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Desgagnés N, Senior L, Vis D, Alikhani K, Lithgow K. Emergence of De Novo Conditions Following Remission of Cushing Syndrome: A Case Report and Scoping Review. Endocrinol Diabetes Metab 2024; 7:e00476. [PMID: 38597588 PMCID: PMC11005458 DOI: 10.1002/edm2.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVE Onset and exacerbation of autoimmune, inflammatory or steroid-responsive conditions have been reported following the remission of Cushing syndrome, leading to challenges in distinguishing a new condition versus expected symptomatology following remission. We describe a case of a 42-year-old man presenting with new-onset sarcoidosis diagnosed 12 months following the surgical cure of Cushing syndrome and synthesise existing literature reporting on de novo conditions presenting after Cushing syndrome remission. METHODS A scoping review was conducted in Medline, Epub, Ovid and PubMed. Case reports and case series detailing adult patients presenting with new-onset conditions following Cushing syndrome remission were included. RESULTS In total, 1641 articles were screened, 138 full-text studies were assessed for eligibility, and 43 studies were included, of which 84 cases (including our case) were identified. Most patients were female (85.7%), and the median reported age was 39.5 years old (IQR = 13). Thyroid diseases were the most commonly reported conditions (48.8%), followed by sarcoidosis (15.5%). Psoriasis, lymphocytic hypophysitis, idiopathic intracranial hypertension, multiple sclerosis, rheumatoid arthritis, lupus and seronegative arthritis were reported in more than one case. The median duration between Cushing remission and de novo condition diagnosis was 4.1 months (IQR = 3.75). Of those patients, 59.5% were receiving corticosteroid therapy at the time of onset. CONCLUSION Our scoping review identified several cases of de novo conditions emerging following the remission of Cushing syndrome. They occurred mostly in women and within the year following remission. Clinicians should remain aware that new symptoms, particularly in the first year following the treatment of Cushing syndrome, may be manifestations of a wide range of conditions aside from adrenal insufficiency or glucocorticoid withdrawal syndrome.
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Affiliation(s)
| | - Laura Senior
- Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Daniel Vis
- Division of Respirology, Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Katayoun Alikhani
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada
| | - Kirstie Lithgow
- Division of Endocrinology, Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
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Izawa M, Takeda T, Anno T, Iwasawa T, Yasumizu Y, Tanaka N, Matsumoto K, Morita S, Kosaka T, Mizuno R, Asanuma H, Oya M. Risk factors for postoperative fever after laparoscopic adrenalectomy focusing on hormones produced: a case control study. BMC Urol 2024; 24:90. [PMID: 38637748 PMCID: PMC11025189 DOI: 10.1186/s12894-024-01469-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Laparoscopic adrenalectomy is widely performed for a number of hormone-producing tumors and postoperative management depends on the hormones produced. In the present study, we conducted a retrospective analysis to clarify the risk factors for postoperative complications, particularly postoperative fever after laparoscopic adrenalectomy. METHODS We analyzed 406 patients who underwent laparoscopic adrenalectomy at our hospital between 2003 and 2019. Postoperative fever was defined as a fever of 38 °C or higher within 72 h after surgery. We investigated the risk factors for postoperative fever after laparoscopic adrenalectomy. RESULTS There were 188 males (46%) and 218 females (54%) with a median age of 52 years. Among these patients, tumor pathologies included 188 primary aldosteronism (46%), 75 Cushing syndrome (18%), and 80 pheochromocytoma (20%). Postoperative fever developed in 124 of all patients (31%), 30% of those with primary aldosteronism, 53% of those with pheochromocytoma, and 8% of those with Cushing syndrome. A multivariate logistic regression analysis identified pheochromocytoma and non-Cushing syndrome as independent predictors of postoperative fever. Postoperative fever was observed in 42 out of 80 cases of pheochromocytoma (53%), which was significantly higher than in cases of non-pheochromocytoma (82/326, 25%, p < 0.01). In contrast, postoperative fever developed in 6 out of 75 cases of Cushing syndrome (8%), which was significantly lower than in cases of non-Cushing syndrome (118/331, 35.6%, p < 0.01). CONCLUSION Since postoperative fever after laparoscopic adrenalectomy is markedly affected by the hormone produced by pheochromocytoma and Cushing syndrome, it is important to carefully consider the need for treatment.
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Affiliation(s)
- Mizuki Izawa
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Toshikazu Takeda
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Tadatsugu Anno
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Tomohiro Iwasawa
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yota Yasumizu
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Nobuyuki Tanaka
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Kazuhiro Matsumoto
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Shinya Morita
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Takeo Kosaka
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Ryuichi Mizuno
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Hiroshi Asanuma
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
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Zhang CD, Ioachimescu AG. Challenges in the postsurgical recovery of cushing syndrome: glucocorticoid withdrawal syndrome. Front Endocrinol (Lausanne) 2024; 15:1353543. [PMID: 38681763 PMCID: PMC11045978 DOI: 10.3389/fendo.2024.1353543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/29/2024] [Indexed: 05/01/2024] Open
Abstract
Glucocorticoid withdrawal syndrome is a challenging clinical phenomenon that can complicate the postsurgical recovery of Cushing syndrome. It is characterized by physical tolerance and dependence to supraphysiologic glucocorticoid exposure during active Cushing syndrome followed by the abrupt decline in cortisol levels after surgical treatment. The symptoms of glucocorticoid withdrawal often overlap with those of postoperative adrenal insufficiency and can be difficult for patients to cope with and for clinicians to treat. This mini review will discuss the clinical characteristics, pathophysiology, and management of glucocorticoid withdrawal syndrome while highlighting recent data in the field.
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Affiliation(s)
- Catherine D. Zhang
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Adriana G. Ioachimescu
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
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Tizianel I, Detomas M, Deutschbein T, Fassnacht M, Albiger N, Iacobone M, Scaroni C, Ceccato F. Corticotropin-releasing hormone test predicts the outcome of unilateral adrenalectomy in primary bilateral macronodular adrenal hyperplasia. J Endocrinol Invest 2024; 47:749-756. [PMID: 37796369 PMCID: PMC10904413 DOI: 10.1007/s40618-023-02204-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/17/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Primary bilateral adrenal hyperplasia (PBMAH) is associated with hypercortisolism and a heterogeneous clinical expression in terms of cortisol secretion and related comorbidities. Historically, treatment of choice was bilateral adrenalectomy (B-Adx); however, recent data suggest that unilateral adrenalectomy (U-Adx) may be an effective alternative. For the latter, factors predicting the postsurgical outcome (e.g., biochemical control) have not been identified yet. METHODS PBMAH patients undergoing U-Adx for overt Cushing's syndrome (CS) in two tertiary care centers were retrospectively analysed. Remission was defined as a normalization of urinary free cortisol (UFC) without the need for medical treatment. The potential of hCRH test as a predictor of U-Adx outcome was evaluated in a subgroup. RESULTS 23 patients were evaluated (69% females, mean age 55 years). Remission rate after U-Adx was 74% at last follow up (median 115 months from UAdx). Before U-Adx, a positive ACTH response to hCRH (Δ%ACTH increase > 50% from baseline) was associated with higher remission rates. CONCLUSIONS Three of four patients with PBMAH are surgically cured with U-Adx. Pre-operative hCRH testing can be useful to predict long-term remission rates.
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Affiliation(s)
- I Tizianel
- Endocrine Unit, Department of Medicine DIMED, Padua, Italy
- Endocrine Unit, University-Hospital of Padova, Padua, Italy
| | - M Detomas
- University Hospital, University of Würzburg, Würzburg, Germany, Department of Internal Medicine I, Division of Endocrinology and Diabetes, Würzburg, Germany
| | - T Deutschbein
- University Hospital, University of Würzburg, Würzburg, Germany, Department of Internal Medicine I, Division of Endocrinology and Diabetes, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - M Fassnacht
- University Hospital, University of Würzburg, Würzburg, Germany, Department of Internal Medicine I, Division of Endocrinology and Diabetes, Würzburg, Germany
| | - N Albiger
- Radiotherapy Unit, Istituto Oncologico Veneto, Endocrinology, ULSS6, Padua, Euganea, Italy
| | - M Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - C Scaroni
- Endocrine Unit, Department of Medicine DIMED, Padua, Italy
- Endocrine Unit, University-Hospital of Padova, Padua, Italy
| | - F Ceccato
- Endocrine Unit, Department of Medicine DIMED, Padua, Italy.
- Endocrine Unit, University-Hospital of Padova, Padua, Italy.
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Hacioglu A, Firat ST, Caglar AS, Karaca Z, Kalay N, Taheri S, Tanriverdi F, Selcuklu A, Unluhizarci K, Kelestimur F. Cardiovascular evaluation and endothelial dysfunction in Cushing syndrome following remission: a prospective study. J Endocrinol Invest 2024; 47:645-653. [PMID: 37648907 DOI: 10.1007/s40618-023-02183-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Cushing syndrome (CS) is a well-known risk factor for cardiovascular morbidities. We aimed to evaluate endothelial and cardiovascular functions, endothelial mediators and pro-inflammatory cytokines in patients with CS before and after remission. METHODS Adult patients with newly diagnosed endogenous CS were included. Metabolic [body mass index (BMI), glucose, and lipid values] and cardiovascular evaluation studies [24-h ambulatory blood pressure monitoring, carotid intima-media thickness (CIMT), flow-mediated dilation (FMD), and echocardiography] were performed, and endothelial mediators [asymmetric dimethyl arginine (ADMA) and endothelin-1 (ET-1)] and pro-inflammatory cytokines [interleukin-1β (IL-1β) and tumor necrosis factor-alpha (TNF-α)] were measured. Control group was matched in terms of age, gender, and BMIs. RESULTS Twenty-five patients, mean age 40.60 ± 14.04 years, completed the study. Compared to controls (n = 20) mean arterial pressure (MAP) and CIMT were higher (p < 0.005 and p = 0.012, respectively), and FMD (p < 0.001) and mitral E/A ratio (p = 0.007) lower in the patients during active disease. Baseline serum ADMA, ET-1, and IL-1β were similar between the groups, while TNF-α was lower in the patients (p = 0.030). All patients were in complete remission 1 year following surgery. BMI, LDL cholesterol, serum total cholesterol, fasting plasma glucose, MAPs, and CIMT significantly decreased (p < 0.005), while there was no improvement in FMD (p = 0.11) following remission. There was no significant change in ADMA, IL-1β, and TNF-α levels, but ET-1 increased (p = 0.011). CONCLUSIONS Remission in CS improves some cardiovascular parameters. ADMA and ET-1 are not reliable markers for endothelial dysfunction in CS. Metabolic improvements may not directly reflect on serum concentrations of TNF-α and IL-1β following remission of CS.
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Affiliation(s)
- A Hacioglu
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - S T Firat
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - A S Caglar
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - Z Karaca
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey.
| | - N Kalay
- Department of Cardiology, Erciyes University Medical School, Kayseri, Turkey
| | - S Taheri
- Department of Medical Biology, Erciyes University Medical School, Kayseri, Turkey
| | - F Tanriverdi
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - A Selcuklu
- Department of Neurosurgery, Erciyes University Medical School, Kayseri, Turkey
| | - K Unluhizarci
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - F Kelestimur
- Faculty of Medicine, Department of Endocrinology, Yeditepe University, Istanbul, Turkey
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Cai Y, Zhao X, Ren L, Liu S, Liu X, Gang X, Wang G. Clinical features and risk factors for postoperative recurrence in patients with Cushing's syndrome of different etiologies. Sci Rep 2024; 14:4666. [PMID: 38409302 PMCID: PMC10897300 DOI: 10.1038/s41598-024-53913-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/06/2024] [Indexed: 02/28/2024] Open
Abstract
The clinical characteristics of Cushing's syndrome (CS) vary with etiology, and few studies have investigated the risk factors affecting CS recurrence after surgery. This retrospective study involved 202 patients diagnosed with CS between December 2012 and December 2022. The patients were divided into three groups according to etiology: Cushing's disease (CD), adrenocortical adenoma (ACA), and ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS). Of the patients with CS, 41.9% had hypokalemia and 15.0% had hypophosphatemia. The cortisol levels were negatively correlated with blood potassium, blood chlorine, and blood phosphorus. Moreover, 22.4% of patients had an abnormal heart structure, 11.2% had centripetal remodeling, 5.6% had centripetal hypertrophy, and 5.6% had centrifugal hypertrophy. The overall recurrence rate of CS caused by pituitary tumors and adrenal adenoma was 25.7%. The recurrence times were longer in the ACA group versus the CD group, in patients < 50 years of age versus in patients ≥ 50 years old group, and in patients with CD with tumors ≥ 1 cm versus tumors < 1 cm. Age, preoperative cortisol level, postoperative cortisol level, and absolute neutrophil value were closely related to postoperative recurrence, and etiology was an independent predictor of tumor recurrence in patients with CS. The results of this study showed that CS caused by different etiologies showed different clinical manifestations, blood electrolyte characteristics, and that CS could affect patient cardiac structure and function. Etiology is an independent predictor of tumor recurrence in patients with CS.
