal of the ACTH-producing source allows for curing or reduction of symptoms and serum cortisol levels. The aim of this study is to present a 20-year experience in the diagnosis and clinical course of patients with EAS in a single Clinical Centre in Southern Poland as well as a comparison of clinical course and outcomes depending on the source of ectopic ACTH production–especially neuroendocrine tumors with other neoplasms. Methods Twenty-four patients were involved in the clinical study with EAS diagnosed at the Department of Endocrinology between years 2000 and 2018. The diagnosis of EAS was based on the clinical presentation, hypercortisolemia with high ACTH levels, high dose dexamethasone suppression test and/or corticotropin-releasing hormone tests. To find the source of ACTH various imaging studies were performed. Results Half of the patients were diagnosed with neuroendocrine tumors, whereby muscle weakness was the leading symptom. Typical cushingoid appearance was seen in merely a few patients, and weight loss was more common than weight gain. Patients with neuroendocrine tumors had significantly higher midnight cortisol levels than the rest of the group. Among patients with infections, we observed a significantly higher concentrations of cortisol 2400 levels in gastroenteropancreatic neuroendocrine tumors. Chromogranin A correlated significantly with potassium in patients with neuroendocrine tumors and there was a significant correlation between ACTH level and severity of hypokalemia. Conclusion EAS is not common, but if it occurs it increases the mortality of patients; therefore, it should be taken into consideration in the case of coexistence of severe hypokalemia with hypertension and muscle weakness, especially when weight loss occurs. Because the diagnosis of gastroenteropancreatic neuroendocrine tumor worsens the prognosis-special attention should be paid to these patients.
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Ceccato F, Tizianel I, Vedolin CK, Boscaro M, Barbot M, Scaroni C. Human Corticotropin-Releasing Hormone Tests: 10 Years of Real-Life Experience in Pituitary and Adrenal Disease. J Clin Endocrinol Metab 2020; 105:5895038. [PMID: 32818260 DOI: 10.1210/clinem/dgaa564] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 06/01/2020] [Accepted: 08/14/2020] [Indexed: 02/13/2023]
Abstract
CONTEXT The human corticotropin-releasing hormone (CRH) test (hCRHtest) is used to differentiate Cushing disease (CD) from ectopic adrenocorticotropin (ACTH) secretion (EAS), to assess autonomous cortisol secretion by the adrenal glands, and to characterize pseudo-Cushing syndrome (CS) or adrenal insufficiency (AI). MAIN OUTCOME MEASURE The main outcome measure of this study was to assess the diagnostic accuracy of the hCRHtest. METHODS We measured ACTH and cortisol levels; collected the peak values (peakACTH and peakcortisol), and calculated the percentage increases (∆%ACTH and ∆%cortisol) after an intravenous bolus of 100 μg hCRH. DESIGN AND SETTING This cross-sectional study of hCRH tests from 2010 to 2019 took place in a referral university hospital center. PATIENTS We enrolled 200 patients: 86 CD, 15 EAS, 18 adrenal CS, 25 mild adrenal autonomous cortisol secretion, 31 pseudo-CS, and 25 suspected AI. RESULTS The hCRHtest was performed mainly for the differential diagnosis of ACTH-dependent CS or adrenal lesions (P = .048). PeakACTH and peakcortisol were higher in CD, and ∆%ACTH and ∆%cortisol were able to differentiate CD from EAS with a sensitivity and specificity greater than 80%. In patients with low (< 10 pg/mL) or indeterminate (10-20 pg/mL) basalACTH levels, an absent or reduced peakACTH response was able to differentiate adrenal from ACTH-dependent forms. PeakACTH and peakcortisol after hCRHtest were lower in pseudo-CS than in CD, but ∆%ACTH and ∆%cortisol were similar. The role of hCRHtest in patients with AI was limited. CONCLUSIONS The hCRHtest test is the mainstay of the differential diagnosis of ACTH-dependent CS. It is also useful for pointing to a diagnosis of CD in the event of bilateral adrenal masses, and in patients with low basalACTH.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine-DIMED; University Hospital of Padova, Padova, Italy
- Department of Neuroscience-DNS, University of Padova, Padova, Italy
| | - Irene Tizianel
- Endocrinology Unit, Department of Medicine-DIMED; University Hospital of Padova, Padova, Italy
| | - Carlotta Keiko Vedolin
- Endocrinology Unit, Department of Medicine-DIMED; University Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine-DIMED; University Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine-DIMED; University Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine-DIMED; University Hospital of Padova, Padova, Italy
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Frete C, Corcuff JB, Kuhn E, Salenave S, Gaye D, Young J, Chanson P, Tabarin A. Non-invasive Diagnostic Strategy in ACTH-dependent Cushing's Syndrome. J Clin Endocrinol Metab 2020; 105:5864157. [PMID: 32594169 DOI: 10.1210/clinem/dgaa409] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [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: 03/21/2020] [Accepted: 06/22/2020] [Indexed: 01/29/2023]
Abstract
CONTEXT Inferior petrosal sinus sampling (IPSS) is used to diagnose Cushing's disease (CD) when dexamethasone-suppression and CRH tests, and pituitary magnetic resonance imaging (MRI), are negative or give discordant results. However, IPSS is an invasive procedure and its availability is limited. OBJECTIVE To test a noninvasive diagnostic strategy associated with 100% positive predictive value (PPV) for CD. DESIGN Retrospective study. SETTING Two university hospitals. PATIENTS A total of 167 patients with CD and 27 patients with ectopic ACTH-syndrome investigated between 2001 and 2016. MAIN OUTCOME MEASURE(S) Performance of a strategy involving the CRH and desmopressin tests with pituitary MRI followed by thin-slice whole-body computed tomography (CT) scan in patients with inconclusive results. RESULTS Using thresholds of a cortisol increase > 17% with an ACTH increase > 37% during the CRH test and a cortisol increase > 18% with an ACTH increase > 33% during the desmopressin test, the combination of both tests gave 73% sensitivity and 98% PPV of CD. The sensitivity and PPV for pituitary MRI were 71% and 99%, respectively. CT scan identified 67% EAS at presentation with no false-positives. The PPV for CD was 100% in patients with positive responses to both tests, with negative pituitary MRI and CT scan. The Negative Predictive Value was 100% in patients with negative responses to both tests, with negative pituitary MRI and positive CT scan. Using this strategy, IPPS could have been avoided in 47% of patients in whom it is currently recommended. CONCLUSIONS In conjunction with expert radiologic interpretation, the non-invasive algorithm studied significantly reduces the need for IPSS in the investigation of ACTH-dependent Cushing's syndrome.
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Affiliation(s)
- Caroline Frete
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Pessac, France
| | - Jean-Benoît Corcuff
- Department of Nuclear Medicine, University Hospital of Bordeaux, Pessac, France
- Nutrition et Neurobiologie Intégrée, UMR 1286, University of Bordeaux, Bordeaux, France
| | - Emmanuelle Kuhn
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Sylvie Salenave
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Delphine Gaye
- Department of Radiology, University Hospital of Bordeaux, Pessac, France
| | - Jacques Young
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
- Université Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
- Université Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Le Kremlin-Bicêtre, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Pessac, France
- Physiopathologie de la Plasticité Neuronale, INSERM U1215, Neurocentre Magendie, Bordeaux, France
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Wang H, Ba Y, Xing Q, Cai RC. Differential diagnostic value of bilateral inferior Petrosal sinus sampling (BIPSS) in ACTH-dependent Cushing syndrome: a systematic review and Meta-analysis. BMC Endocr Disord 2020; 20:143. [PMID: 32943040 PMCID: PMC7499975 DOI: 10.1186/s12902-020-00623-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 11/09/2019] [Accepted: 09/13/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Previous studies have shown inconsistent results about the usefulness of bilateral inferior petrosal sinus sampling (BIPSS) in differential diagnosis of adrenocorticotropic hormone (ACTH)-dependent Cushing syndrome. This meta-analysis evaluated the diagnostic value of BIPSS via the published literature. METHODS This study searched PubMed, Embase, Web of Science, Cochrane library, and Wanfang database for published data on the use of BIPSS in Cushing syndrome differential diagnosis as of October 2019. Sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and receiver operating characteristic (ROC) curves were calculated based on the relevant data. RESULTS This meta-analysis included a total of 23 studies with 1642 patients. The calculated sensitivity, specificity, PLR, and NLR were 0.94 (95% confidence interval, CI: 0.91-0.96), 0.89 (95% CI: 0.79-0.95), 8.8 (95% CI: 4.3-17.9), and 0.07 (95% CI: 0.04-0.11), respectively. The pooled DOR and area under the ROC curve were 129 (95% CI: 48-345) and 0.97 (95% CI: 0.95-0.98), respectively. CONCLUSION This meta-analysis indicated that BIPSS had high diagnostic value for detecting ACTH in patients with ACTH-dependent Cushing syndrome, and BIPSS should be used as an effective method to identify ACTH-secretion sources.
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Affiliation(s)
- Hao Wang
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China.
| | - Ying Ba
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China.
| | - Qian Xing
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Run-Ce Cai
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
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Belaya Z, Khandaeva P, Nonn L, Nikitin A, Solodovnikov A, Sitkin I, Grigoriev A, Pikunov M, Lapshina A, Rozhinskaya L, Melnichenko G, Dedov I. Circulating Plasma microRNA to Differentiate Cushing's Disease From Ectopic ACTH Syndrome. Front Endocrinol (Lausanne) 2020; 11:331. [PMID: 32582027 PMCID: PMC7291947 DOI: 10.3389/fendo.2020.00331] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022] Open
Abstract
Corticotropinomas and adrenocorticotropic hormone (ACTH)-secreting neuroendocrine tumors exhibit differential levels of some microRNAs (miRs) compared to normal tissue. Because miRs can be released from tissues into circulation, they offer promise as novel disease biomarkers. Objective: To evaluate whether miRs are differentially detected in plasma samples of patients with ACTH-dependent Cushing's syndrome (CS). Design: Case-control study. Methods: Morning fasting plasma samples were collected from 41 consecutive patients with confirmed ACTH-dependent CS and 11 healthy subjects and stored at -80°C. Twenty-one miRs previously reported to be differentially expressed in ACTH-secreting tumors vs. healthy tissue samples were quantified in plasma by qPCR. Results: Among enrolled subjects, 28 were confirmed to have Cushing's disease (CD), 13 had ectopic ACTH secretion (EAS) and 11 were healthy controls. We found statistically significant differences in the circulating levels of miR-16-5p [45.04 (95% CI 28.77-61.31) in CD vs. 5.26 (2.65-7.87) in EAS, P < 0.001; q = 0.001], miR-145-5p [0.097 (0.027-0.167) in CD vs. undetectable levels in EAS, P = 0.008; q = 0.087] and differences in miR-7g-5p [1.842 (1.283-2.400) in CD vs. 0.847 (0.187-1.507) in EAS, P = 0.02; q = 0.14]. The area under the receiver-operator (ROC) curve was 0.879 (95% CI 0.770-0.987), p < 0.001, when using miR-16-5p to distinguish between CD and EAS. Circulating levels of miR-16-5p in the healthy control group differed from that of both the CD and EAS groups. Conclusions: Plasma miR levels differ in patients with CD and EAS. In particular, miR-16-5p, miR-145-5p and miR-7g-5p are promising biomarkers for further research to differentiate ACTH-dependent CS.
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Affiliation(s)
- Zhanna Belaya
- The National Medical Research Centre for Endocrinology, Moscow, Russia
- *Correspondence: Zhanna Belaya
| | - Patimat Khandaeva
- The National Medical Research Centre for Endocrinology, Moscow, Russia
| | - Larisa Nonn
- Department Pathology College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Alexey Nikitin
- Federal Research and Clinical Center FMBA of Russia, Moscow, Russia
| | | | - Ivan Sitkin
- The National Medical Research Centre for Endocrinology, Moscow, Russia
| | - Andrey Grigoriev
- The National Medical Research Centre for Endocrinology, Moscow, Russia
| | - Mikhail Pikunov
- National Medical Research Center of Surgery Named After A.V. Vishnevsky, Moscow, Russia
| | | | | | | | - Ivan Dedov
- The National Medical Research Centre for Endocrinology, Moscow, Russia
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10
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Mei C, Peng BK, Zhu LQ, Zhou Q, Tang Z. [A case report of mediastinal paraganglioma with ectopic adrenocorticotropic hormone secretion]. Zhonghua Nei Ke Za Zhi 2020; 59:66-68. [PMID: 31887840 DOI: 10.3760/cma.j.issn.0578-1426.2020.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- C Mei
- Department of Endocrinology, The Affiliated Yan'an Hospital of Kunming Medical University, Kunming 650051, China
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11
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Mehta R, Lam-Chung CE, Hinojosa-Amaya JM, Roldán-Sarmiento P, Guillen-Placencia MF, Villanueva-Rodriguez G, Juarez-Leon OA, Leon-Domínguez J, Grajales-Gómez M, Ventura-Gallegos JL, León-Suárez A, Gómez-Pérez FJ, Cuevas-Ramos D. High Molecular Weight ACTH-Precursor Presence in a Metastatic Pancreatic Neuroendocrine Tumor Causing Severe Ectopic Cushing's Syndrome: A Case Report. Front Endocrinol (Lausanne) 2020; 11:557. [PMID: 32903471 PMCID: PMC7438413 DOI: 10.3389/fendo.2020.00557] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022] Open
Abstract
Ectopic ACTH-secretion causing Cushing's syndrome is unusual and its diagnosis is frequently challenging. The presence of high-molecular-weight precursors throughout pro-opiomelanocortin (POMC) translation by these tumors is often not reported. We present the case of a 49-year-old woman with a 3-month history of proximal muscular weakness, skin pigmentation, and weight loss. Upon initial evaluation, she had a full moon face, hirsutism, and a buffalo hump. Laboratory workup showed hyperglycemia, hypokalemia and metabolic alkalosis. ACTH, plasma cortisol, and urinary free cortisol levels were quite elevated. Serum cortisol levels were not suppressed on dexamethasone suppression testing. An octreo-SPECT scan showed enhanced nucleotide uptake in the liver and pancreas. Transendoscopic ultrasound-guided biopsy confirmed the diagnosis of a pancreatic ACTH-secreting neuroendocrine tumor (NET). Surgical excision of both pancreatic and liver lesions was carried out. Western blot analysis of the tumor and metastases revealed the presence of a high-molecular-weight precursor possibly POMC (at 30 kDa) but not ACTH (normally 4.5 kDa). ACTH-precursor secretion is more frequent in ectopic ACTH-secreting tumors compared with other causes of Cushing's syndrome. Hence, the measurement of such ACTH precursors warrants further evaluation, especially in the context of ACTH-dependent hypercortisolism.
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Affiliation(s)
- Roopa Mehta
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - César Ernesto Lam-Chung
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José Miguel Hinojosa-Amaya
- Pituitary Clinic, Endocrinology Division, Department of Medicine, Hospital Universitario “Dr. José E. González” UANL. Francisco I. Monterrey, Monterrey, Mexico
| | - Paola Roldán-Sarmiento
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Maria Fernanda Guillen-Placencia
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gerladine Villanueva-Rodriguez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Oscar Alfredo Juarez-Leon
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jefsi Leon-Domínguez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mariana Grajales-Gómez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jose Luis Ventura-Gallegos
- Biochemistry Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Andrés León-Suárez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Francisco J. Gómez-Pérez
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- *Correspondence: Daniel Cuevas-Ramos
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12
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Hána V, Ježková J, Kosák M, Kršek M, Hána V, Hill M. Serum steroid profiling in Cushing's syndrome patients. J Steroid Biochem Mol Biol 2019; 192:105410. [PMID: 31201926 DOI: 10.1016/j.jsbmb.2019.105410] [Citation(s) in RCA: 6] [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] [Received: 11/30/2018] [Revised: 05/11/2019] [Accepted: 06/12/2019] [Indexed: 12/24/2022]
Abstract
CONTEXT Cushing's syndrome is caused by increased exposure to cortisol. Discrimination of different causes of endogenous hypercortisolism can make a diagnostic dilemma. PATIENTS AND METHODS In serum samples from patients with Cushing's syndrome (47 with Cushing's disease, 6 with ectopic ACTH-dependent Cushing's syndrome, 16 with adrenal adenoma, 7 bilateral adrenal hyperplasia (BMAH) with overt Cushing's syndrome, 42 controls from the general population) using novel method based on gas chromatography-tandem mass spectrometry (GC-MS/MS) we measured 94 serum steroids to search for steroid fingerprint of each subtype. RESULTS Patients with Cushing's disease and ectopic ACTH producing tumors showed elevated levels of androgens and their metabolites when compared with healthy controls. Mineralocorticoid precursors were also elevated in ectopic ACTH syndrome. The levels of androgens were decreased in adrenal adenomas and BMAH. ROC analysis showed 100% sensitivity and 93.6% specificity for 11β-hydroxyepiandrosterone sulfate for discrimination of Cushing's disease from ectopic ACTH secretion. We didn't find any significant (p < 0.05) difference in steroids that would discriminate BMAH from unilateral adenomas causing Cushing's syndrome. CONCLUSION Various causes of Cushing's syndrome show particular steroid fingerprints that can be used to discriminate and may help to achieve appropriate clinical diagnosis.
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Affiliation(s)
- Václav Hána
- 3rd Department of Internal Medicine, General University Hospital, 1st Faculty of Medicine, Charles University, U Nemocnice 1, Prague 2, 128 08, Czech Republic.
| | - Jana Ježková
- 3rd Department of Internal Medicine, General University Hospital, 1st Faculty of Medicine, Charles University, U Nemocnice 1, Prague 2, 128 08, Czech Republic
| | - Mikuláš Kosák
- 3rd Department of Internal Medicine, General University Hospital, 1st Faculty of Medicine, Charles University, U Nemocnice 1, Prague 2, 128 08, Czech Republic
| | - Michal Kršek
- 3rd Department of Internal Medicine, General University Hospital, 1st Faculty of Medicine, Charles University, U Nemocnice 1, Prague 2, 128 08, Czech Republic
| | - Václav Hána
- 3rd Department of Internal Medicine, General University Hospital, 1st Faculty of Medicine, Charles University, U Nemocnice 1, Prague 2, 128 08, Czech Republic
| | - Martin Hill
- Steroid Hormone Unit, Institute of Endocrinology, Národní 8/139, 113 94, Prague 1, Czech Republic
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13
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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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14
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Wannachalee T, Turcu AF, Auchus RJ. Mifepristone in the treatment of the ectopic adrenocorticotropic hormone syndrome. Clin Endocrinol (Oxf) 2018; 89:570-576. [PMID: 30019523 DOI: 10.1111/cen.13818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 05/26/2018] [Revised: 07/03/2018] [Accepted: 07/15/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Mifepristone, a glucocorticoid receptor antagonist, can be used to manage hypercortisolism in patients with ectopic adrenocorticotropic hormone syndrome (EAS) when surgical cure is not feasible. Outcomes of EAS patients treated with mifepristone have been limited to reports of isolated cases. We aimed to determine the efficacy and limitations of mifepristone in the treatment of EAS and to compare outcomes with those of patients who underwent bilateral adrenalectomy. METHOD A retrospective cohort study of EAS patients from the University of Michigan between 1997 and 2017 was conducted. RESULTS Of the 55 patients with EAS, 16 were treated with mifepristone: eight neuroendocrine tumours, two carcinomas and six occult tumours. Treatment with mifepristone was most commonly prompted by psychosis, uncontrolled glucose and/or hypertension. The median maintenance dose was 600 mg/d. Amelioration of psychosis was observed within 48 hours in 3/3 patients, and the glycaemic control was improved in 14/16 patients. The median duration of treatment was 9 months, and three patients were treated for more than 24 months. The overall survival at 24 months was equivalent between patients with EAS treated with mifepristone vs bilateral adrenalectomy (N = 12) (P = 0.6). CONCLUSIONS Mifepristone is effective in treating EAS for over 2 years, and survival was not different from that of patients treated with bilateral adrenalectomy. Aggressive concomitant therapy for hypokalaemia and hypertension is necessary.