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Affiliation(s)
- Yunjia Cai
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Xue Zhao
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Linan Ren
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Siyuan Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Xinming Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China.
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, 71 Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, People's Republic of China.
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Isand K, Feelders R, Brue T, Toth M, Deutschbein T, Reincke M, Kršek M, Santos A, Demtröder F, Chabre O, Strasburger CJ, Aulinas Maso A, Volke V, Pereira AM, Lohmann R, Gich Saladich I, Webb SM, Wass J, Valassi E. High prevalence of venous thrombotic events in Cushing's syndrome: data from ERCUSYN and details in relation to surgery. Eur J Endocrinol 2024; 190:75-85. [PMID: 38146835 DOI: 10.1093/ejendo/lvad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the prevalence of venous thromboembolism (VTE) in patients included in the European Registry on Cushing's syndrome (ERCUSYN), compare their clinical characteristics with those who did not develop VTE and identify risk factors for VTE. DESIGN A retrospective observational cohort study. METHODS Data extraction from the registry was taken on February, 7, 2022. At the time there were 2174 patients diagnosed with Cushing's syndrome (CS) and 95 VTEs were reported in the database. RESULTS Of 95 VTE events 70 (74%) were in pituitary-dependent CS patients, 12 (12.5%) in adrenal-dependant CS, 10 (10.5%) in ectopic CS, and 3 (3%) in CS due to other causes. Sex, 24-hour urinary free cortisol (UFC) value at diagnosis, as well as the number of operations remained statistically significant predictors of VTE. Of patients who were treated with at least one surgery, 12 (13%) VTE occurred before and 80 (87%) after the surgery. Nearly half of these VTEs occurred within six months since the operation (36; 45%). Over half of the centers that reported VTE did not routinely anticoagulate CS patients. Anticoagulation schemes varied widely. CONCLUSION Patients with CS have an elevated risk of developing VTE for an extended period of time. From ERCUSYN cohort patients have higher risk for VTE if they need multiple surgeries to treat CS, are males and have high UFC values at the diagnosis of CS. Since there is no agreement on thromboprohpylaxis, a protocol for VTE prevention that is widely adopted appears to be necessary for patients with CS.
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Affiliation(s)
- Kristina Isand
- Institute of Biomedicine and Translational Medicine, University of Tartu, Ülikooli 18, 50090, Tartu, Estonia
| | - Richard Feelders
- Department of Internal Medicine, Section of Endocrinology, ENETS Center of Excellence, Erasmus MC and Erasmus Cancer Institute, 3015 Rotterdam, The Netherlands
| | - Thierry Brue
- Aix Marseille Univ, APHM, INSERM, MMG, Department of Endocrinology Hospital La Conception, MarMaRa Institute, 13305 Marseille, France
| | - Miklos Toth
- Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - Michal Kršek
- Third Department of Internal Medicine, First Faculty of Medicine, Charles University, General University Hospital, 12808 Prague, Czech Republic
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
| | - Frank Demtröder
- Zentrum für Endokrinologie, Diabetologie, Rheumatologie Dr. Demtröder & Kollegen, 44137 Dortmund, Germany
| | - Olivier Chabre
- University Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie CHU Grenoble Alpes, F-38000 Grenoble, France
| | | | - Anna Aulinas Maso
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
| | - Vallo Volke
- Institute of Biomedicine and Translational Medicine, University of Tartu, Ülikooli 18, 50090, Tartu, Estonia
| | - Alberto M Pereira
- Department of Endocrinology & Metabolism, Amsterdam University Medical Center, and University of Amsterdam, 1081 Amsterdam, Netherlands
| | - Rüdiger Lohmann
- Health Care Consulting GmbH, Lohmann & Birkner Health Care Consulting GmbH, 13407 Berlin, Germany
| | - Ignasi Gich Saladich
- Department of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain
| | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
| | - John Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals, OX37LE Oxford, United Kingdom
| | - Elena Valassi
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
- Endocrinology and Nutrition Department, Germans Trias i Pujol Hospital and Research Institute, Badalona 08916, Spain
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Alesina PF, Kniazeva P, Pinto G, Pontin A, Walz MK. Long-term outcome of retroperitoneoscopic partial versus total adrenalectomy in patients with Cushing's syndrome. World J Surg 2024; 48:121-129. [PMID: 38651548 DOI: 10.1002/wjs.12023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND We analyze the long-term outcome of surgery for Cushing's syndrome (CS) and the influence of the extent of surgical resection on the duration of postoperative cortisone substitution. METHODS One-hundred forty-one patients (129 female, 12 males; mean age: 45.7 ± 12.8 years) operated between January 2000 to June 2020 were included in the analysis. Patients suffered from manifest (124) or subclinical (17) CS due to benign unilateral adrenal neoplasia. All tumors were removed by the posterior retroperitoneoscopic approach. 105 patients had total (TA) and 36 partial (PA) adrenalectomies. All patients were discharged with ongoing corticosteroid supplementation therapy. RESULTS Follow-up data could be obtained for 83 patients. Twenty-four (1 male, 23 females; mean age 42.3 years) underwent PA and 59 TA (6 males, 53 females; mean age 44.6 years). Mean follow-up time was 107 ± 68 months (range: 6-243 months). The median duration of postoperative corticosteroid therapy was 9.5 months after PA and 11 months after TA (p = 0.1). Significantly, more patients after total adrenalectomy required corticosteroid therapy for more than 24 months (25% vs. 4%; p = 0.03). Recurrent ipsilateral disease occurred in one case after partial adrenalectomy and was treated by completion adrenalectomy. A case of contralateral recurrence associated with subclinical Cushing's syndrome was observed after total adrenalectomy. CONCLUSIONS The risk of local recurrence after partial adrenalectomy in CS is low. Cortical-sparing surgery may shorten corticosteroid supplementation therapy after surgery.
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Affiliation(s)
- P F Alesina
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - P Kniazeva
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - G Pinto
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - A Pontin
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - M K Walz
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
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9
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McCormick BP, Sequeira SB, Hasenauer MD, McKinstry RP, Boucher HR. Cushing's Syndrome Is Associated With Early Medical- and Surgical-Related Complications Following Total Joint Arthroplasty: A National Database Study. J Arthroplasty 2023; 38:2568-2572. [PMID: 37315630 DOI: 10.1016/j.arth.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Cushing's syndrome (CS) is a disorder characterized by exposure to supraphysiologic levels of glucocorticoids. The purpose of this study was to evaluate the association between CS and postoperative complication rates following total joint arthroplasty (TJA). METHODS Patients diagnosed with CS undergoing TJA for degenerative etiologies were identified from a large national database and matched 1:5 to a control cohort using propensity scoring. Propensity score matching resulted in 1,059 total hip arthroplasty (THA) patients with CS matched to 5,295 control THA patients and 1,561 total knee arthroplasty (TKA) patients with CS matched to 7,805 control TKA patients. Rates of medical complications occurring within 90 days of TJA and surgical-related complications occurring within 1 year of TJA were compared using odds ratios (ORs). RESULTS The THA patients with CS had higher incidences of pulmonary embolism (OR 2.21, P = .0026), urinary tract infection (UTI) (OR 1.29, P = .0417), pneumonia (OR 1.58, P = .0071), sepsis (OR 1.89, P = .0134), periprosthetic joint infection (OR 1.45, P = .0109), and all-cause revision surgery (OR 1.54, P = .0036). The TKA patients with CS had significantly higher incidences of UTI (OR 1.34, P = .0044), pneumonia (OR 1.62, P = .0042), and dislocation (OR 2.43, P = .0049) and a lower incidence of manipulation under anesthesia (MUA) (OR 0.63, P = .0027). CONCLUSION CS is associated with early medical- and surgical-related complications following TJA and a reduced incidence of MUA following TKA.
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Affiliation(s)
- Brian P McCormick
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Sean B Sequeira
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Mark D Hasenauer
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Robert P McKinstry
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Henry R Boucher
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
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10
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Pennestrì F, De Crea C, Voloudakis N, Raffaelli M. Laparoscopic transabdominal anterior bilateral adrenalectomy (La-TABA): an alternative approach for severe Cushing's syndrome. Updates Surg 2023; 75:2403-2411. [PMID: 37864624 DOI: 10.1007/s13304-023-01653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/23/2023] [Indexed: 10/23/2023]
Abstract
Severe uncontrolled Cushing's syndrome (CS) is an acute life-threatening condition. As it is often not responsive to medical therapy, emergency bilateral adrenalectomy (BA) may present the only therapeutic option. Moreover, multiple bone fractures, representing one of the clinical consequences of hypercortisolism, may not permit both prone and lateral patient's positioning during surgery, thus making minimally invasive approaches nonfeasible. We report our preliminary experience with an alternative approach in this selected patients' category. Among 613 patients who underwent endoscopic adrenalectomy at our centre (34-5.6% BA) between January 1997 and October 2021, 3 patients were scheduled for laparoscopic transabdominal anterior bilateral adrenalectomy (La-TABA). Surgery was performed with patient in supine position, with fastened arms and legs to allow Trendelenburg and anti-Trendelenburg movements and lateral rotations. The procedure consisted in a synchronous bilateral adrenalectomy. A modern multi-articulated operative table provided rotations on the right and left side to perform left and right adrenalectomy, respectively. One male and two female patients with a mean age of 34 ± 3.1 years underwent La-TABA. Mean operative time was 200 ± 138.3 min. No perioperative complications were registered. Mean postoperative hospital stay was 8 ± 4.4 days. In very severe ACTH-dependent CS, BA should be performed as soon as possible. La-TABA may represent the most appropriate therapeutic option, as this patients' category is not able to tolerate prone and lateral positioning required during the conventional surgery. Despite the higher technical complexity of the procedure compared with the other endoscopic approaches to adrenalectomy, it retains the benefits of minimally invasive surgery in terms of postoperative complications and recovery.