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Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan
- 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, Michigan
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan
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15
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Araya AV, Romero C, Lemp M. Combined dexamethasone and desmopressin test in the differential diagnosis of ACTH-dependent Cushing's syndrome and pseudo-cushing's states. Pituitary 2017; 20:602-603. [PMID: 28871364 DOI: 10.1007/s11102-017-0824-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- A Verónica Araya
- Universidad de Chile Clinical Hospital, Santos Dumont 999-Independencia, Santiago, Chile.
| | - Carmen Romero
- Universidad de Chile Clinical Hospital, Santos Dumont 999-Independencia, Santiago, Chile
| | - Melchor Lemp
- Universidad de Chile Clinical Hospital, Santos Dumont 999-Independencia, Santiago, Chile
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Rydzewska M, Krawczuk-Rybak M, Zajkowska A, Jurczuk N, Polnik D, Szalecki M, Moszczyńska E, Savage MO, Bossowski A. Cushing's syndrome in infancy due to ectopic ACTH secretion by a sacro-coccygeal teratoma. J Pediatr Endocrinol Metab 2017; 30:475-478. [PMID: 28328532 DOI: 10.1515/jpem-2016-0339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 08/28/2016] [Accepted: 02/06/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Adenocorticotropic hormone (ACTH)-dependent Cushing's syndrome in infancy is extremely rare. We describe the case of a sacro-coccygeal ectopic ACTH-secreting immature teratoma in an infant who also presented the triad of defects characteristic of Currarino syndrome. CASE PRESENTATION A girl was born with a large immature teratoma in the sacro-coccygeal region associated with anal atresia. At the age of 7 days, the concentration of α-fetoprotein (AFP) was above the age-specific normal range. Two non-radical surgical excisions of the tumour were performed. At the age of 7 months, she developed polyphagia, acne, hirsutism, hypertension and hypokalemia with elevated ACTH and absence of serum cortisol circadian rhythm. Immunostaining of tumour tissue showed ACTH-immunoreactive cells. Due to unsuccessful therapy with ketoconazole and resistance to antihypertensive medications [blood pressure (BP) 210/160 mmHg], metyrapone was administered, which controlled her ACTH and cortisol levels in the normal range. Following further removal of tumour bulk after three operations during the first year of life, there was a decrease of BP to normal values. CONCLUSIONS A rare case of ectopic ACTH syndrome causing Cushing's syndrome in infancy in the context of Currarino syndrome is reported. Radical surgery has resulted in excision of the tumour and current control of Cushing's syndrome.
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Affiliation(s)
- Marta Rydzewska
- Department of Pediatrics, Endocrinology and Diabetes with a Cardiology Unit, Medical University in Bialystok, Bialystok
| | - Maryna Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Bialystok
| | - Adrianna Zajkowska
- Department of Pediatrics, Endocrinology and Diabetes with a Cardiology Unit, Medical University in Bialystok, Bialystok
| | - Natalia Jurczuk
- Department of Pediatrics, Endocrinology and Diabetes with a Cardiology Unit, Medical University in Bialystok, Bialystok
| | - Dariusz Polnik
- Department of Children's Surgery and Transplantology, Children's Memorial Health Institute, Warsaw
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, Children's Memorial Health Institute, Warsaw
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, Children's Memorial Health Institute, Warsaw
| | - Martin O Savage
- Barts and the London School of Medicine and Dentistry, London
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology and Diabetes with a Cardiology Unit, Medical University in Bialystok, ul. Waszyngtona 17, 15-274 Białystok
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17
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Li Y, Peng Y, Jiang X, Cheng Y, Zhou W, Su T, Xie J, Zhong X, Song D, Wu L, Fan L, Li M, Hong J, Wang W, Ning G, Cao Y. Whole exome sequencing of thymic neuroendocrine tumor with ectopic ACTH syndrome. Eur J Endocrinol 2017; 176:187-194. [PMID: 27913610 DOI: 10.1530/eje-16-0546] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 11/06/2016] [Accepted: 11/15/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Thymic neuroendocrine tumor is the second-most prevalent cause of ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS), which is a rare disease characterized by ectopic ACTH oversecretion from nonpituitary tumors. However, the genetic abnormalities of thymic neuroendocrine tumors with EAS remain largely unknown. We aim to elucidate the genetic abnormalities and identify the somatic mutations of potential tumor-related genes of thymic neuroendocrine tumors with EAS by whole exome sequencing. DESIGN AND METHODS Nine patients with thymic neuroendocrine tumors with EAS who were diagnosed at Shanghai Clinical Center for Endocrine and Metabolic Diseases in Ruijin Hospital between 2002 and 2014 were enrolled. We performed whole exome sequencing on the DNA obtained from thymic neuroendocrine tumors and matched peripheral blood using the Hiseq2000 platform. RESULTS We identified a total of 137 somatic mutations (median of 15.2 per tumor; range, 1-24) with 129 single-nucleotide mutations (SNVs). The predominant substitution in these mutations was C:G > T:A transition. Approximately 80% of detected mutations resulted in amino acid changes. However, we failed to discover any recurrent mutations in these nine patients. By functional predictions, HRAS, PAK1 and MEN1, previously reported in neuroendocrine tumors, were identified as candidate tumor-related genes associated with thymic neuroendocrine tumors. CONCLUSIONS Using whole exome sequencing, we identified genetic abnormalities in thymic neuroendocrine tumors with EAS. Thereby, this study acts as a further supplement of the genetic features of neuroendocrine tumors. Somatic mutations of three potential tumor-related genes (HRAS, PAK1 and MEN1) might contribute to the tumorigenesis of thymic neuroendocrine tumors with EAS.
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Affiliation(s)
- Yanli Li
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Ying Peng
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Xiuli Jiang
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Yulong Cheng
- Laboratory of Endocrinology and MetabolismInstitute of Health Sciences, Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS) & Shanghai Jiao-Tong University School of Medicine (SJTUSM), Shanghai, China
| | - Weiwei Zhou
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Tingwei Su
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Jing Xie
- Department of PathologyRui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Xu Zhong
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Dalong Song
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Luming Wu
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Liwen Fan
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Min Li
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Jie Hong
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Weiqing Wang
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
| | - Guang Ning
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
- Laboratory of Endocrinology and MetabolismInstitute of Health Sciences, Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS) & Shanghai Jiao-Tong University School of Medicine (SJTUSM), Shanghai, China
| | - Yanan Cao
- Shanghai Clinical Center for Endocrine and Metabolic DiseasesShanghai Key Laboratory for Endocrine Tumors
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Abstract
The remarkable conservation of the primary structures and anatomical location of dogfish α-melanocyte-stimulating hormone (MSH), corticotrophin-like intermediate lobe peptide (CLIP) and adrenocorticotrophic hormone (ACTH) compared with mammals reinforced the tissue-specific processing hypothesis of ACTH peptides in the pituitary gland. The cloning of dogfish pro-opiomelanocortin (POMC) led to the identification of δ-MSH and simultaneously revealed the high conservation of the γ-MSH sequence during evolution. These studies have also shown that β-MSH is much less conserved during evolution and in some species is not even processed from β-LPH. Human pro-γ-MSH potentiates the corticosteroidogenic activity of ACTH and peptides generated from its N-terminal, in particular big-γ-MSH, appear to have adrenal mitogenic activity. Human big-γ-MSH (from the zona intermedia) may also cause the adrenache. The review finishes with a cautionary note with regard to the misdiagnosis of the ectopic ACTH syndrome in which partial processing of ACTH can result in large concentrations of α-MSH and CLIP, which can interfere in the performance of two-site immunoassays, and the problem of the correct disulphide bridge arrangement in synthetic N-POMC peptides is also discussed.
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Affiliation(s)
- Philip Lowry
- Emeritus Professor School of Biological SciencesUniversity of Reading, Reading, UK
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19
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Modica R, Colao A, Faggiano A. Complete clinical and biochemical control with cabergoline and octreotide in a patient with ectopic ACTH syndrome before surgery. J Endocrinol Invest 2015; 38:373-4. [PMID: 25480427 DOI: 10.1007/s40618-014-0221-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Affiliation(s)
- R Modica
- Division of Endocrinology, Department of Clinical Medicine and Surgery, Section of Endocrinology, University Federico II of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - A Colao
- Division of Endocrinology, Department of Clinical Medicine and Surgery, Section of Endocrinology, University Federico II of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - A Faggiano
- Division of Endocrinology, Department of Clinical Medicine and Surgery, Section of Endocrinology, University Federico II of Naples, Via S. Pansini 5, 80131, Naples, Italy.
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Takashi Y, Kinoshita Y, Makita N, Taguchi M, Takahashi K, Nangaku M, Fukumoto S. Rapid Recovery of Hypothalamic-Pituitary Axis after Successful Resection of an ACTH-secreting Neuroendocrine Tumor. Intern Med 2015; 54:2201-5. [PMID: 26328647 DOI: 10.2169/internalmedicine.54.4915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 30-year-old man with ectopic adrenocorticotropic hormone (ACTH) syndrome. Before the operation, there was no diurnal variation of ACTH, and ACTH did not respond to CRH or dexamethasone suppression tests. These abnormalities disappeared after the removal of a neuroendocrine tumor in the lung. In addition, plasma ACTH was measureable at as early as postoperative day 3 with ACTH levels increasing thereafter. Furthermore, an insulin tolerance test and inferior petrosal sinus sampling indicated that ACTH was secreted from the pituitary. This case indicates that the hypothalamic-pituitary function can recover within a couple of weeks after curative surgery for ectopic ACTH syndrome.
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Affiliation(s)
- Yuichi Takashi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan
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Page-Wilson G, Freda PU, Jacobs TP, Khandji AG, Bruce JN, Foo ST, Meece K, White A, Wardlaw SL. Clinical utility of plasma POMC and AgRP measurements in the differential diagnosis of ACTH-dependent Cushing's syndrome. J Clin Endocrinol Metab 2014; 99:E1838-45. [PMID: 25013995 PMCID: PMC4184073 DOI: 10.1210/jc.2014-1448] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CONTEXT Distinguishing between pituitary [Cushing's disease (CD)] and ectopic causes [ectopic ACTH syndrome (EAS)] of ACTH-dependent Cushing's syndrome can be challenging. Inferior petrosal sinus sampling (IPSS) best discriminates between CD and occult EAS but is a specialized procedure that is not widely available. Identifying adjunctive diagnostic tests may prove useful. In EAS, abnormal processing of the ACTH precursor proopiomelanocortin (POMC) and the accumulation of POMC-derived peptides might be expected and abnormal levels of other neuropeptides may be detected. OBJECTIVE The objective of the study was to evaluate the diagnostic utility of POMC measurements for distinguishing between CD and occult EAS in patients referred for IPSS. Another objective of the study was to evaluate in parallel the diagnostic utility of another neuropeptide, agouti-related protein (AgRP), because we have observed a 10-fold elevation of AgRP in plasma in a patient with EAS from small-cell lung cancer. DESIGN AND PARTICIPANTS Plasma POMC and AgRP were measured in 38 Cushing's syndrome patients presenting for IPSS, with either no pituitary lesion or a microadenoma on magnetic resonance imaging, and in 38 healthy controls. RESULTS Twenty-seven of 38 patients had CD; 11 of 38 had EAS. The mean POMC was higher in EAS vs CD [54.5 ± 13.0 (SEM) vs 17.2 ± 1.5 fmol/mL; P < .05]. Mean AgRP was higher in EAS vs CD (280 ± 76 vs 120 ± 16 pg/mL; P = .01). Although there was an overlap in POMC and AgRP levels between the groups, the POMC levels greater than 36 fmol/mL (n = 7) and AgRP levels greater than 280 pg/mL (n = 3) were specific for EAS. When used together, POMC greater than 36 fmol/mL and/or AgRP greater than 280 pg/mL detected 9 of 11 cases of EAS, indicating that elevations in these peptides have a high positive predictive value for occult EAS. CONCLUSIONS Expanding upon previous observations of high POMC in EAS, this study specifically demonstrates elevated POMC levels can identify occult ectopic tumors. Elevations in AgRP also favor the diagnosis of EAS, suggesting AgRP should be further evaluated as a potential neuroendocrine tumor marker.
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Affiliation(s)
- Gabrielle Page-Wilson
- Department of Medicine (G.P.-W., P.U.F., T.P.J., K.M., S.L.W.), Department of Radiology (A.G.K.), Department of Neurological Surgery (J.N.B.), Columbia University College of Physicians & Surgeons, New York, New York 10032; Department of Medicine (S.T.F.), Mt Sinai/St Luke's Roosevelt Hospital, New York, New York 10019; and Faculties of Life Sciences and Medical and Human Sciences (A.W.), University of Manchester, Manchester M13 9PT, United Kingdom
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Pikunov MI, Kuznetsov NS, Latkina NV, Dobreva EA, Remizov OV. [Bronchopulmonary ACTH-producing tumors]. Khirurgiia (Mosk) 2014:21-27. [PMID: 24874220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Neuroendocrine tumors have the ability to produce the hormones and vasoactive peptides. Excess of these hormones leads to different symptoms and syndromes because of organs' injuries. Detection of ACTH origin by using of modern diagnostic methods is not always possible. Lungs and bronchi are one of the most frequent localization of ACTH-producing tumors. It is considered that carcinoids with bronchopulmonary localization like a benign tumors in the clinical course. But at the same time carcinoid tends to metastasize, so timely diagnostics and treatment improve quality of life significant and increase the life expectancy of patients. The modern state of diagnostics and surgical treatment problem of ACTH-producing tumors with bronchopulmonary localization is presented in the article. It was described the brief historical background, clinical symptoms, instrumental and biochemical methods of diagnosis. The principles of surgical treatment are presented in the article.
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Abstract
Spontaneous remission is rare in ectopic ACTH syndrome (EAS). We describe four patients with presumed EAS in whom long-term treatment with steroidogenesis inhibitors was followed by prolonged remission of hypercortisolemia. Biochemical testing was consistent with EAS, but imaging failed to identify a tumor. Patients were treated with ketoconazole alone or with mitotane and/or metyrapone to control hypercortisolemia. Dexamethasone was added when a block and replace strategy was used. Treatment with steroidogenesis inhibitors for 3-10 years in these patients was followed by a prolonged period of remission (15-60 months). During remission, the first patient had an elevated ACTH, low cortisol and 24-h urinary free cortisol (UFC), and adrenal atrophy on computerized tomography scan during remission, suggesting a direct toxic effect on the adrenal glands. Cases 2 and 3 had normal to low ACTH levels and low-normal UFC, consistent with an effect at the level of the ectopic tumor. They did not have a history of cyclicity and case 3 has been in remission for ~5 years, making cyclic Cushing's syndrome less likely. Case 4, with a history of cyclic hypercortisolism, had normal to slightly elevated ACTH levels and low-normal UFC during remission. The most likely etiology of remission is cyclic production of ACTH by the ectopic tumor. Spontaneous and sustained remission of hypercortisolemia is possible in EAS after long-term treatment with steroidogenesis inhibitors; a drug holiday may be warranted during chronic therapy to evaluate this. The pathophysiology remains unclear but may involve several different mechanisms.
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Affiliation(s)
- S T Sharma
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, 1 East, Rm 3140, Bethesda, Maryland 20892-1109, USA.
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Bons JAP, Havekes B, Menheere PPCA. [Cortisol and Cushing's syndrome]. Ned Tijdschr Geneeskd 2012; 156:A3556. [PMID: 22394438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Judith A P Bons
- Maastricht Universitair Medisch Centrum, Afd. Klinische Chemie, Maastricht, the Netherlands.
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Abstract
CONTEXT Anomalous venous drainage can lead to false-negative inferior petrosal sinus sampling (IPSS) results. Baseline inferior petrosal sinus to peripheral (IPS/P) prolactin ratio higher than 1.8 ipsilateral to the highest ACTH ratio has been proposed to verify successful catheterization. Prolactin-normalized ACTH IPS/P ratios may differentiate Cushing's disease (CD) from ectopic ACTH syndrome (EAS). OBJECTIVE Our objective was to examine the utility of prolactin measurement during IPSS. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective analysis of prolactin levels in basal and CRH-stimulated IPSS samples in ACTH-dependent Cushing's syndrome (2007-2010). RESULTS Twenty-five of 29 patients had a pathologically proven diagnosis (17 CD and eight EAS). IPSS results were partitioned into true positive for CD (n = 16), true negative (n = 7), false negative (n = 1), and false positive (n = 1). Prolactin IPS/P ratio suggested successful IPSS in eight of 11 with abnormal venograms. Baseline prolactin IPS/P ratio was helpful in two patients with abnormal venograms and false-negative (catheterization unsuccessful) or true-negative (catheterization successful) IPSS results; the normalized ratio correctly diagnosed their disease. Normalized ACTH IPS/P ratio was at least 1.3 in all with CD, but prolactin IPS/P ratios were misleadingly low in two. One patient with cyclic EAS had a false-positive IPSS when eucortisolemic (baseline prolactin IPS/P = 1.7; normalized ratio = 5.6). All other EAS patients had normalized ratios no higher than 0.7. CONCLUSION Prolactin measurement and evaluation of the venogram can improve diagnostic accuracy when IPSS results suggest EAS but is not necessary with positive IPSS results. Confirmation of hypercortisolemia remains a prerequisite for IPSS. A normalized ratio of 0.7-1.3 was not diagnostic.
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Affiliation(s)
- S T Sharma
- Program on Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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Grunewald TGP, von Luettichau I, Welsch U, Dörr HG, Höpner F, Kovacs K, Burdach S, Rabl W. First report of ectopic ACTH syndrome and PTHrP-induced hypercalcemia due to a hepatoblastoma in a child. Eur J Endocrinol 2010; 162:813-8. [PMID: 20133447 DOI: 10.1530/eje-09-0961] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Only occasionally, endocrine-active tumors develop directly from hepatic tissue, and may lead to paraneoplastic syndromes (PNS). PNS mostly accompany malignancy of adulthood and are exceedingly rare in children. PATIENT A girl aged 6 years and 9 months presented with a 2-month history of rapidly progressive weight gain, abdominal distension, and polyuria/pollakiuria accompanied by short episodes of abdominal pain. She showed the typical clinical features of Cushing's syndrome and a huge hepatic mass. An abdominal computed tomography (CT) scan revealed a large liver tumor. Blood glucose and serum calcium were greatly elevated. DESIGN AND OBJECTIVE Case report describing the causative relationship of the clinical findings. METHODS Physical examination; ultrasound of the abdomen; CT scan of the abdomen and the chest; conventional X-rays; routine hematology; blood chemistry and multiple parameters of calcium and phosphorus metabolism; multisteroid analysis in serum and urine; adrenocortical stimulation and suppression tests; histopathological assessment of the resected tumor; immunohistochemistry for ACTH, beta-endorphin, corticotrophin-releasing hormone (CRH), and PTH-related peptide (PTHrP); electron microscopy of tumor cells; ACTH and CRH extraction from the tumor tissue; and clinical follow-up for more than 20 years. RESULTS Giant hepatoblastoma (HB; approximately 1000 ml volume) of the right lobe of the liver with combined ectopic ACTH syndrome and PTHrP-induced tumor-associated hypercalcemia. Wide local excision and polychemotherapy led to complete reversal of the paraneoplastic phenotype. CONCLUSIONS This is the first report of an endocrine-active HB causing both Cushing's syndrome and PTHrP-related 'humoral hypercalcemia of malignancy'. This information should be added to the well-known beta-human chorionic gonadotropin-related paraneoplastic effects of HB in children.