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Affiliation(s)
- Francesco Pennestrì
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmela De Crea
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Nikolaos Voloudakis
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Raffaelli
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Vetrivel S, Tamburello M, Oßwald A, Zhang R, Khan A, Jung S, Baker JE, Rainey WE, Nowak E, Altieri B, Detomas M, Watts D, Williams TA, Wielockx B, Beuschlein F, Reincke M, Sbiera S, Riester A. PPARG dysregulation as a potential molecular target in adrenal Cushing's syndrome. Front Endocrinol (Lausanne) 2023; 14:1265794. [PMID: 38098864 PMCID: PMC10720662 DOI: 10.3389/fendo.2023.1265794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/07/2023] [Indexed: 12/17/2023] Open
Abstract
Background We performed a transcriptomic analysis of adrenal signaling pathways in various forms of endogenous Cushing's syndrome (CS) to define areas of dysregulated and druggable targets. Methodology Next-generation sequencing was performed on adrenal samples of patients with primary bilateral macronodular adrenal hyperplasia (PBMAH, n=10) and control adrenal samples (n=8). The validation groups included cortisol-producing adenoma (CPA, n=9) and samples from patients undergoing bilateral adrenalectomy for Cushing's disease (BADX-CD, n=8). In vivo findings were further characterized using three adrenocortical cell-lines (NCI-H295R, CU-ACC2, MUC1). Results Pathway mapping based on significant expression patterns identified PPARG (peroxisome proliferator-activated receptor gamma) pathway as the top hit. Quantitative PCR (QPCR) confirmed that PPARG (l2fc<-1.5) and related genes - FABP4 (l2fc<-5.5), PLIN1 (l2fc<-4.1) and ADIPOQ (l2fc<-3.3) - were significantly downregulated (p<0.005) in PBMAH. Significant downregulation of PPARG was also found in BADX-CD (l2fc<-1.9, p<0.0001) and CPA (l2fc<-1.4, p<0.0001). In vitro studies demonstrated that the PPARG activator rosiglitazone resulted in decreased cell viability in MUC1 and NCI-H295R (p<0.0001). There was also a significant reduction in the production of aldosterone, cortisol, and cortisone in NCI-H295R and in Dihydrotestosterone (DHT) in MUC1 (p<0.05), respectively. Outcome This therapeutic effect was independent of the actions of ACTH, postulating a promising application of PPARG activation in endogenous hypercortisolism.
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Affiliation(s)
- Sharmilee Vetrivel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Mariangela Tamburello
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Section of Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Andrea Oßwald
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ru Zhang
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ali Khan
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Sara Jung
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Jessica E. Baker
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - William E. Rainey
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Elisabeth Nowak
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Mario Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Deepika Watts
- Institute of Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden (TUD)/Universitätsklinikum Carl Gustav Carus Dresden (UKD), Dresden, Germany
| | - Tracy Ann Williams
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ben Wielockx
- Institute of Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden (TUD)/Universitätsklinikum Carl Gustav Carus Dresden (UKD), Dresden, Germany
| | - Felix Beuschlein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Martin Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Silviu Sbiera
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Anna Riester
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
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12
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Yan ZC, Jiang N, Zhang HX, Zhou Q, Liu XL, Sun F, Yang RM, He HB, Zhao ZG, Zhu ZM. [Efficacy and feasibility of catheter-based adrenal ablation on Cushing's syndrome associated hypertension]. Zhonghua Xin Xue Guan Bing Za Zhi 2023; 51:1152-1159. [PMID: 37963750 DOI: 10.3760/cma.j.cn112148-20230801-00045] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Objective: To explore the value of catheter-based adrenal ablation in treating Cushing's syndrome (CS)-associated hypertension. Methods: A clinical study was conducted in patients with CS, who received catheter-based adrenal ablation between March 2018 and July 2023 in Daping Hospital. Parameters monitored were blood pressure (outpatient and 24-hour ambulatory), body weight, clinical characteristics, serum cortisol and adrenocorticotropic hormone (ACTH) at 8 am, 24-hour urinary free cortisol (24 h UFC), fasting blood glucose and postoperative complications. Procedure effectiveness was defined as blood pressure returning to normal levels (systolic blood pressure<140 mmHg (1 mmHg=0.133 kPa) and diastolic blood pressure<90 mmHg), cortisol and 24 h UFC returning to normal and improvement of clinical characteristics. The parameters were monitored during follow up in the outpatient department at 1, 3, 6, and 12 months after catheter-based adrenal ablation. Results: A total of 12 patients (aged (40.0±13.2) years) were reviewed. There were 5 males, with 5 cases of adenoma and 7 with hyperplasia from imaging studies. Catheter-based adrenal ablation was successful in all without interruption or surgical conversion. No postoperative complication including bleeding, puncture site infection, adrenal artery rupture or adrenal bleeding was observed. The mean follow up was 28 months. Compared to baseline values, body weight declined to (59.48±11.65) kg from (64.81±10.75) kg (P=0.008), fasting blood glucose declined to (4.54±0.83) mmol from (5.53±0.99) mmol (P=0.044), outpatient systolic blood pressure declined to (128±21) mmHg from (140±19) mmHg (P=0.005), diastolic blood pressure declined to (78±10) mmHg from (86±11) mmHg (P=0.041), and the mean ambulatory daytime diastolic blood pressure declined to (79±12) mmHg from (89±8) mmHg (P=0.034). Catheter-based adrenal ablation in 8 patients was defined as effective with their 24 h UFC significantly reduced after the procedure (1 338.41±448.06) mmol/L from (633.66±315.94) mmol/L, P=0.011). The change of 24 h UFC between the effective treatment group and ineffective group was statistically significant (P=0.020). The postoperative systolic blood pressure in the treated adenoma group was significantly lower than those of hyperplasia group (112±13) mmHg vs. (139±20) mmHg, P=0.026). Conclusions: For patients with CS-associated hypertension who are unwilling or unable to undergo surgical treatment, catheter-based adrenal ablation could improve the blood pressure and cortisol level. Catheter-based adrenal ablation could be a safe, effective, and minimally invasive therapy. However, our results still need to be validated in further large-scale studies.
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Affiliation(s)
- Z C Yan
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - N Jiang
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - H X Zhang
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Q Zhou
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - X L Liu
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - F Sun
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - R M Yang
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - H B He
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Z G Zhao
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Z M Zhu
- Department of Hypertension and Endocrinology, Center for Hypertension and Cardiometabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
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13
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Gao RR, Chilukuri N, Rokhlin P, Shebrain S. Thirty day postoperative outcomes following laparoscopic adrenalectomy for functional adrenal tumors. Surg Endosc 2023; 37:7893-7900. [PMID: 37415017 DOI: 10.1007/s00464-023-10255-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Functional adrenal tumors (FATs) are rare and if left untreated, there is a substantial risk of morbidity and mortality due to uncontrolled excess hormone secretion. The three most common FATs are cortisone-producing tumors (hypercortisolism), aldosterone-producing tumors (hyperaldosteronism), and catecholamines-producing tumors (pheochromocytomas). The study aims to evaluate demographic characteristics and 30-day outcomes after laparoscopic adrenalectomy of FATs. METHODS Patients who underwent laparoscopic adrenalectomy for FATs were selected from the ACS-NSQIP database (2015-2017), and divided into three groups (hyperaldosteronism, hypercortisolism, and pheochromocytoma). Preoperative demographics, medical comorbidities, and 30-day postoperative outcomes among the three groups were analyzed using the chi-squared test, analysis of variance (ANOVA) and Kruskal-Wallis one-way analysis of variance. Multivariable logistic regression was performed to assess the effects independent variables on the likelihood of increased overall morbidity. RESULTS Of a total of 2410 patients who underwent laparoscopic adrenalectomy, 345 (14.3%) patients with FATs were included. Patients in the hypercortisolism group were younger, had higher proportion of females, had higher BMI, had a higher proportion of White ethnicity and had a higher proportion of diabetes. The hyperaldosteronism group had a higher proportion of Black ethnicity and a higher proportion of hypertension (HTN) requiring medication. Thirty day postoperative outcomes showed that the pheochromocytoma group had a higher rate of serious morbidity, overall morbidity, and highest readmission rates. There were three deaths, 1 in the pheochromocytoma and 2 in the hypercortisolism groups. Operative time (in minutes) was longer in the hypercortisolism group. Median length of stay was higher in hypercortisolism (2 days) and pheochromocytoma (1.5 day) groups. CONCLUSION Functional adrenal tumors show distinct variations in patient demographics and postoperative outcomes. It is essential to use this information during the preoperative period to optimize patients prior to intervention and counsel patients about potential postoperative outcomes.
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Affiliation(s)
- Raisa R Gao
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA.
| | - Nitin Chilukuri
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA
| | - Pnina Rokhlin
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA
| | - Saad Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA
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14
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Birtolo MF, Grossrubatscher EM, Antonini S, Loli P, Mazziotti G, Lania AG, Chiodini I. Preoperative management of patients with ectopic Cushing's syndrome caused by ACTH-secreting pheochromocytoma: a case series and review of the literature. J Endocrinol Invest 2023; 46:1983-1994. [PMID: 37195583 DOI: 10.1007/s40618-023-02105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE ACTH-secreting pheochromocytoma is a rare cause of ectopic Cushing's syndrome, posing a clinical challenge for the severity of its clinical presentation, the difficulty in the prevention and the management of surgical complications. Sparse data are currently available about the optimal preoperative management of the severe symptoms due to both hypercortisolism and catecholamine excess, especially regarding the role and timing of medical therapies. METHODS We present a series of three patients with ACTH-secreting pheochromocytoma. A brief review of the available literature evidence on the preoperative management of this rare clinical condition is also conducted. DISCUSSION Patients with ACTH-secreting pheochromocytoma show peculiarities as compared to other forms of ACTH-dependent Cushing's syndrome, in terms of clinical presentation, preoperative management, and peri- and post-surgical short-term outcome. Pheochromocytoma should be ruled out in patient with ectopic CS of unknown origin because of the high anesthesiologic risk of proceeding to surgery with an undiagnosed pheochromocytoma. Proper preoperative recognition of complications of both hypercortisolism and catecholamines excess is the key to prevent the morbidity and mortality of an ACTH-producing pheochromocytoma. In these patients the absolute priority is to control excessive cortisol secretion since the rapid correction of the hypercortisolism is the most effective treatment of all the related comorbidities and it is mandatory to prevent severe complications during surgery, opting if necessary for a "block-and-replace" regimen. CONCLUSION Our additional cases and this literature review could provide a better understanding of the complications to be evaluated at diagnosis and some suggestions on their management during the preoperative period.
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Affiliation(s)
- M F Birtolo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy
| | - E M Grossrubatscher
- Endocrine Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - S Antonini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy
| | - P Loli
- Endocrinology, Clinica San Carlo, Via Ospedale 21, 20037 Paderno Dugnano, Milan, Italy
| | - G Mazziotti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy
| | - A G Lania
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy.
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy.
| | - I Chiodini
- Endocrine Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20122, Milan, Italy
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15
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Utsumi T, Iijima S, Sugizaki Y, Mori T, Somoto T, Kato S, Oka R, Endo T, Kamiya N, Suzuki H. Laparoscopic adrenalectomy for adrenal tumors with endocrine activity: Perioperative management pathways for reduced complications and improved outcomes. Int J Urol 2023; 30:818-826. [PMID: 37376729 DOI: 10.1111/iju.15218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/15/2023] [Indexed: 06/29/2023]
Abstract
The major adrenal tumors with endocrine activity are primary aldosteronism, Cushing's syndrome/mild autonomous cortisol secretion, and pheochromocytoma/paraganglioma. Excessive aldosterone secretion in primary aldosteronism causes cardiovascular, renal, and other organ damage in addition to hypertension and hypokalemia. Cortisol hypersecretion in Cushing's syndrome/mild autonomous cortisol secretion causes obesity, hypertension, impaired glucose tolerance, and cardiometabolic syndrome. Massive secretion of catecholamines in pheochromocytoma/paraganglioma causes hypertension and cerebrocardiovascular disease due to rapid blood pressure fluctuation. Moreover, pheochromocytoma multi-system crisis is a feared and possibly fatal presentation of pheochromocytoma/paraganglioma. Thus, adrenal tumors with endocrine activity are considered an indication for adrenalectomy, and perioperative management is very important. They have a risk of perioperative complications, either due to direct hemodynamic effects of the hormone hypersecretion or due to hormone-related comorbidities. In the last decades, deliberate preoperative evaluation and advanced perioperative management have significantly reduced complications and improved outcomes. Furthermore, improvements in anesthesia and surgical techniques with the feasibility of laparoscopic adrenalectomy have contributed to reduced morbidity and mortality. However, there are still several challenges to be considered in the perioperative care of these patients. There are very few data available prospectively to guide clinical management, due to the rarity of adrenal tumors with endocrine activity. Therefore, most guidelines are based on retrospective data analyses or small case series. In this review, the latest knowledge is summarized, and practical pathways to reduce perioperative complications and improve outcomes in adrenal tumors with endocrine activity are presented.
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Affiliation(s)
- Takanobu Utsumi
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Shota Iijima
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Yuka Sugizaki
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Takamichi Mori
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Takatoshi Somoto
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Seiji Kato
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Ryo Oka
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Takumi Endo
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Naoto Kamiya
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Hiroyoshi Suzuki
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
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16
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Tan L, Zhao L, Tang G, Ren Y, Tian H, Chen T. Unexpected exacerbation of cryptococcal meningitis after unilateral adrenalectomy in a PMAH patient: a case report and literature review. BMC Endocr Disord 2023; 23:199. [PMID: 37723545 PMCID: PMC10506208 DOI: 10.1186/s12902-023-01457-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 09/13/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Primary bilateral macronodular adrenal hyperplasia (PMAH) combined with infection by an opportunistic pathogen is complicated. Clinical evidence on managing PMAH patients with infections by opportunistic pathogens is insufficient. CASE PRESENTATION A 66-year-old male was admitted with bilateral adrenal masses and was diagnosed with PMAH. Fever and disturbance of consciousness appeared after laparoscopic left adrenalectomy. Cryptococcal meningitis was confirmed by cerebrospinal fluid (CSF) culture. The exacerbation of his medical condition was suspected to result from immune reconstitution inflammatory syndrome (IRIS), and he had been treated with antifungal therapy and glucocorticoid replacement, but he responded poorly and eventually died of multiorgan failure. We summarized the clinical observations of 12 Cushing's syndrome (CS) patients infected by Cryptococcus. Seven out of nine patients who were treated for cryptococcus infection before receiving CS survived, while three patients treated for cryptococcus infection after CS treatment developed signs of IRIS and eventually died. CONCLUSION Cushing's syndrome, complicated with cryptococcal infection, has a high mortality rate, mainly when IRIS emerges. Carefully identifying the presence of the suspected infection, and controlling cryptococcal infection before removing the culprit adrenals could be the rational choice.
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Affiliation(s)
- Lu Tan
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Lianling Zhao
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Guangmin Tang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, P. R. China
| | - Yan Ren
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Tao Chen
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China.
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17
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Mohammedi K, Bertherat J, Raverot G, Drui D, Reznik Y, Castinetti F, Chanson P, Fafin M, Brossaud J, Tabarin A. Evidence of Persistent Mild Hypercortisolism in Patients Medically Treated for Cushing Disease: the Haircush Study. J Clin Endocrinol Metab 2023; 108:e963-e970. [PMID: 37144820 DOI: 10.1210/clinem/dgad251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/28/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/06/2023]
Abstract
CONTEXT Cortisol-lowering drugs may not restore a normal cortisol secretion in Cushing disease (CD). OBJECTIVE This work aimed to assess the long-term cortisol exposure in medically treated CD patients using hair-cortisol (HF) and hair-cortisone (HE) measurement. METHODS This multicenter prospective study included 3 groups of female patients: CushMed = 16 treated with a stable cortisol-lowering drug dosage and normal urinary free cortisol (UFC); CushSurg = 13 cured by pituitary surgery; CushBla = 15 receiving stable recommended doses of hydrocortisone following bilateral adrenalectomy. Patients were evaluated for 3 months with their usual treatments. Two late-night saliva and 24-hour urine samples were collected monthly in CushMed, and at study end in CushSurg and CushBla patients. A 3-cm hair sample was collected at study end from all patients. Main outcome measures included clinical score and centralized measurement of UFC, late-night salivary cortisol (LNSF), late-night salivary cortisone (LNSE), HE, HF. RESULTS Despite having almost all UFCs normalized, CushMed patients exhibited increased HE as compared to CushSurg controls (P = .003). CushMed patients also had increased clinical score (P = .001), UFC (P = .03), LNSF, LNSE (P = .0001), and variability in the latter parameters (P = .004). CushBla patients had increased HF and HE, contrasting with LNSEs similar to CushSurg patients. Six of 15 CushMed patients exhibited increased HE concentrations and had increased antihypertensive drug dosage compared to CushMed patients with normal HE (P = .05). CONCLUSION Despite normalized UFCs, a subset of medically treated CD patients displays an altered circadian rhythm of serum cortisol. A single HE measurement identifies chronic mild persistent hypercortisolism and could replace multiple saliva analyzes to monitor medical treatments in CD patients once UFC is normalized.
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Affiliation(s)
- Kamel Mohammedi
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
| | - Jerome Bertherat
- Department of Endocrinology, French Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Université Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, F-75014, Paris, France
| | - Gerald Raverot
- Department of Endocrinology, French Reference Center for Rare Pituitary Diseases HYPO, Hospices Civils de Lyon and Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Cancer Research Center of Lyon, F-69001, Lyon, France
| | - Delphine Drui
- Department of Endocrinology and Institut du thorax, CHU de Nantes, F-44000 Nantes, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte de Nacre, F-14033 Caen, France
| | - Frederic Castinetti
- Department of Endocrinology, Assistance Publique-Hopitaux de Marseille, French Reference Center for Rare Pituitary Diseases, EURACAN European Expert Center on Rare Pituitary Tumors, La Conception Hospital, Aix Marseille University, F-13385, Marseille, France
| | - Philippe Chanson
- Department of Endocrinology, Reference Center for Rare Pituitary Diseases HYPO, CHU Bicêtre, F-94270 Le Kremlin-Bicêtre, France
| | - Manon Fafin
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
| | - Julie Brossaud
- Laboratory of Hormonology and Tumor Markers, Nutrition and Integrated Neurobiology Laboratory, UMR 1286, CHU de Bordeaux, F-33300, Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
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18
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Park SS, Kim JH. Recent Updates on the Management of Adrenal Incidentalomas. Endocrinol Metab (Seoul) 2023; 38:373-380. [PMID: 37583083 PMCID: PMC10475962 DOI: 10.3803/enm.2023.1779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023] Open
Abstract
Adrenal incidentalomas represent an increasingly common clinical conundrum with significant implications for patients. The revised 2023 European Society of Endocrinology (ESE) guideline incorporates cutting-edge evidence for managing adrenal incidentalomas. This paper provides a concise review of the updated contents of the revised guideline. In the 2023 guideline, in patients without signs and symptoms of overt Cushing's syndrome, a post-dexamethasone cortisol level above 50 nmol/L (>1.8 μg/dL) should be considered as mild autonomous cortisol secretion. Regarding the criteria of benign adrenal adenomas, a homogeneous adrenal mass with ≤10 Hounsfield units on non-contrast computed tomography requires no further follow-up, irrespective of its size. The updated guideline also discusses steroid metabolomics using tandem mass spectrometry to discriminate malignancy. It underscores the importance of high-volume surgeons performing adrenalectomy and emphasizes the pivotal role of a multidisciplinary team approach in deciding the treatment plan for indeterminate adrenal masses. The guideline advocates for more proactive surgical treatment for indeterminate adrenal masses in young patients (<40 years) and pregnant women. This review of the 2023 ESE guideline underscores the ongoing evolution of the adrenal incidentaloma management landscape, emphasizing the need for further research and adaptation of diagnostic and therapeutic strategies.
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Affiliation(s)
- Seung Shin Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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19
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Zhang CD, Li D, Singh S, Suresh M, Thangamuthu K, Nathani R, Achenbach SJ, Atkinson EJ, Van Gompel JJ, Young WF, Bancos I. Glucocorticoid withdrawal syndrome following surgical remission of endogenous hypercortisolism: a longitudinal observational study. Eur J Endocrinol 2023; 188:592-602. [PMID: 37395115 PMCID: PMC10376560 DOI: 10.1093/ejendo/lvad073] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Glucocorticoid withdrawal syndrome (GWS) is a scarcely studied phenomenon that complicates the recovery following surgical remission of hypercortisolism. We aimed to characterize the presence and trajectory of glucocorticoid withdrawal symptoms in the postoperative period and to determine presurgical predictors of GWS severity. DESIGN Longitudinal observational study. METHODS Glucocorticoid withdrawal symptoms were prospectively evaluated weekly for the first 12 weeks following surgical remission of hypercortisolism. Quality of life (CushingQoL and Short-Form-36) and muscle function (hand grip strength and sit-to-stand test) were assessed at the baseline and at 12 weeks after surgery. RESULTS Prevalent symptoms were myalgias and arthralgias (50%), fatigue (45%), weakness (34%), sleep disturbance (29%), and mood changes (19%). Most symptoms persisted, while myalgias, arthralgias, and weakness worsened during weeks 5-12 postoperatively. At 12 weeks after surgery, normative hand grip strength was weaker than at baseline (mean Z-score delta -0.37, P = .009), while normative sit-to-stand test performance improved (mean Z-score delta 0.50, P = .013). Short-Form-36 Physical Component Summary score worsened (mean delta -2.6, P = .015), but CushingQoL score improved (mean delta 7.8, P < .001) at 12 weeks compared to baseline. Cushing syndrome (CS) clinical severity was predictive of postoperative GWS symptomology. CONCLUSION Glucocorticoid withdrawal symptoms are prevalent and persistent following surgical remission of hypercortisolism with baseline CS clinical severity predictive of postoperative GWS symptom burden. Differential changes observed in muscle function and quality of life in the early postoperative period may reflect the competing influences of GWS and recovery from hypercortisolism.
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Affiliation(s)
- Catherine D Zhang
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Sumitabh Singh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, Medstar Health, Baltimore, MD 21237, USA
| | - Karthik Thangamuthu
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Rohit Nathani
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Sara J Achenbach
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Elizabeth J Atkinson
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
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20
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He Y, Tang Z, Tang N, Lu Y, Niu F, Ye J, Zhang Z, Fang C, Yao L. Cushing syndrome caused by an ectopic ACTH-producing pituitary adenoma of the clivus region: A rare case report and literature review. Medicine (Baltimore) 2023; 102:e34137. [PMID: 37352051 PMCID: PMC10289495 DOI: 10.1097/md.0000000000034137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/08/2023] [Indexed: 06/25/2023] Open
Abstract
RATIONALE Ectopic ACTH-producing pituitary adenoma (EAPA) of the clivus region is extraordinarily infrequent condition and merely a few reports have been reported to date. PATIENT CONCERNS The patient was a 53-year-old woman who presented with Cushing-like appearances and a soft tissue mass in the clivus region. DIAGNOSES The final diagnosis of clivus region EAPA was established by clinical, radiological and histopathological findings. INTERVENTIONS The patient underwent gross total clivus tumor resection via transsphenoidal endoscopy. OUTCOMES Half a year after surgery, the patient Cushing-like clinical manifestations improved significantly, and urinary free cortisol and serum adrenocorticotropin (ACTH) returned to normal. LESSONS Given the extreme scarcity of these tumors and their unique clinical presentations, it may be possible to misdiagnose and delayed treatment. Accordingly, it is especially crucial to summarize such lesions through our present case and review the literature for their precise diagnosis and the selection of optimal treatment strategies.
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Affiliation(s)
- Yutao He
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Ziyi Tang
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Na Tang
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Yu Lu
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Fangfang Niu
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Jiao Ye
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Zheng Zhang
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Chenghong Fang
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
| | - Lei Yao
- Department of Laboratory Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, China
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21
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Raffaelli M, Gallucci P, Voloudakis N, Pennestrì F, De Cicco R, Arcuri G, De Crea C, Bellantone R. The new robotic platform Hugo™ RAS for lateral transabdominal adrenalectomy: a first world report of a series of five cases. Updates Surg 2023; 75:217-225. [PMID: 36333563 PMCID: PMC9834370 DOI: 10.1007/s13304-022-01410-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
Robotic assisted surgery is the most rapidly developing field of minimally invasive surgery. Its wide diffusion has led to the development and standardization of robotic-assisted approaches also for adrenalectomy. In this study, we present the first five robotic-assisted lateral transabdominal adrenalectomies performed with the new Hugo RAS™ system (Medtronic, Minneapolis, MN, USA). After an official training course of the surgical team, five consecutive patients scheduled for unilateral adrenalectomy, underwent robotic-assisted operations in our institution. Patients that were candidates for partial adrenalectomy were excluded. A description of the operating theatre, robotic arms and docking setup is provided. Four female and one male patient underwent lateral transabdominal adrenalectomy, three for lesions on the left side and two on the right. Median lesion size was 3.9 cm (range: 30-90) and preoperative diagnosis was Cushing's syndrome in three patients, an adrenal cystic lesion and a pheochromocytoma. The median docking time was 5 min (range: 5-8) and the median console time was 55 min (range: 29-108). Procedures were performed without intraoperative complications and no conversions or additional ports were needed. System's function and docking were uneventful. Based on our initial experience, adrenalectomy with the Hugo™ system is feasible. This study provides technical notes for other centres that wish to perform robotic-assisted adrenalectomies with the Hugo™ RAS as well as general information and our preliminary insights on this new platform.