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Affiliation(s)
- Thomas G P Grunewald
- Department of Pediatrics, Klinikum rechts der Isar, Technische Universität München, Kölner Platz 1, D-80804 Munich, Germany
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Sugiyama M, Sugiyama T, Yamaguchi M, Izumiyama H, Yoshimoto T, Kishino M, Akashi T, Hirata Y. Successful localization of ectopic ACTH-secreting bronchial carcinoid by selective pulmonary arterial sampling. Endocr J 2010; 57:959-64. [PMID: 20890054 DOI: 10.1507/endocrj.k10e-192] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Among patient with ACTH-dependent Cushing's syndrome, about 10-20% of those with ectopic ACTH syndromes (EAS) have occult or unknown tumors. Despite the intensive search for the culprit tumors by dynamic endocrine tests and imaging tests, it is often difficult to localize and confirm the source of occult ectopic ACTH secretion. We report a patient with EAS caused by a small bronchial carcinoid tumor, which was successfully localized by a selective pulmonary arterial sampling for the first time. A 69-year-old woman presented with typical Cushingoid features and elevated plasma ACTH and cortisol levels, which showed lack of circadian rhythm, no suppression by high-dose dexamethasone, and no response to CRH stimulation. No mass lesion was detected by pituitary MRI, and inferior petrosal sinus sampling showed no central to peripheral ACTH gradient. Although CT scan of the chest revealed a very small nodule in the right lung, it could not be confirmed by either somatostatin receptor scintigraphy or fluorodeoxyglucose positron emission tomography. Selective pulmonary arterial sampling of the wedged blood from a pulmonary artery branch affecting the nodule showed a marked ACTH gradient, and the lobectomy of the right middle lung resulted in dramatic decreases in plasma ACTH and cortisol levels. The resected tumor was diagnosed as a bronchial carcinoid tumor with positive immunostaining for ACTH. Thus, selective pulmonary arterial sampling, because of its more site-selective measurement of hormonal secretion, could be one of the useful tools to localize and confirm the ectopic ACTH production by a small pulmonary tumor.
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Affiliation(s)
- Miho Sugiyama
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
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Zemskova MS, Nylen ES, Patronas NJ, Oldfield EH, Becker KL, Nieman LK. Diagnostic accuracy of chromogranin A and calcitonin precursors measurements for the discrimination of ectopic ACTH secretion from Cushing's disease. J Clin Endocrinol Metab 2009; 94:2962-5. [PMID: 19470624 PMCID: PMC2730869 DOI: 10.1210/jc.2009-0604] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Inferior petrosal sinus sampling (IPSS) best discriminates between the two causes of ACTH-dependent Cushing's syndrome, Cushing's disease (CD) and ectopic ACTH secretion (EAS). However, when sampling is not available, adjunctive diagnostic tests might be helpful. Neuroendocrine tumors may secrete chromogranin A (CgA), calcitonin (CT), procalcitonin (ProCT), a fragment of the amino terminus of procalcitonin (NProCT), and/or ACTH. OBJECTIVE The aim of the study was to evaluate the ability of serum CgA, CT, ProCT, or NProCT values to distinguish CD from EAS. DESIGN AND SETTING We conducted a prospective pilot study at a clinical research center. SUBJECTS AND METHODS Serum ProCT, NProCT, and CgA were measured in six patients with occult EAS diagnosed by IPSS, 25 CD patients, and 11 patients with histologically proven EAS. RESULTS Nine EAS patients (53%) had at least one value above the reference range, including CgA alone (n = 4), ProCT alone (n = 3), CgA and ProCT (n = 1), and NProCT and ProCT (n = 1). Of nine (36%) CD patients with one or two abnormal values, seven had increased ProCT only, one had increased NProCT only, and one had increased CgA and ProCT. CgA had a positive predictive value of 83% and a negative predictive value of 70% for the diagnosis of EAS; other markers showed less discrimination. On pituitary magnetic resonance imaging, no EAS patient had an abnormality, whereas 21 of 25 patients with CD had a mass. CONCLUSION These preliminary results suggest that an abnormal CgA and normal pituitary magnetic resonance imaging favor the diagnosis of EAS, but normal tumor markers do not exclude the diagnosis.
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Affiliation(s)
- Marina S Zemskova
- The Program in Reproductive and Adult Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892-1109, USA
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De Rosa G, Testa A, Liberale I, Pirronti T, Granone P, Picciocchi A. Successful treatment of ectopic Cushing's syndrome with the long-acting somatostatin analog octreotide. Exp Clin Endocrinol 2009; 101:319-25. [PMID: 8299710 DOI: 10.1055/s-0029-1211252] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We report on the efficacy of the long-acting somatostatin analog octreotide in a 43-yr old woman with ectopic ACTH syndrome. Plasma cortisol, ACTH, beta-endorphin (beta-END) and urinary free cortisol (UFC) were elevated (range 743-920 nmol/l, 29.2-49.7 pmol/l, 71.0-84.1 pmol/l, 2117-3119 nmol/day respectively). Ovine CRH (oCRH) and high dose dexamethasone did not affect cortisol and ACTH levels, while UFC significantly decreased after dexamethasone. Initially radiological investigation failed to localize the ACTH secreting tumor. Ketoconazole was not tolerated. Plasma cortisol significantly decreased both after single (100 micrograms sc) (baseline 531 nmol/l, nadir 218 nmol/l) and 3-day octreotide administration (from 810 to 448 nmol/l); plasma ACTH decreased slightly (from 30.4 to 21.3 pmol/l and from 32.4 to 22.5 pmol/l respectively); UFC decreased from 2616 to 711 nmol/day after the 3-day test. Long-term octreotide treatment (100 micrograms/8h per 54 weeks) led to clinical and biochemical improvement and recurrence followed drug withdrawal; no side effects were observed. Six months after octreotide administration a 2 cm lung mass was detected with CT and MR. Surgery was performed and a bronchial carcinoid was removed. Immunoreactive ACTH in the tumor has been demonstrated by histochemistry. Postoperatively a lasting remission of Cushing's syndrome was observed without further therapy.
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Affiliation(s)
- G De Rosa
- Institute of Endocrinology, Catholic University School of Medicine, Rome, Italy
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Arnaldi G, Tirabassi G, Papa R, Furlani G, Trementino L, Cardinaletti M, Faloia E, Boscaro M. Human corticotropin releasing hormone test performance in the differential diagnosis between Cushing's disease and pseudo-Cushing state is enhanced by combined ACTH and cortisol analysis. Eur J Endocrinol 2009; 160:891-8. [PMID: 19321661 DOI: 10.1530/eje-09-0125] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Corticotropin releasing hormone (CRH) test does not reliably distinguish Cushing's disease (CD) from normality or pseudo-Cushing state (PC). We assessed whether this could be achieved with a novel approach while preserving the ability of the test to distinguish CD from ectopic ACTH syndrome (EAS). Design Retrospective/prospective study. SUBJECTS AND METHODS We studied 51 subjects with CD, 7 with EAS, 26 with PC, and 31 controls (CT). Human CRH (hCRH) test was performed at 0830 h by measuring plasma ACTH and serum cortisol at -15, 0, 15, 30, 45, 60, 90, and 120 min. RESULTS The area under the curve-ACTH exhibited a significant negative correlation with baseline serum cortisol in CT and PC, but not in CD or EAS patients. ACTH response to hCRH was blunted in PC compared with CT, whereas peak serum cortisol was higher in PC than in CT subjects. These findings suggested that ACTH-dependent Cushing's syndrome can be diagnosed by the presence of two hCRH test parameters and excluded if either or both are absent. Application of i) basal serum cortisol >12 microg/dl and peak plasma ACTH >54 pg/ml, or ii) peak serum cortisol >21 microg/dl and peak plasma ACTH >45 pg/ml, had 91.3% (95% confidence intervals (CI) 81-97.1) and 94.8% (CI 85.6-98.9) sensitivity and 98.2% (CI 90.6-99.9) and 91.2% (CI 80.7-97) specificity respectively, in diagnosing ACTH-dependent Cushing's syndrome. The >14% serum cortisol increase from mean baseline values to the mean of 15 and 30 min values in patients who were positive for the test completely discriminated between CD and EAS. CONCLUSIONS Simultaneous plasma ACTH and serum cortisol analysis enables the hCRH test to distinguish CD from PC and from normality, while preserving its ability to discriminate CD from EAS.
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Affiliation(s)
- Giorgio Arnaldi
- Division of Endocrinology, Polytechnic University of Marche, 60100 Ancona, Italy Social Gerontology Unit, Research Department, INRCA (Italian National Institute on Ageing), 60100 Ancona, Italy
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Rashid F, Riccio SA, Munk PL, Malfair D, Heran MK. Vertebroplasty for vertebral compression fractures secondary to Cushing's syndrome induced by an ACTH-producing bronchial carcinoid tumour. Singapore Med J 2009; 50:e147-e150. [PMID: 19421671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Adrenocorticotropic hormone (ACTH)-producing bronchial carcinoid tumours are a rare cause of Cushing's syndrome. Cushing's syndrome is frequently complicated by osteoporosis, which results in an increased tendency for the development of vertebral compression fractures. Percutaneous vertebroplasty has been shown to be an effective treatment option in the setting of painful osteoporotic compression fractures refractory to conservative therapies. We report a case where vertebroplasty was performed on a 36-year-old woman with osteoporosis and compression fractures secondary to hypercorticolism. A bronchial carcinoid tumour was found to be the source of excess ACTH production. Three-level percutaneous vertebroplasty resulted in a marked improvement in pain.