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Affiliation(s)
- Marco Raffaelli
- U.O. Chrirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Pierpaolo Gallucci
- U.O. Chrirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Nikolaos Voloudakis
- U.O. Chrirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Pennestrì
- U.O. Chrirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto De Cicco
- U.O Anestesie delle Chirurgie Generali e dei Trapianti, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Arcuri
- U.O. Direzione Tecnica e Innovazione - Tecnologia Sanitaria, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Carmela De Crea
- U.O. Chrirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rocco Bellantone
- U.O. Chrirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
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22
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Lousada LM, Tapia MJB, Cescato VAS, da Silva GO, Musolino NRC, Fragoso MCBV, Bronstein MD, Machado MC. Pregnancy after pituitary surgery does not influence the recurrence of Cushing's disease. Endocrine 2022; 78:552-558. [PMID: 35930216 DOI: 10.1007/s12020-022-03151-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Pregnancy is associated with the activation of the hypothalamus-pituitary-adrenal axis, which can cause a misdiagnosis of Cushing's syndrome. The aim of this study is to evaluate the impact of pregnancy after pituitary surgery on the recurrence rate in Cushing's disease (CD) patients. METHODS This was a retrospective study in a tertiary center. Between 1990 and 2020, 355 CD patients underwent pituitary surgery. Of those, we included 113 female patients who were ≤ 45 years old (median age of 32 years, 14-45), PS remission, a follow-up of ≥6 months (median of 122 months, 6-402) and an available obstetric history. Recurrence was defined as the diagnosis of Cushing's syndrome via at least two altered first-line methods. The patients were divided into two subgroups according to pregnancy: no pregnancy or pregnancy prior to CD diagnosis (NP/PP) and pregnancy after CD pituitary surgery (PA). RESULTS Overall, recurrence occurred in 43 out of 113 patients (38%). A higher recurrence rate was seen in the PA subgroup (11/22, 50%), but there was no significant difference between the NP/PP subgroup (32/91, 35%). No difference in survival-free recurrence (SFR) was found between NP/PP and PA subgroups. The lower SFR was related to a higher PS plasma ACTH and normal pituitary at pathological analyses. CONCLUSIONS There was no difference in the recurrence rate in patients according to pregnancy history. Other studies with higher numbers of patients are needed to confirm these data.
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Affiliation(s)
- Lia Mesquita Lousada
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Mariuxi Jacqueline Borja Tapia
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | | | | | | | - Marcello Delano Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
- Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Marcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
- Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
- Endocrinology Service, AC Camargo Cancer Center, Sao Paulo, SP, Brazil.
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23
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Kim J, Kim HK, Chung CH. Missed Ipsilateral Adrenal Adenoma With Recurrent Hypercortisolism After Prior Left Adrenalectomy. J Korean Med Sci 2022; 37:e278. [PMID: 36217569 PMCID: PMC9550635 DOI: 10.3346/jkms.2022.37.e278] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jihoon Kim
- Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hae Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Choon Hee Chung
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea.
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24
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Abstract
Cushing's syndrome (CS) is associated with a hypercoagulable state resulting in an increased risk on venous thromboembolism (VTE). In patients with untreated active CS VTE incidence is up to 18-fold higher compared to the general population, whereas after pituitary and adrenal surgery a postoperative VTE risk between 2.6 and 5.6% has been reported. Interestingly, after surgery the VTE risk is not only increased in the first week but also during several months postoperatively. The hypercoagulable state in CS is thought to be caused, at least in part, by an imbalance between activity of pro- and anticoagulant pathways. However, changes in activated partial thromboplastin time and plasma concentrations of pro-and anticoagulant factors are not observed in every CS patient. Only retrospective studies have shown that thromboprophylaxis lowers VTE risk in CS. Future prospective studies should asses the optimal timing, duration and type of thromboprophylaxis in CS to improve VTE-related morbidity and mortality.
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Affiliation(s)
- Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, Netherlands.
| | - Lynnette K Nieman
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
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25
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Abstract
Transsphenoidal surgery is the first-line treatment for Cushing's disease. However, some situations may require the use of a primary medical treatment, such as in patients with severe life-threatening hypercortisolism, a situation which can be handled by fast-acting steroidogenesis inhibitors, instead of classical bilateral adrenalectomy. Primary medical treatment could also be considered in patients with non-severe hypercortisolism, but the evidence is far less convincing for its systematic use. The aim of this short review is to explain briefly the different circumstances in which primary medical therapy could be considered, the limits of this approach, and the way in which to initiate and monitor the treatment.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology, Assistance Publique-Hopitaux de Marseille, INSERM, Marseille Medical Genetics, Marmara Institute, French Reference Center for Rare Pituitary Diseases, Endo-European Reference Network and EURACAN European Expert Center on Rare Pituitary Tumors, La Conception Hospital, Aix Marseille University, 147 Boulevard Baille, 13385, Marseille Cedex 05, France.
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26
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Abstract
Cushing's Syndrome (CS), or chronic endogenous hypercortisolism, is a rare and serious disease due to corticotroph pituitary (Cushing's disease, CD) and extra-pituitary (ectopic CS) tumours overproducing ACTH, or cortisol-secreting adrenal tumours or lesions (adrenal CS). The first-line treatment for CS is represented by the surgical removal of the responsible tumour, but surgery might be unfeasible or ineffective and medical treatment can be required in a relevant percentage of patients with CS, especially CD and ectopic CS. Corticotroph pituitary and extra-pituitary tumours, as well as adrenal tumours and lesions responsible for CS express dopamine receptors (DRs), which have been found to mediate inhibition of hormone secretion and/or cell proliferation in experimental setting, suggesting that dopaminergic system, particularly DRs, might represent a target for the treatment of CS. Dopamine agonists (DAs), particularly cabergoline (CAB), are currently used as off-label treatment for CD, the most common form of CS, demonstrating efficacy in controlling hormone secretion and tumour growth in a relevant number of cases, with the improvement of clinical picture, and displaying good safety profile. Therefore, CAB may be considered a reasonable alternative treatment for persistent or recurrent CD after pituitary surgery failure, but occasionally also before pituitary surgery, as adjuvant treatment, or even instead of pituitary surgery as first-line treatment in case of surgery contraindications or refusal. A certain beneficial effect of CAB has been also reported in ectopic CS. However, the role of DAs in the clinical management of the different types of CS requires further evaluations.
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Affiliation(s)
- R Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy.
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy.
| | - C Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - C Simeoli
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - M C De Martino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - A Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
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27
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Li ST, Lin Y, Ou BX, Liu DE, Li QW, Nong YJ, Wu SM, Qiu ZX, Huang Z. [Effects of comprehensive treatment of infected wounds in patients with iatrogenic Cushing 's syndrome]. Zhonghua Shao Shang Yu Chuang Mian Xiu Fu Za Zhi 2022; 38:512-519. [PMID: 35764576 DOI: 10.3760/cma.j.cn501225-20220329-00106] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: To investigate the characteristics and comprehensive treatment of infected wounds in patients with iatrogenic Cushing's syndrome. Methods: A retrospective observational study was conducted. From May 2012 to December 2021, the data of 19 patients with iatrogenic Cushing's syndrome discharged from the Department of Burns and Plastic Surgery of the First Affiliated Hospital of Guangxi Medical University were collected, including 8 males and 11 females, aged 28-71 (56±11) years, with 12 cases of infected acute wounds and 7 cases of infected chronic wounds. The lesions were located in the limbs, perianal, and sacrococcygeal regions, with original infection ranging from 9 cm×5 cm to 85 cm×45 cm. After admission, the patients were performed with multidisciplinary assisted diagnosis and treatment, and the wounds were treated with debridement and vacuum sealing drainage, according to the size, severity of infection, suture tension, and bone and tendon tissue exposure of wounds, direct suture or autologous skin and/or artificial dermis and/or autologous tissue flap transplantation was selected for wound repair. The levels of cortisol and adrenocorticotropic hormone (ACTH) of patients at 8:00, 16:00, and 24:00 within 24 h after admission were counted. After admission, the number of operations, wound repair methods, and wound and skin/flap donor site healing of patients were recorded. During follow-up, the wounds were observed for recurrent infection. Results: The cortisol levels of 16 patients at 8:00, 16:00, and 24:00 within 24 h after admission were (130±54), (80±16), and (109±39) nmol/L, respectively, and ACTH levels were (7.2±2.8), (4.1±1.8), and (6.0±3.0) pg/mL, respectively; and the other 3 patients had no such statistical results. After admission, the number of surgical operation for patients was 3.4±0.9. The following methods were used for wound repair, including direct suturing in 4 cases and autologous skin and/or artificial dermis grafting in 9 cases, of which 2 cases underwent stage Ⅱ autologous skin grafting after artificial dermis grafting in stage Ⅰ, and 6 cases had pedicled retrograde island flap+autologous skin grafting. The wound healing was observed, showing that all directly sutured wounds healed well; the wounds in 6 cases of autologous skin and/or artificial dermis grafting healed well, and the wounds in 3 cases also healed well after the secondary skin grafting; the flaps in 4 cases survived well with the wounds in 2 cases with distal perforators flap arteries circumfluence obstacle of posterior leg healed after stage Ⅱ debridement and autologous skin grafting. The healing status of skin/flap donor sites was followed showing that the donor sites of medium-thickness skin grafts in the thigh of 4 cases were well healed after transplanted with autologous split-thickness grafts from scalp; the donor sites of medium-thickness skin grafts in 3 cases did not undergo split-thickness skin grafting, of which 2 cases had poor healing but healed well after secondary skin grafting 2 weeks after surgery; the donor sites of split-thickness skin grafts in the head of 2 patients healed well; and all donor sites of flaps healed well after autologous skin grafting. During follow-up of more than half a year, 3 gout patients were hospitalized again for surgical treatment due to gout stone rupture, 4 patients were hospitalized again for surgical treatment due to infection, and no recurrent infection was found in the rest of patients. Conclusions: The infected wounds in patients with iatrogenic Cushing's syndrome have poor ability to regenerate and are prone to repeated infection. Local wound treatment together with multidisciplinary comprehensive treatment should be performed to control infection and close wounds in a timely manner, so as to maximize the benefits of patients.