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Affiliation(s)
- F Rashid
- Department of Radiology, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada
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Abstract
We evaluated the usefulness and accuracy of diagnostic tests for adrenocorticotropic hormone (ACTH)- dependent Cushing's syndrome, based on our experience of 88 cases, including 73 cases with Cushing's disease, and 15 cases with ectopic ACTH syndrome (EAS). In our study, 0.5 mg of dexamethasone failed to suppress the morning cortisol secretion in 100% of cases with Cushing's disease and EAS. Plasma ACTH levels were significantly increased by desmopressin (DDAVP) in 86% of cases with Cushing's disease, especially in microadenomas (90%), while these levels were not affected in normal subjects. In EAS, 44% responded to DDAVP. Plasma ACTH levels were increased in response to the human corticotropin-releasing hormone (CRH) test in 100% of microadenomas and 73% of macroadenomas with Cushing's disease, but only in 27% of cases with EAS. A high dose (8 mg) of dexamethasone suppressed the morning cortisol secretion in 89% of microadenomas with Cushing's disease, and in 82% of all cases with Cushing's disease, while it did in only 20% of cases with EAS. Taken together, the 0.5 mg dexamethasone suppression test (DST) and DDAVP test are considerably useful for the screening of ACTH-dependent Cushing's syndrome. The CRH test and 8 mg DST would be effective for the diagnosis of Cushing's diseases, because our study shows a sensitivity of 81% in cases with Cushing's disease when these tests are considered together. These data were submitted to prepare the diagnostic criteria for Cushing's disease, suggested by the working group of the Ministry of Health, Labour, and Welfare of Japan.
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Affiliation(s)
- Toshihiro Suda
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Aomori, Japan
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Burman P, Lethagen A, Ivancev K, Johansson L, Sundin A. Dual bronchial carcinoids and Cushing's syndrome with a paradoxical response to dexamethasone and a false positive outcome of inferior petrosal sinus sampling. Eur J Endocrinol 2008; 159:483-8. [PMID: 18625689 DOI: 10.1530/eje-08-0385] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Establishing the cause of Cushing's syndrome (CS) can be a considerable challenge, in particular in ectopic adrenocorticotropic hormone (ACTH) syndrome, and often requires a combination of biochemical tests and imaging procedures. SUBJECT A 27-year-old man presented with signs of CS. P-ACTH levels were three times above the upper limit of normal (ULN) and free urinary cortisol around 2000 nmol/24 h. The work-up showed remarkable results. RESULTS A 2-day low-dose dexamethasone suppression test demonstrated paradoxical increases in cortisol. Sampling from the bilateral inferior petrosal sinus sampling (BIPSS) showed a central to peripheral ACTH ratio of 4.7 after corticotrophin-releasing hormone (CRH) stimulation, i.e. indicated pituitary disease, but magnetic resonance imaging of the pituitary was normal. Computed tomography (CT) scan of the lungs showed two oval-shaped masses, 1.3 x 1.8 and 1.3 x 2 cm, in the middle lobe. Both were positive at somatostatin receptor scintigraphy, compatible with tumors or inflammatory lesions. Subsequently, (11)C-5-hydroxytryptophan-PET showed distinct uptake in the tumors but not elsewhere. Two carcinoids situated 3 cm apart, both staining for ACTH, were removed at surgery. CONCLUSION This unique case with dual bronchial carcinoids inducing hypercortisolism illustrates the problems with identifying the source of ACTH in CS. Possibly, an abnormal regulation of ACTH production in response to dexamethasone, or steroid-induced tumor necrosis, explains the paradoxical outcome at dexamethasone suppression, and the false positive result at BIPSS reflects an unusual sensitivity of the pituitary corticotrophs to CRH in this patient. The work-up illustrates the great value of (11)C-5-hydroxytryptophan-PET as a diagnostic procedure when other investigations have produced ambiguous results.
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Affiliation(s)
- Pia Burman
- Departments of Endocrinology, University Hospital MAS, SE-205 02 Malmö, Sweden.
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Cassier PA, Abou-Amara-Olivieri S, Artru P, Lapalus MG, Riou JP, Lombard-Bohas C. Mifepristone for ectopic ACTH secretion in metastatic endocrine carcinomas: report of two cases. Eur J Endocrinol 2008; 158:935-8. [PMID: 18390992 DOI: 10.1530/eje-07-0792] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ectopic adrenocorticotropin secretion (EAS) remains a therapeutic challenge whenever the tumor responsible for the syndrome is not amenable to curative resection. Two cases of EAS related to metastatic foregut-derived endocrine carcinomas led us to use mifepristone, an antagonist of both progesterone and glucocorticoids. Mifepristone clearly improved skin lesions and diabetes associated with hypercorticism. The beneficial effect lasted for about 10 months. In both cases, recurrent hypertension and hypokalemia eventually required adrenalectomy.
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Affiliation(s)
- Philippe A Cassier
- Unité de Jour d'Oncologie Médicale Multidisciplinaire, Hôpital Edouard Herriot, Lyon, France
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Ogo A, Eto T, Hiramatsu S, Watanabe A, Sakai Y, Yoshizumi H, Uesugi N, Nakajima O. Autopsy of a patient with Cushing's Syndrome who was revealed to have pulmonary tumorlets producing ectopic ACTH. Endocr J 2007; 54:863-70. [PMID: 18000346 DOI: 10.1507/endocrj.k07-125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The patient, a 78-year-old female with a 10-year history of type 2 diabetes mellitus, was admitted to our department for evaluation of leg edema and general fatigue. Biochemical investigations revealed hypokalemia and elevated serum cortisol and plasma ACTH levels, with a loss of diurnal rhythm and failure of suppression at high doses (8 mg) of dexamethasone. No pituitary tumor or parasellar tumor was detected by contrast-enhanced computed tomography (CT) or magnetic resonance image scan of the pituitary. High resolution CT of the lung and bronchoscopic examination revealed no abnormalities. Abdominal and pelvic CT indicated bilateral, slightly diffuse, adrenal gland hyperplasia only. These findings led to a diagnosis of ACTH-dependent hypercortisolism from an undefined source. Ten days after admission the patient had a fever and was diagnosed with disseminated intravascular coagulation. Despite intensive treatment about 1 month after admission the patient died from progressive multiple organ failure. At autopsy, a histological examination of the periphery of the right middle lobe of the lung revealed the presence of tumorlets. Immunohistochemical staining of the tumorlets revealed scattered cells containing ACTH and many cells containing chromogranin A that were positive for Grimelius staining. In addition, multiple microabscesses were present throughout most tissues of the body. The ectopic hormonal production observed in the present case suggests that pulmonary tumorlets should thus be considered in the differential diagnosis of Cushing's syndrome, and medical treatment to inhibit steroidogenesis should be started immediately to reduce the risk of complications from hypercortisolism.
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Affiliation(s)
- Atsushi Ogo
- Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka City, Japan
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Servonnet A, Delacour H, Roux X, Dehan C, Gardet V, Morand C. [Ectopic ACTH syndrome and severe hypokalaemia]. Ann Biol Clin (Paris) 2007; 65:425-30. [PMID: 17627926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2007] [Accepted: 04/14/2007] [Indexed: 05/16/2023]
Abstract
Cushing's syndrome is rare and remains a challenge to diagnose. Particularly difficult are the differentiation between Cushing's syndrome and Pseudo-Cushing's states and between the two forms of ACTH dependent Cushing's: Cushing's disease and ectopic ACTH syndrome. We report the case of a patient diagnosed with a metastatic small cells lung carcinoma associated with ectopic ACTH-syndrome. Hypokalaemia was a clue to diagnosis. We focus on critical questions addressing diagnosis and differential diagnosis of Cushing's syndrome and we explain the mechanism of hypokalaemia.
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Affiliation(s)
- A Servonnet
- Fédération de biologie clinique, Hôpital d'Instruction des Armées Robert Picqué, Bordeaux.
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Abstract
OBJECTIVE To report the preparation and use of etomidate in a patient with Cushing's syndrome caused by an ectopic adrenocorticotropic hormone (ACTH)-producing tumor. CASE SUMMARY A 73-year-old man with a 5 year history of prostate cancer was admitted for symptoms consistent with Cushing's syndrome. He was started on oral metyrapone for elevated serum cortisol, ACTH, and 24 hour urinary unbound cortisol levels. Shortly after starting metyrapone, he was transferred to the medical intensive care unit for new-onset atrial fibrillation, neutropenic fever, and respiratory failure. A nasogastric tube could not be inserted to administer metyrapone. Intravenous etomidate 4 mg/h (0.06 mg/kg/h) was initiated to decrease cortisol production and provide sedation for mechanical ventilation. Despite supportive treatment, the patient died from multiple organ dysfunction. DISCUSSION For patients exhibiting signs and symptoms of Cushing's syndrome who have no enteral access, administering etomidate intravenously may be a viable alternative treatment route. Although several articles report the use of etomidate to control cortisol overproduction, the intravenous preparation and stability are discussed only vaguely. In our patient, etomidate was infused via a 30 mL syringe, 2 mg/mL undiluted through a central venous catheter; syringe use was limited to 24 hours. Etomidate should be infused only with continuous monitoring of hemodynamics and periodic assessment of adrenal function. CONCLUSIONS When oral or enteral medications cannot be administered and sedation is required in critically ill patients, etomidate is an appropriate intravenous agent for hypercortisolemia. There were no obvious problems with stability when undiluted etomidate 2 mg/mL was infused through a dedicated central venous catheter lumen.