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Affiliation(s)
- S T Li
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Y Lin
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - B X Ou
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - D E Liu
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Q W Li
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Y J Nong
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - S M Wu
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Z X Qiu
- Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Zhenxing Huang
- Department of Endocrinology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
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Ebbehoj A, Søndergaard E, Jepsen P, Stochholm K, Svane HML, Madsen M, Poulsen PL, Jørgensen JOL. The Socioeconomic Consequences of Cushing's Syndrome: A Nationwide Cohort Study. J Clin Endocrinol Metab 2022; 107:e2921-e2929. [PMID: 35311897 DOI: 10.1210/clinem/dgac174] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT The long-term somatic and psychiatric consequences of Cushing's syndrome are well-described, but the socioeconomic consequences are largely unknown. OBJECTIVE We studied employment status, educational level, risk of depression, and other socioeconomic outcomes of Cushing's syndrome in the years before diagnosis and after surgery. DESIGN Nationwide register-based cohort study. METHODS We used a validated algorithm to identify 424 patients operated for adrenal (n = 199) or pituitary Cushing's syndrome (n = 225) in Denmark from January 1, 1986 to December 31, 2017. We obtained socioeconomic registry data from 10 years before diagnosis (year -10) to 10 years after surgery (year +10) and included a sex- and age-matched reference population. We identified prognostic factors for returning to work using modified Poisson regression. RESULTS Compared to the reference population, the patients' employment was permanently reduced from year -6 [relative risk (RR) 0.92, 95% CI 0.84-0.99] to year +10 (RR 0.66, 95% CI 0.57-0.76). Sick leave (RR 2.15, 95% CI 1.40-3.32) and disability pension (RR 2.60, 95% CI 2.06-3.27) were still elevated in year +10. Annual income, education, parenthood, relationship status, and risk of depression were also negatively impacted, but parenthood and relationship status normalized after surgery. Among patients, negative predictors of full-time employment after surgery included female sex, low education, comorbidity, and depression. CONCLUSION Cushing's syndrome negatively affects a wide spectrum of socioeconomic variables many years before diagnosis of which only some normalize after treatment. The data underpin the importance of early diagnosis and continuous follow-up of Cushing's syndrome and, not least, the pervasive health threats of glucocorticoid excess.
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Affiliation(s)
- Andreas Ebbehoj
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Esben Søndergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Jepsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Morten Madsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Løgstrup Poulsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Otto Lunde Jørgensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Shaikh J, Raymond A, Somasundaram A, Loya MF, Nezami N. Novel Protocol for CT-Guided Percutaneous Ablation of Hyperplastic Adrenal Glands in Cushing Syndrome. Cardiovasc Intervent Radiol 2022; 45:1041-1043. [PMID: 35355093 DOI: 10.1007/s00270-022-03121-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/04/2021] [Accepted: 03/07/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Jamil Shaikh
- Division of Vascular and Interventional Radiology, Morsani College of Medicine, Tampa General Hospital, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA.
| | - Aislynn Raymond
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aravind Somasundaram
- Division of Interventional Radiology, Department of Radiology, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30342, USA
| | - Mohammed F Loya
- Division of Interventional Radiology, Department of Radiology, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30342, USA
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
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30
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Amado A, Torre A, Graça SAR, Tavares AB. Subclinical Cushing's syndrome: resection of adrenal incidentaloma. BMJ Case Rep 2022; 15:e247600. [PMID: 35351749 PMCID: PMC8966519 DOI: 10.1136/bcr-2021-247600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
- Andreia Amado
- Department of General Surgery, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Ana Torre
- Department of General Surgery, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | | | - Amelia Brandao Tavares
- Department of General Surgery, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
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DeLozier OM, Dream SY, Findling JW, Carroll TB, Evans DB, Wang TS. Selective Glucocorticoid Replacement Following Unilateral Adrenalectomy for Hypercortisolism and Primary Aldosteronism. J Clin Endocrinol Metab 2022; 107:e538-e547. [PMID: 34558612 DOI: 10.1210/clinem/dgab698] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 07/13/2021] [Indexed: 01/06/2023]
Abstract
CONTEXT An institutional study previously demonstrated that cosyntropin stimulation testing on postoperative day 1 (POD1-CST) identified patients at risk for adrenal insufficiency (AI) following unilateral adrenalectomy (UA) for adrenal-dependent hypercortisolism (HC) and primary aldosteronism (PA), allowing for selective glucocorticoid replacement (GR). OBJECTIVE This study re-evaluates the need for GR following UA for patients with HC and PA in a larger cohort. METHODS A prospective database identified 108 patients who underwent UA for mild autonomous cortisol excess (MACE) (n = 47), overt hypercortisolism (OH) (n = 27), PA (n = 22), and concurrent PA/HC (n = 12) from September 2014 to October 2020; all underwent preoperative evaluation for HC. MACE was defined by the 1 mg dexamethasone suppression test (cortisol >1.8 μg/dL), with ≥5 defined as OH. GR was initiated for basal cortisol ≤5 or stimulated cortisol ≤14 (≤18 prior to April 2017) on POD1-CST. RESULTS Fifty-one (47%) patients had an abnormal POD1-CST; 54 (50%) were discharged on GR (27 MACE, 20 OH, 1 PA, 6 PA/HC). Median duration of GR was OH: 6.0 months, MACE: 2.1 months, PA: 1 month, PA/HC: 0.8 months. Overall, 26% (n = 7) of patients with OH and 43% (n = 20) of patients with MACE did not require GR. Two (2%) patients with OH had normal POD1-CST but developed AI several weeks postoperatively requiring GR. None experienced life-threatening AI. CONCLUSION POD1-CST identifies patients with HC at risk for AI after UA, allowing for selective GR. One-quarter of patients with OH and nearly half of patients with MACE can forgo GR after UA. Patients with PA do not require evaluation for AI if concurrent HC has been excluded preoperatively.
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Affiliation(s)
- Olivia M DeLozier
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Sophie Y Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - James W Findling
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ty B Carroll
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Ferrante E, Serban AL, Clerici M, Indirli R, Scalambrino E, Carosi G, Padovan L, Locatelli M, Arosio M, Peyvandi F, Mantovani G, Tripodi A. Evaluation of procoagulant imbalance in Cushing's syndrome after short- and long-term remission of disease. J Endocrinol Invest 2022; 45:9-16. [PMID: 34115342 PMCID: PMC8741706 DOI: 10.1007/s40618-021-01605-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/28/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Patients with Cushing's syndrome (CS) are at high risk of venous thromboembolism related to a hypercoagulability due to procoagulant imbalance. However, whether these alterations are reversible after disease remission is still unclear. The endogenous thrombin potential (ETP) measured with and without the addition of thrombomodulin provides a global representation of coagulation and previous data confirmed hypercoagulable profile in patients with active hypercortisolism. Aim of this study was to assess the short- and long-term modification of ETP in patients with CS after disease remission. DESIGN AND METHODS Nineteen patients with CS for whom surgical remission was achieved, were prospectively evaluated for clinical characteristics, cortisol secretion profile and ETP at different time points: (i) before surgical intervention; (ii) after 6 months and (iii) 5 years from the time of persistent remission. Nineteen healthy subjects matched for age and gender were also evaluated as control group. RESULTS Before surgery, patients showed higher ETP-ratio (with/without thrombomodulin) than controls (0.62 ± 0.09-vs-0.56 ± 0.09, p = 0.034). No significant correlation between ETP-ratio and cortisol secretion was found. 6 months after remission, ETP-ratio was still significantly increased compared to controls (0.64 ± 0.09-vs-0.56 ± 0.09, p = 0.01), but was similar to baseline (0.64 ± 0.09-vs-0.62 ± 0.09, p = 0.87). At 5 years, ETP-ratio showed a significant decrease (0.55 ± 0.14-vs-0.62 ± 0.09, p = 0.02) and was comparable to controls (0.55 ± 0.14-vs-0.56 ± 0.09, p = 0.7). CONCLUSIONS Plasma hypercoagulability detected in patients with active hypercortisolism persists at short-term evaluation and seems to be completely reversible after long-term remission of disease. These data, as part of a whole evaluation of thrombotic risk, can contribute to make appropriate therapeutic choice in these patients.
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Affiliation(s)
- E Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20143, Milano, Italy
| | - A L Serban
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20143, Milano, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - M Clerici
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milano, Italy
| | - R Indirli
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20143, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy
| | - E Scalambrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milano, Italy
| | - G Carosi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20143, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy
| | - L Padovan
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milano, Italy
| | - M Locatelli
- Neurosurgery Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - M Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20143, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy
| | - F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - G Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20143, Milano, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy.
| | - A Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milano, Italy
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Tsurutani Y, Kiriyama K, Kondo M, Hasebe M, Sata A, Mizuno Y, Sugisawa C, Saito J, Nishikawa T. Carney Complex Complicated with Primary Pigmented Nodular Adrenocortical Disease without Cushing's Syndrome Recurrence for Five Years after Unilateral Adrenalectomy. Intern Med 2022; 61:205-211. [PMID: 35034934 PMCID: PMC8851166 DOI: 10.2169/internalmedicine.7418-21] [Citation(s) in RCA: 2] [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] [Indexed: 11/06/2022] Open
Abstract
We herein report a case of Carney complex (CNC) complicated with primary pigmented nodular adrenocortical disease (PPNAD) after unilateral adrenalectomy. A 44-year-old woman was admitted to our hospital for PPNAD surgery. She had previously undergone surgery for cardiac myxoma and had a PRKAR1A mutation with no family history of CNC. She had Cushing's signs, but her metabolic abnormalities were mild. Adrenal insufficiency due to poor medication adherence was a concern, so she underwent unilateral adrenalectomy. Cushing's signs improved postoperatively and without recurrence for five years. Treatment plans for PPNAD should be determined based on the patient's condition, medication adherence, and wishes.
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Affiliation(s)
- Yuya Tsurutani
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Kanako Kiriyama
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Mai Kondo
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Masanori Hasebe
- Division of Endocrinology and Metabolism, Kanto Central Hospital, Japan
| | - Akira Sata
- Division of Endocrinology and Metabolism, Kanto Central Hospital, Japan
| | - Yuzo Mizuno
- Division of Endocrinology and Metabolism, Kanto Central Hospital, Japan
| | - Chiho Sugisawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
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Lase I, Grönberg M, Norlén O, Stålberg P, Welin S, Janson ET. Adrenalectomy in ectopic Cushing's syndrome: A retrospective cohort study from a tertiary care centre. J Neuroendocrinol 2021; 33:e13030. [PMID: 34448524 DOI: 10.1111/jne.13030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/27/2022]
Abstract
Neuroendocrine neoplasms (NENs) causing ectopic Cushing's syndrome (ECS) are rare and challenging to treat. In this retrospective cohort study, we aimed to evaluate different approaches for bilateral adrenalectomy (BA) as a treatment option in ECS. Fifty-three patients with ECS caused by a NEN (35 females/18 men; mean ± SD age: 53 ± 15 years) were identified from medical records. Epidemiological and clinical parameters, survival, indications for surgery and timing, as well as duration of surgery, complications and surgical techniques, were collected and further analysed. The primary tumour location was thorax (n = 30), pancreas (n = 14) or unknown (n = 9). BA was performed in 37 patients. Median time from diagnosis of ECS to BA was 2 months (range 1-10 months). Thirty-two patients received different steroidogenesis inhibitors before BA to control hypercortisolaemia. ECS resolved completely after surgery in 33 patients and severe peri- or postoperative complications were detected in 12 patients. There were fewer severe complications in the endoscopic group compared to open surgery (p = .030). Posterior retroperitoneoscopic BA performed simultaneously by a two surgeon approach had the shortest operating time (p = .001). Despite the frequent use of adrenolytic treatment, BA was necessary in a majority of patients to gain control over ECS. Complication rate was high, probably as a result of the combination of metastatic disease and metabolic disorders caused by high cortisol levels. The two surgeon approach BA may be considered as the method of choice in ECS compared to other BA approaches as a result of fewer complications and a shorter operating time.
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Affiliation(s)
- Ieva Lase
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Malin Grönberg
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Welin
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Eva Tiensuu Janson
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
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Koudelková Z, Gerychová R, Nešporová T. Cushings syndrome in pregnancy caused by an adrenal adenoma. Ceska Gynekol 2021; 86:331-334. [PMID: 34736331 DOI: 10.48095/cccg2021331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The description of a rare case of Cushings syndrome caused by an adrenal adenoma in pregnancy with successful treatment. CASE PRESENTATION 30-ear-old Gravida 3 female was admitted to our hospital with hypertension at the 18th week of gestation. Hormonal analyses revealed primary Cushings syndrome with high plasma cortisol levels and low levels of adrenocorticotropic hormone. Magnetic resonance imaging demonstrated a mass on the right-side of the adrenal gland. Adrenalectomy was performed in the 28th week of gestation and the following histopathology revealed an adrenocortical adenoma. Pregnancy continued until the 38th week of gestation with glucocorticoid replacement therapy and the patient gave birth vaginally to a healthy boy in the 38th week of gestation. CONCLUSION Cushings syndrome in pregnancy rarely occurs; dia-gnosis may be dismissed or determined after birth in most cases. Misdia-gnosis of Cushings syndrome is common because of physiological increase of corticotropin hormones and cortisol levels and overlapping symptoms that can occur even during physiological pregnancy. Cushings syndrome should have a place in the differential dia-gnosis of hypertension in pregnancy (especially before the 20th week of gestation). Analysis of the urinary free cortisol level and circadian rhythm blood cortisol can provide a reasonable strategy to dia-gnose Cushings syndrome in pregnant women. Early dia-gnosis and surgical treatment can significantly reduce maternal and fetal complications.
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Fushimi Y, Tatsumi F, Sanada J, Shimoda M, Kamei S, Nakanishi S, Kaku K, Mune T, Kaneto H. Concurrence of overt Cushing's syndrome and primary aldosteronism accompanied by aldosterone-producing cell cluster in adjacent adrenal cortex: case report. BMC Endocr Disord 2021; 21:163. [PMID: 34384396 PMCID: PMC8359021 DOI: 10.1186/s12902-021-00818-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/25/2021] [Accepted: 07/18/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Various adrenal disorders including primary aldosteronism and Cushing's syndrome lead to the cause of hypertension. Although primary aldosteronism is sometimes complicated with preclinical Cushing's syndrome, concurrence of overt Cushing's syndrome and primary aldosteronism is very rare. In addition, it has been drawing attention recently that primary aldosteronism is brought about by the presence of aldosterone-producing cell cluster in adjacent adrenal cortex rather than the presence of aldosterone-producing adenoma. CASE PRESENTATION A 67-year-old Japanese female was referred to our institution due to moon face and central obesity. Based on various clinical findings and data, we diagnosed this subject as overt Cushing's syndrome and primary aldosteronism. Furthermore, in immunostaining for cytochrome P450 (CYP) 11B1, a cortisol-producing enzyme, diffuse staining was observed in tumorous lesion. Also, in immunostaining for CYP11B2, an aldosterone-producing enzyme, CYP11B2 expression was not observed in tumorous lesion, but strong CYP11B2 expression was observed in adjacent adrenal cortex, indicating the presence of aldosterone-producing cell cluster. CONCLUSIONS We should bear in mind the possibility that concurrence of overt Cushing's syndrome and primary aldosteronism is accompanied by aldosterone-producing cell cluster in adjacent adrenal cortex.
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Affiliation(s)
- Yoshiro Fushimi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Fuminori Tatsumi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Junpei Sanada
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Masashi Shimoda
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Shinji Kamei
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Shuhei Nakanishi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Kohei Kaku
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Tomoatsu Mune
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
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García-Marchiñena P, Wright F, Nolazco JI, de Miguel V, Paissan A, Gueglio G, Beskow A, Jurado A, Cavadas D. [Current role of bilateral adrenalectomy in Ectopic Cushing syndrome.]. ARCH ESP UROL 2021; 74:587-591. [PMID: 34219061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The aim of this paper is to describe the clinical features and the perioperative results of the bilateral laparoscopic adrenalectomy (BLA) of salvaje in 5 patients treated for an Ectopic Cushing Syndrome (CS) who were refractory to medical treatment. MATERIALS AND METHODS We performed a retrospective analysis of the clinical records of our institution. Five BLAs were performed in patients with Ectopic CS refractory to medical treatment during the period from January 2009 and June 2017. All patients were evaluated by a multidisciplinary team that jointly decided the most appropriate time for surgery. The following protocol data were analyzed: age, sex, location of the secreting tumor, duration of hypercortisolism, reason for hospitalization, initial therapeutic management), biochemical data (pre-op serum cortisol, plasma ACTH and free urinary cortisol), surgical data (surgical approach, surgical time, type of surgery, need for conversion toopen surgery), perioperative data (post op surgical stay, post op complications according to the Clavien-Dindo scale 14, mortality, clinical cure rate and biochemical cure rate, follow up time). RESULTS Five patients underwent BLA. The approach for the BLA was minimally invasive, either trans peritoneal (n=3) or posterior retroperitoneoscopic (n=2). Mean hospitalization time was 23.4 days (r=4-81). None of the patients died because of surgical complications, and all of them achieved biochemical and clinical remission of their hypercortisolism after surgery. CONCLUSIONS BLA is an effective salvage alter native to control the symptoms associated with overproduction of corticosteroids in patients with ectopic CS refractory to medical treatment.
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Affiliation(s)
| | - Fernando Wright
- Servicio de Cirugía. Hospital Italiano de Buenos Aires. Argentina
| | | | - Valeria de Miguel
- Servicio de Endocrinología. Hospital Italiano de Buenos Aires. Argentina
| | - Andrea Paissan
- Servicio de Endocrinología. Hospital Italiano de Buenos Aires. Argentina
| | | | - Axel Beskow
- Servicio de Cirugía. Hospital Italiano de Buenos Aires. Argentina
| | - Alberto Jurado
- Servicio de Urología. Hospital Italiano de Buenos Aires. Argentina
| | - Demetrio Cavadas
- Servicio de Cirugía. Hospital Italiano de Buenos Aires. Argentina
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Abstract
Cushing syndrome is the result of excessive levels of glucocorticoids. Endogenous Cushing syndrome is rare with an incidence of two to three cases per million per year. Clinically, the presentation consists of a characteristic phenotype including skin symptoms and metabolic manifestations. A frequent co-morbidity with high impact on quality of life is Cushing syndrome associated myopathy. It characteristically affects the proximal myopathy, impairing stair climbing and straightening up. The pathophysiology is complex and involves protein degradation via the forkhead box O3 (FOXO3) pathway, intramuscular fat accumulation, and inactivity-associated muscle atrophy. Surgical remission of Cushing syndrome is the most important step for recovery of muscle function. Restoration depends on age, co-morbidities and postoperative insulin-like growth factor concentrations. At average, functionality remains impaired during the long-term compared to age and sex matched control persons. Growth hormone therapy in individuals with impaired growth hormone secretion could be an option but has not been proved in a randomized trial.
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Affiliation(s)
- Martin Reincke
- Medical Department IV, LMU-University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
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Vogel F, Braun L, Rubinstein G, Zopp S, Benedix S, Schneider H, Ritzel K, Schilbach K, Schmidmaier R, Beuschlein F, Bidlingmaier M, Reincke M. Patients with low IGF-I after curative surgery for Cushing's syndrome have an adverse long-term outcome of hypercortisolism-induced myopathy. Eur J Endocrinol 2021; 184:813-821. [PMID: 33830940 DOI: 10.1530/eje-20-1285] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Received: 12/07/2020] [Accepted: 04/07/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Glucocorticoid excess leads to muscle atrophy and weakness in patients with endogenous Cushing's syndrome. Insulin-like growth factor I (IGF-I) is known to have protective effects on muscle loss. We hypothesized that individual serum IGF-I concentrations might be predictive for long-term myopathy outcome in Cushing's syndrome. PATIENTS AND METHODS In a prospective longitudinal study of 31 patients with florid Cushing's syndrome, we analyzed IGF-I and IGF binding protein 3 (IGFBP 3) concentrations at the time of diagnosis and following surgical remission over a period of up to 3 years. We assessed muscle strength by grip strength measurements using a hand grip dynamometer and muscle mass by bio-impedance measurements. FINDINGS Individual serum IGF-I concentrations in the postoperative phase were strongly predictive of long-term grip strength outcome (rs = 0.696, P ≤ 0.001). Also, lower IGF-I concentrations were associated with a lower muscle mass after 3 years (rs = 0.404, P = 0.033). While patients with high IGF-I s.d. scores (SDS; >1.4) showed an improvement in grip strength within the follow-up period (P = 0.009), patients with lower IGF-I SDS (≤-0.4) had a worse outcome with persisting muscle dysfunction. In contrast, preoperative IGF-I concentrations during the florid phase of Cushing's syndrome did not predict long-term muscle function outcome (rs = 0.285, P = 0.127). CONCLUSION Lower individual IGF-I concentrations 6 months after curative surgery for Cushing's syndrome are associated with adverse long-term myopathy outcome and IGF-I might be essential for muscle regeneration in the early phase after correction of hypercortisolism.
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Affiliation(s)
- Frederick Vogel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Sarina Benedix
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Holger Schneider
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Ralf Schmidmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
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Varlamov EV, Langlois F, Vila G, Fleseriu M. MANAGEMENT OF ENDOCRINE DISEASE: Cardiovascular risk assessment, thromboembolism, and infection prevention in Cushing's syndrome: a practical approach. Eur J Endocrinol 2021; 184:R207-R224. [PMID: 33539319 DOI: 10.1530/eje-20-1309] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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] [Received: 11/11/2020] [Accepted: 02/03/2021] [Indexed: 11/08/2022]
Abstract
Cushing's syndrome (CS) is associated with increased mortality that is driven by cardiovascular, thromboembolic, and infection complications. Although these events are expected to decrease during disease remission, incidence often transiently increases postoperatively and is not completely normalized in the long-term. It is important to diagnose and treat cardiovascular, thromboembolic, and infection complications concomitantly with CS treatment. Management of hyperglycemia/diabetes, hypertension, hypokalemia, hyperlipidemia, and other cardiovascular risk factors is generally undertaken in accordance with clinical care standards. Medical therapy for CS may be needed even prior to surgery in severe and/or prolonged hypercortisolism, and treatment adjustments can be made based on disease pathophysiology and drug-drug interactions. Thromboprophylaxis should be considered for CS patients with severe hypercortisolism and/or postoperatively, based on individual risk factors of thromboembolism and bleeding. Pneumocystis jiroveci pneumonia prophylaxis should be considered for patients with high urinary free cortisol at the initiation of hypercortisolism treatment.
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Affiliation(s)
- Elena V Varlamov
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Greisa Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
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Abstract
Estrogen is known to increase exogenous corticosteroid levels. In this case, a 27-year-old Japanese woman was referred to our hospital for examination of an adrenal tumor and was diagnosed with Cushing syndrome. Resection of the tumor resulted in secondary adrenal insufficiency. She also developed microcytic anemia due to hypermenorrhea, which was masked by Cushing syndrome. An oral contraceptive was administered for the treatment of hypermenorrhea, but this led to a marked increase in serum cortisol and the reduction of plasma adenocorticotropic hormone, disturbing the recovery of the adrenal function. Attention is required when oral contraceptives are used to treat hypermenorrhea masked by Cushing syndrome.
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Affiliation(s)
- Yosuke Okuno
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Japan
| | - Satoshi Kawata
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Japan
| | - Yuri Shimizu
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Japan
| | - Kosuke Mukai
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Japan
| | - Michio Otsuki
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Japan
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Shekhar S, McGlotten R, Auh S, Rother KI, Nieman LK. The Hypothalamic-Pituitary-Thyroid Axis in Cushing Syndrome Before and After Curative Surgery. J Clin Endocrinol Metab 2021; 106:e1316-e1331. [PMID: 33236107 PMCID: PMC7947758 DOI: 10.1210/clinem/dgaa858] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We do not fully understand how hypercortisolism causes central hypothyroidism or what factors influence recovery of the hypothalamic-pituitary-thyroid axis. We evaluated thyroid function during and after cure of Cushing syndrome (CS). METHODS We performed a retrospective cohort study of adult patients with CS seen from 2005 to 2018 (cohort 1, c1, n = 68) or 1985 to 1994 (cohort 2, c2, n = 55) at a clinical research center. Urine (UFC) and diurnal serum cortisol (F: ~8 am and ~midnight [pm]), morning 3,5,3'-triiodothyronine (T3), free thyroxine (FT4), and thyrotropin (TSH) (c1) or hourly TSH from 1500 to 1900 h (day) and 2400 to 04000 h (night) (c2), were measured before and after curative surgery. RESULTS While hypercortisolemic, 53% of c1 had central hypothyroidism (low/low normal FT4 + unelevated TSH). Of those followed long term, 31% and 44% had initially subnormal FT4 and T3, respectively, which normalized 6 to 12 months after cure. Hypogonadism was more frequent in hypothyroid (69%) compared to euthyroid (13%) patients. Duration of symptoms, morning and midnight F, adrenocorticotropin, and UFC were inversely related to TSH, FT4, and/or T3 levels (r = -0.24 to -0.52, P < .001 to 0.02). In c2, the nocturnal surge of TSH (mIU/L) was subnormal before (day 1.00 ± 0.04 vs night 1.08 ± 0.05, P = .3) and normal at a mean of 8 months after cure (day 1.30 ± 0.14 vs night 2.17 ± 0.27, P = .01). UFC greater than or equal to 1000 μg/day was an independent adverse prognostic marker of time to thyroid hormone recovery. CONCLUSIONS Abnormal thyroid function, likely mediated by subnormal nocturnal TSH, is prevalent in Cushing syndrome and is reversible after cure.