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Affiliation(s)
- Tami N Johnson
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Gasińska T, Dec R, Wichary H, Kulawik G. [Difficulties in the diagnosis of Cushing's disease--usefulness of desmopressin test]. Wiad Lek 2007; 60:80-2. [PMID: 17607974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A 39-year-old man with occult eutopic corticotropin microadenoma leading to Cushing's syndrome was presented. Magnetic resonance imaging was unable to identify the pituitary microadenoma. In another department bilateral adrenalectomy was justified. In our department to identify or exclude a pituitary source of autonomous corticotropin secretion desmopressin test was performed. Intravenous desmopressin administration enhanced both circulating concentrations ofACTH and cortisol by 217.36% (peak vs. baseline) and 67% respectively. The patient underwent a transsphenoidal adenomectomy. Immunostaining demonstrated ACTH in adenoma cells. After surgery cortisol levels returned to the normal range, moreover no ACTH and cortisol response was elicited by desmopressin administration. This clinical case represents the demonstration of the possibility to unmask an occult eutopic Cushing's syndrome with the desmopressin test.
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Affiliation(s)
- Teresa Gasińska
- Z Katedry i Kliniki Chorób Wewnetrznych i Chemioterapii Onkologicznej, Slaskiej Akademii Medycznej w Katowicach
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Machado MC, de Sa SV, Domenice S, Fragoso MCBV, Puglia P, Pereira MAA, de Mendonça BB, Salgado LR. The role of desmopressin in bilateral and simultaneous inferior petrosal sinus sampling for differential diagnosis of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 2007; 66:136-42. [PMID: 17201813 DOI: 10.1111/j.1365-2265.2006.02700.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Bilateral inferior petrosal sinus sampling (BIPSS) with corticotrophin-releasing hormone (CRH) stimulation is currently the gold standard test for the differential diagnosis of ACTH-dependent Cushing's syndrome. Reports on the use of desmopressin in this approach are limited. The aim of this study was to evaluate the use of desmopressin during BIPSS in a cohort of patients with ACTH-dependent Cushing's syndrome. DESIGN A retrospective case-record study. PATIENTS Fifty-six patients with confirmed ACTH-dependent Cushing's syndrome underwent BIPSS with desmopressin stimulation when presenting negative pituitary tumour imaging. MEASUREMENTS Central to peripheral (CEN:PER) ACTH gradient, lateralization of the ACTH source and surgical tumour confirmation were evaluated. RESULTS A CEN:PER ACTH gradient was found in 40 patients under basal conditions (CEN:PER >or= 2) and in 47 patients after desmopressin stimulation (CEN:PER >or= 3). Ectopic ACTH-producing tumours (three lung carcinoid tumour, one thymus carcinoid tumour and one thymus hyperplasia) were confirmed in five out of nine patients without the CEN:PER ACTH gradient, and four cases were false negative for Cushing's disease. Lateralization (IPS:IPS >or= 1.4) was observed in 80.8% of patients under basal conditions (38/47) and in 97.8% after desmopressin (46/47), and it was surgically confirmed in 78.7%. There were no false-positive cases. Sensitivity and specificity were 92.1% and 100%, respectively. CONCLUSIONS Desmopressin improves the differential diagnosis of ACTH-dependent Cushing's syndrome by amplifying the CEN:PER and IPS:IPS ACTH gradients, and is therefore a useful ACTH secretagogue in BIPSS.
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Affiliation(s)
- Marcio Carlos Machado
- Division of Endocrinology and Metabolism, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
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Gasińska T. [Desmopressin stimulation test for diagnosis of ACTH-dependent Cushing's syndrome]. Pol Arch Med Wewn 2006; 115:572-7. [PMID: 17263230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- Teresa Gasińska
- Katedra i Klinika Chorób Wewnetrznych i Chemioterapii Onkologicznej Slaskiej Akademii Medycznej, Katowicach.
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Isidori AM, Kaltsas GA, Pozza C, Frajese V, Newell-Price J, Reznek RH, Jenkins PJ, Monson JP, Grossman AB, Besser GM. The ectopic adrenocorticotropin syndrome: clinical features, diagnosis, management, and long-term follow-up. J Clin Endocrinol Metab 2006; 91:371-7. [PMID: 16303835 DOI: 10.1210/jc.2005-1542] [Citation(s) in RCA: 287] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT There are few large series of patients with ectopic, nonpituitary, corticotropin (ACTH) secretion (EAS). OBJECTIVE The objective of this study was to analyze the clinical, biochemical, and radiological features, management, and treatment outcome of patients with EAS. DESIGN This was a retrospective case-record study. SETTING The setting for this study was a tertiary referral hospital center. PATIENTS Forty patients with EAS were studied. MAIN OUTCOME MEASURES Clinical, biochemical, and radiological features and response to therapy and survival were measured. RESULTS The median follow-up was 5 yr (range, 2-30 yr). None of the dynamic tests achieved 100% accuracy, but bilateral inferior petrosal sinus sampling showed an absent central gradient in all but one case (one of 12). Imaging correctly identified the lesion at first investigation in 65% of cases. Bronchial carcinoid tumors were the most common cause of EAS (n = 12; 30%), followed by other neuroendocrine tumors (n = 13, 32.5%). In 12.5% of patients, the source of EAS was never found. Octreotide scintigraphy and whole-body venous sampling were of limited value. Surgical attempt at curative resection was successful in 83% (10 of 12) of patients with bronchial carcinoid tumors; others responded generally well to adrenolytic therapy or bilateral adrenalectomy. Tumor histology and the presence of distant metastases were the main predictors of overall survival (P < 0.05). CONCLUSIONS A variety of tests and imaging studies are necessary for the correct diagnosis of the EAS, but even then, up to 20% of cases present a covert or occult EAS syndrome. These cases require a prolonged follow-up, review, and repetition of diagnostic tests and scans.
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Affiliation(s)
- Andrea M Isidori
- Department of Endocrinology, St. Bartholomew's Hospital, London EC1A 7BE, United Kingdom
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Takagi J, Otake K, Morishita M, Kato H, Nakao N, Yoshikawa K, Ikeda H, Hirooka Y, Hattori Y, Larsson C, Nogimori T. Multiple endocrine neoplasia type I and Cushing's syndrome due to an aggressive ACTH producing thymic carcinoid. Intern Med 2006; 45:81-6. [PMID: 16484744 DOI: 10.2169/internalmedicine.45.1427] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Thymic carcinoid in multiple endocrine neoplasia type 1 (MEN 1) is previously reported as a non-ACTH producing tumor. The present case is a 39-year-old man with mortal outcome from thymic carcinoid and Cushing's syndrome with high plasma ACTH. The symptom was first observed at age 29 and was relieved after extended thymectomy, with reduction of ACTH level. The tumor was positive for ACTH, Grimelius silver staining and Chromogranin A. The finding of primary hyperparathyroidism, pituitary adenoma, and a novel germline nonsense mutation (W423X) established the diagnosis of MEN 1. Cushing's syndrome due to ACTH producing thymic carcinoid should be also considered as one phenotype of the MEN 1 spectrum.
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Affiliation(s)
- Junko Takagi
- Department of Laboratory Medicine, Aichi Medical University School of Medicine, Nagakute, Aichi
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Yano M, Fukai I, Kobayashi Y, Mizuno K, Konishi A, Haneda H, Suzuki E, Endo K, Fujii Y. ACTH Secreting Thymic Carcinoid Associated With Multiple Endocrine Neoplasia Type 1. Ann Thorac Surg 2006; 81:366-8. [PMID: 16368411 DOI: 10.1016/j.athoracsur.2004.07.084] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 07/27/2004] [Accepted: 07/29/2004] [Indexed: 11/21/2022]
Abstract
Thymic carcinoids are classified into three categories: (1) nonsecretory tumors, (2) hormonal secretory tumors, and (3) tumors associated with multiple endocrine neoplasia type 1. We report a rare case with adrenocorticotropic hormone secreting thymic carcinoid with multiple endocrine neoplasia type 1. Radiologic examination showed an anterior mediastinal mass and a parathyroid tumor. Blood analysis revealed high levels of parathyroid hormone and adrenocorticotropic hormone. Urine cortisol and 17-hydroxycorticoids levels were also elevated. Extended thymectomy was performed. Subsequently adjuvant radiation therapy and parathyroid tumor resection were performed. A germline mutation of exon 7 in the multiple endocrine neoplasia type 1 gene was detected and a somatic mutation of exon 9 was demonstrated in the thymic tumor.
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Affiliation(s)
- Motoki Yano
- Department of Surgery II, Nagoya City University Medical School, Nagoya, Aichi, Japan.
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44
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Abstract
A 39-year-old woman who presented with typical Cushingoid appearance (moon facies, central obesity, purpura) was admitted to our hospital because of pulmonary infection. She was found to have hypertension, severe hypokalemia, and metabolic alkalosis. Endocrine data revealed elevated plasma levels of ACTH and cortisol with lack of circadian rhythm, non-suppressibility to high-dose dexamethasone, and hyperresponsiveness to CRH stimulation. Although no pituitary mass was detected by MRI of the brain, inferior petrosal sinus sampling showed a step-up of central to peripheral ACTH levels; these data are consistent with the diagnosis of Cushing's disease. She was successfully treated with metyrapone to control hypercortisolemia. Ten months later, a mass was detected in the ethmoid sinus, which was surgically removed. After resection of the ethmoid sinus tumor, her Cushingoid features and hypercortisolemia disappeared, but recurred after enlargement of a second mass in the maxillary sinus. After resection of the maxillary sinus tumor, her hypercortisolemia subsided. Histologically, the tumor tissues from both the ethmoid and maxillary sinus were identical and consistent with the diagnosis of olfactory neuroblastoma. Immunohistochemically, the immunoreactivities of ACTH and POMC were positive in the cytoplasm of tumor cells, and immunoreactive ACTH was demonstrated in both tumor tissues. Thus, this is the second rare case with ectopic ACTH syndrome caused by olfactory neuroblastoma thus far reported.
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Affiliation(s)
- Kazuo Kanno
- Division of Endocrinology and Metabolism, Musashino Red Cross Hospital, Tokyo
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Tsuchiya K, Minami I, Tateno T, Izumiyama H, Doi M, Nemoto T, Mae S, Kasuga T, Osamura RY, Oki Y, Hirata Y. Malignant gastric carcinoid causing ectopic ACTH syndrome: discrepancy of plasma ACTH levels measured by different immunoradiometric assays. Endocr J 2005; 52:743-50. [PMID: 16410667 DOI: 10.1507/endocrj.52.743] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Discrepancy of plasma ACTH levels measured by different immunoradiometric assays (IRMA) in a case with malignant gastric carcinoid causing ectopic ACTH syndrome was examined by gel chromatography and immunohistochemical analysis. A 49-year-old male was found to have a large gastric tumor, with muscle wasting, hypertension, diabetes and hypokalemia caused by hypercortisolemia. His plasma ACTH levels, although initially elevated, were found to be almost in normal ranges. The discrepancy of plasma ACTH levels was proven to be due to different IRMA kits used; the initial assay was performed by a kit that could recognize high-molecular weight (HMW) form as well as ACTH(1-39), but the later assay by another kit that could recognize only ACTH(1-39). Pathological examination of the gastric tumor was consistent with the diagnosis of malignant carcinoid. Immunohistochemical study revealed that immunoreactivity of proopiomelanocortin (POMC) was positive within the tumor cells, whereas those of ACTH and prohormone convertase 1/3 were negative. Molecular sieving analysis of patient's plasma by gel chromatography coupled with ACTH radioimmunoassay which could recognize HMW form and ACTH(1-39) and two different IRMAs revealed that the predominant form of ACTH was HMW form with a minor peak of ACTH(1-39). This is a rare case of ectopic ACTH syndrome caused by malignant gastric carcinoid with preferential production of HMW form of ACTH, possibly due to unprocessed POMC.
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Affiliation(s)
- Kyoichiro Tsuchiya
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, Tokyo
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Abstract
Evaluation of adrenalectomy in patients diagnosed with ectopic ACTH syndrome was studied. Twenty-three clinical cases diagnosed with ectopic ACTH syndrome were analyzed at Chinese Academy of Medical Sciences and Peking Union Medical College Hospital (PUMCH). Cases consisted of 14 males and 9 females, with mean age of 38 years. All 23 cases had positive clinical, biochemical and radiology evidence for diagnosis of Cushing's syndrome. Sixteen of the 23 cases were treated with total adrenalectomy and the remaining 7 were treated without surgical intervention. Sixteen cases, having no identifiable source of ectopic hormone production, experienced resolution of presenting signs and symptoms after undergoing bilateral or unilateral total adrenalectomy; 1-year survival was 67%, 2-year survival 41% and 5-year survival 15%. In patients treated conservatively without surgical intervention, 1-year survival was 0%. In patients with no identifiable source of ectopic hormone production, bilateral adrenalectomy followed by hormone replacement treatment is effective.
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Affiliation(s)
- Hanzhong Li
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
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47
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Liu C, Lo JC, Dowd CF, Wilson CB, Kunwar S, Aron DC, Tyrrell JB. Cavernous and inferior petrosal sinus sampling in the evaluation of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 2004; 61:478-86. [PMID: 15473881 DOI: 10.1111/j.1365-2265.2004.02115.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Central venous sampling (CVS) is used frequently in the evaluation of ACTH-dependent Cushing's syndrome. However, several controversies exist including the diagnostic accuracy, the sampling site of choice (cavernous sinus vs. inferior petrosal sinus) and the use of lateralization data in tumour localization. We have analysed our experience with CVS to address these controversies. DESIGN We retrospectively reviewed CVS data in patients with ACTH-dependent Cushing's syndrome, in whom cavernous sinus sampling (CSS), inferior petrosal sinus sampling (IPSS) and IPSS after administration of ovine corticotrophin releasing hormone (oCRH) were performed. PATIENTS Data on 95 patients were analysed, including 79 patients with suspected Cushing's disease (CD) and 16 patients with suspected ectopic ACTH syndrome (EAS). RESULTS For the differential diagnosis of ACTH-dependent Cushing's syndrome, the diagnostic accuracy of IPSS after oCRH stimulation was 97% compared to 86% for CSS. While no single sampling site was perfect in diagnostic accuracy, sampling both CS and IPS achieved a combined diagnostic accuracy of 100%. Lateralization data predicted tumour location in 62-68% of the patients with various central venous drainage patterns and in 77-80% of the patients with symmetrical drainage. CSS was not significantly superior to IPSS in tumour lateralization. In patients with suspected CD based on CVS and in whom an adenoma was not found on magnetic resonance imaging (MRI) and not located by the surgeon intraoperatively, hemihypophysectomy based on lateralization data was successful in only 10 of the 18 patients (56%) with various central venous drainage patterns and in 5 of 10 patients with symmetrical drainage. CONCLUSION CVS is a powerful method for differentiating CD from the EAS. CSS without oCRH was not superior to IPSS after oCRH stimulation; however, we achieved a 100% diagnostic accuracy if at least two sites were sampled. Tumour localization by CVS did not accurately predict the tumour site at surgery and should not be used to guide surgical resection.
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Affiliation(s)
- Chienying Liu
- Department of Medicine, University of California, San Francisco 94117, USA
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Tzanela M, Karavitaki N, Stylianidou C, Tsagarakis S, Thalassinos NC. Assessment of GH reserve before and after successful treatment of adult patients with Cushing's syndrome. Clin Endocrinol (Oxf) 2004; 60:309-14. [PMID: 15008995 DOI: 10.1046/j.1365-2265.2004.01976.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Several studies have demonstrated impaired GH secretion in patients with active Cushing's syndrome (CS). It has been suggested that persistence of GH deficiency, despite treatment of cortisol excess, may delay the recovery of these patients and therefore temporary treatment with GH may have some benefit. However, the time course of restoration of GH secretion after successful treatment of CS has only been investigated in a limited number of mostly paediatric reports. The aim of the present study was the evaluation of GH reserve in adult patients with CS before and after correction of cortisol excess. DESIGN AND PATIENTS Sixteen patients (12 females, four males) with CS aged 44.7 +/- 5.05 years were recruited. These included seven patients with Cushing's disease, four patients with ectopic ACTH secretion and five patients with adrenal adenoma. All patients were evaluated before any therapeutic intervention. Twelve patients were successfully treated following appropriate surgery and these were further studied. The combined pyridostigmine/GHRH test was used to assess GH reserve in these patients. In a proportion of cases an insulin tolerance test (ITT) was also used. RESULTS Before any therapeutic intervention, an impaired GH response to PD/GHRH was noted in all patients. Restoration of GH response at 6 months was observed in six patients (50%); at 12 months in two; at 18 months in one patient. Two of the patients with no restoration of GH response at 12 months did not accept further investigation. Only one patient did not achieve an adequate GH response even when tested 30 months following cure of CS. Restoration of GH reserve was more commonly observed in those patients in whom there was recovery of the HPA axis. There was a good correlation between peak GH levels to PD + GHRH and ITT. No statistically significant difference was revealed in IGF-I levels between pre- and post-treatment evaluation. CONCLUSIONS Adult patients with active Cushing's syndrome demonstrate a profound suppression of stimulated GH secretion. In the majority of these patients the disruption of GH secretion is normalized within a year after successful treatment of endogenous cortisol excess.
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Affiliation(s)
- Marinella Tzanela
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, 10676 Athens, Greece
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Imaki T, Naruse M, Takano K. Adrenocortical hyperplasia associated with ACTH-dependent Cushing's syndrome: comparison of the size of adrenal glands with clinical and endocrinological data. Endocr J 2004; 51:89-95. [PMID: 15004414 DOI: 10.1507/endocrj.51.89] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Diffuse or nodular hyperplasia of adrenal glands is associated frequently with ACTH-dependent Cushing's syndrome. We carried out a retrospective analysis of 28 patients with ACTH-dependent Cushing's syndrome admitted to our institution between 1984 and 1999 in order to clarify the incidence of adrenal hyperplasia in ACTH-dependent Cushing's syndrome and also to determine the correlation between adrenal gland images and clinical, biochemical and endocrinological data. Of the 28 patients, 16 (57%) showed diffuse adrenal hyperplasia while only 3 had focal adrenal nodules in the hypertrophied adrenals. There was a positive, significant correlation between the width of the adrenal glands measured on CT and circulating plasma ACTH, cortisol levels and urinary free cortisol (UFC) levels. Duration of the disease also correlated positively with adrenal width. No correlation was found between age and adrenal size and there was no difference in the prevalence of diffuse hyperplasia between normotensive and hypertensive patients. These results suggest that chronic ACTH hypersecretion may lead to diffuse adrenal hyperplasia in patients with ACTH-dependent Cushing's syndrome.
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Affiliation(s)
- Toshihiro Imaki
- Department of Medicine, Tokyo Women's Medical University, Kawasaki, Japan
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50
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Abstract
Cushing's disease is most commonly caused by a corticotrope adenoma of the pituitary. Between 50 and 70% of patients with spontaneous hypercortisolism have ACTH-producing pituitary adenomas. The tumors are usually microadenomas with approximately 20% of patients with the disease showing no evidence of tumor on CT-scans or MR imaging of their pituitary glands. In contrast to patients with ectopic ACTH production, plasma ACTH concentrations in patients with spontaneous disease are generally within the normal range. We describe here a patient with a pituitary macroadenoma that showed evidence of necrosis on MRI. The patient had an atypical clinical presentation with plasma ACTH levels considerably higher than that seen in patients with non-ectopic ACTH-secretory syndrome, markedly elevated urine free cortisol, lack of phenotypical signs of hypercortisolism such as wide purplish striae, and whose most prominent and distressing symptom was severe myopathy that resulted in the patient becoming bed-ridden. Psychosis was another striking feature in this patient who during his hospital course developed multiple opportunistic infections that contributed to his demise.
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Affiliation(s)
- Minou Tran
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, UC, Irvine Medical Center, 101 City Drive South, Orange, CA 92868, USA
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