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Affiliation(s)
- Skand Shekhar
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Raven McGlotten
- Section on Translational Endocrinology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sunyoung Auh
- Office of the Clinical Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kristina I Rother
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Lynnette K Nieman
- Section on Translational Endocrinology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Correspondence and Reprint Requests: Lynnette K. Nieman, MD, Section on Translational Endocrinology, National Institute of Diabetes and Digestive and Kidney Diseases, Bldg 10-CRC, Rm 1-3140, 10 Center Dr, Bethesda, MD 20892, USA. E-mail:
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Shah HA, Madathil A, Routh C. Rare but serious cause for hypokalaemia and hypertension. BMJ Case Rep 2021; 14:e239955. [PMID: 33664034 PMCID: PMC7934740 DOI: 10.1136/bcr-2020-239955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 11/04/2022] Open
Abstract
Adrenocortical carcinoma is a rare tumour but hypertension conversely is very common. We present the case of a woman in her 30s, with poorly controlled hypertension on four antihypertensive agents. She was referred to the accident and emergency department with hypokalaemia. For a year, she had experienced oedema, weight gain, acne, hirsutism and oligomenorrhea. She had a classic Cushingoid appearance and marked striae. Cushing's syndrome was confirmed biochemically with an abnormal overnight dexamethasone suppression test. She was diagnosed with metastatic adrenocortical carcinoma following CT imaging. This was resected via a right adrenalectomy, nephrectomy and cholecystectomy. She also received mitotane. Unfortunately, she has a terminal prognosis having experienced a recurrence. This case demonstrates the value of a thorough clinical assessment. More importantly, it highlights the need to refer earlier patients under 40 with resistant hypertension to a specialist. Finally, it encourages clinicians to investigate hypokalaemia in the context of hypertension.
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Affiliation(s)
- Hussun-Ara Shah
- Medical Education, Newcastle University, Newcastle upon Tyne, UK
- Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Asgar Madathil
- Diabetes and Endocrinology, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte Routh
- Acute Medicine, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
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Wilson JB, Zopey M, Augustine J, Schaffer R, Chiang M, Friedman TC. High Prevalence of Adrenal Remnant Tissue in Patients Undergoing Bilateral Adrenalectomy for Cushing's Disease. Horm Metab Res 2021; 53:161-168. [PMID: 33091942 PMCID: PMC8570053 DOI: 10.1055/a-1253-2854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Bilateral adrenalectomy (BLA) is a treatment option for patients with Cushing's Disease (CD) if transsphenoidal pituitary surgery fails or is not a therapeutic option. For most patients, BLA eliminates endogenous glucocorticoid and mineralocorticoid production, but for a small number of patients, endogenous secretion of adrenal hormones from adrenal tissue continues or recurs, leading to signs and symptoms of hypercortisolism. If adrenal tissue is confined to the adrenal bed, it is considered adrenal remnant tissue, while if it is outside the adrenal bed, it is considered adrenal rest tissue. We retrospectively evaluated morning serum cortisol, nighttime serum cortisol, nighttime salivary cortisol, and 24-h urine free cortisol on at least three occasions in 10 patients suspected of having endogenous cortisol production. Imaging of adrenal remnant tissue was also reviewed. Ten of 51 patients who underwent BLA during this time period had adrenal remnant/rest tissue marked by detectable endogenous glucocorticoid production; 9 of the 10 patients had signs and symptoms of hypercortisolism. Localization and treatment proved difficult. We conclude that the incidence of adrenal remnant/rest tissue in those undergoing BLA following unsuccessful pituitary surgery was 12% although there may have been a selection bias affecting this prevalence. The first indication of remnant tissue occurrence is a reduction in glucocorticoid replacement with symptoms of hypercortisolism. If this occurs, endogenous cortisol production should be tested for by cortisol measurements using a highly specific cortisol assay while the patient is taking dexamethasone or no glucocorticoid replacement. Endocrinologists need to monitor the development of both adrenal remnant tissue and Nelson's syndrome following BLA.
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Affiliation(s)
- Julian B. Wilson
- Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, 90059, USA
| | - Mohan Zopey
- Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, 90059, USA
| | - Jaimie Augustine
- Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, 90059, USA
| | - Randolph Schaffer
- Department of Surgery, Scripps Green Hospital, La Jolla, CA, 92037, USA
| | - Manfred Chiang
- Brookfield Surgical Associates, Brookfield, WI 53005, USA
| | - Theodore C. Friedman
- Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, 90059, USA
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Abstract
External radiation therapy (RT) directed to the pituitary gland is generally recommended in patients with Cushing's disease (CD) as adjuvant to transsphenoidal surgery, among other second-line therapies offered to patients with residual or recurrent hypercortisolism (i.e., medical treatment, repeat surgery or bilateral adrenalectomy). RT is effective for the control of tumor growth, even in invasive tumors and in Nelson's syndrome. Progress in radiation stereotactic techniques lead to improved tumor targeting and radiation delivery, thus sparing the adjacent brain structures. Stereotactic RT is associated with a 55-65% rate of cortisol normalization after several months to a few years and potentially with a lower risk of long-term complications, compared with conventional RT. Cortisol-lowering medical therapy is recommended while awaiting the radiation effects. Hypopituitarism is the most frequent side-effect, damage to optic or cranial nerves or second brain tumors are rarely reported. This review presents the updates in the efficacy and safety of the stereotactic radiation techniques in CD patients. Practical points which should be considered by the clinician before recommending RT are also presented.
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Affiliation(s)
- Monica Livia Gheorghiu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; National Institute of Endocrinology C.I. Parhon, Bucharest, Romania.
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46
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Abstract
Primary bilateral adrenocortical hyperplasias are rare forms of pituitary ACTH-independent Cushing's syndrome (CS). They are divided between primary bilateral macronodular adrenal hyperplasia (PBMAH) and micronodular adrenal hyperplasia (MiBAH), which is subdivided in primary pigmented nodular adrenocortical disease (PPNAD) and isolated micronodular adrenocortical disease (i-MAD). One of the most debated aspects surrounding these entities is their most appropriate therapy. Although bilateral adrenalectomy (BA) has previously been the most utilized therapy for patients with overt CS, recent studies have indicated that unilateral adrenalectomy (UA) can be effective in patients with PBMAH and some with MiBAH with fewer long-term side effects. Medical therapies can also be used for bridging to surgery or rarely in the long-term for these patients. We review the various degrees of CS resulting from PBMAH and MiBAH, with a special focus on their respective therapies including UA, taking into account the recent pathophysiological and genetics findings.
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Affiliation(s)
- Léamarie Meloche-Dumas
- Surgical Oncology Service, Department of Surgery, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
| | - Frédéric Mercier
- Surgical Oncology Service, Department of Surgery, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
| | - André Lacroix
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
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Zhang K, Shou X, Chen H, Qiao N, He W, Chen Z, Shen M, Li S, Zhao Y, Zhang Z, Li Y, Ye H, Wang Y. Clinical Parameters of Silent Corticotroph Adenomas With Positive and Negative Adrenocorticotropic Hormone Immunostaining: A Large Retrospective Single-Center Study of 105 Cases. Front Endocrinol (Lausanne) 2021; 11:608691. [PMID: 33584540 PMCID: PMC7873875 DOI: 10.3389/fendo.2020.608691] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 09/21/2020] [Accepted: 12/01/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the different clinical characteristics of silent corticotroph adenomas (SCAs) with positive and negative adrenocorticotropic hormone (ACTH) immunostaining, and to explore the value of pituitary-restricted transcription factor (Tpit) immunostaining for diagnosing SCAs. Methods The clinical materials of patients with SCAs who had a typical pathological feature with positive Tpit immunostaining and positive/negative ACTH immunostaining, and without clinical features and biochemical evidence for Cushing's Syndrome in our center from April 2018 to March 2019 were analyzed retrospectively. The differences in clinical characteristics and surgical results between ACTH-positive and -negative SCAs were explored. Results A total of one hundred and five patients (94.3% female) with SCAs were included. There were 66 SCAs with ACTH-negative (66/105, 62.9%), and 39 SCAs with ACTH-positive (39/105, 37.1%). Cases with ACTH-negative SCAs were more likely to have lower ACTH levels (27.5 ± 24.0 vs. 54.4 ± 58.6, P = 0.011), more multiple microcysts (81.8% vs. 61.5%, P = 0.022) and lower levels of Ki-67 expression (low expression rate 90.9% vs. 74.4%, P = 0.023). No statistical significant differences were observed between patients with ACTH-positive and -negative SCAs regarding gender (97.0% vs. 89.7%, P = 0.192), age (50.3 ± 10.3 vs. 49.0 ± 11.2, P = 0.543), surgical history (16.7% vs. 23.1%, P = 0.419), suprasellar extension (66.7% vs. 74.4%, P = 0.408), sphenoid sinus extension (51.5% vs. 56.4%, P = 0.627), cavernous sinus invasion (75.8% vs. 66.7%, P = 0.314), large cyst on Magnetic Resonance Imaging (MRI) (47.0% vs. 61.5%, P = 0.149), or gross total resection rate (42.4% vs. 51.3%, P = 0.379). Conclusions ACTH-negative SCAs were observed to be more clinically silent and more likely to demonstrate multiple microcysts on MRI. The prevalence of SCAs, especially ACTH-negative SCAs, proved to be substantially underestimated and thus they should be given enough attention in consideration of the high aggressiveness of this subtype of refractory pituitary adenoma (PA).
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Affiliation(s)
- Keyi Zhang
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Xuefei Shou
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Hong Chen
- Department of Pathology, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Nidan Qiao
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Wenqiang He
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Zhengyuan Chen
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Ming Shen
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Shiqi Li
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Yao Zhao
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Zhaoyun Zhang
- Department of Endocrinology, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Yiming Li
- Department of Endocrinology, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Hongying Ye
- Department of Endocrinology, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Yongfei Wang
- Department of Neurosurgery, Shanghai Huashan Institute of Neurological Surgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
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Abstract
A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome.
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Affiliation(s)
- Yuji Hiromatsu
- Thyroid Center, Shin Koga Hospital, Japan
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University Medical Center, Japan
| | - Hiroyuki Eguchi
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University Medical Center, Japan
| | - Yui Nakamura
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University Medical Center, Japan
| | - Kei Mukohara
- Department of General and Family Medicine, Kurume University Medical Center, Japan
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Karaca Z, Taheri S, Firat ST, Borlu M, Zararsiz G, Mehmetbeyoglu E, Caglar AS, Hacioglu A, Tanriverdi F, Unluhizarci K, Kelestimur F. Molecular skin changes in Cushing syndrome and the effects of treatment. J Endocrinol Invest 2021; 44:153-163. [PMID: 32410187 DOI: 10.1007/s40618-020-01285-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/12/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We investigated newly diagnosed patients with endogenous CS for molecular changes in skin by biopsy before and a year after treatment of CS. PATIENTS AND METHODS 26 Patients with CS and 23 healthy controls were included. All the patients were evaluated before and a year after treatment. Skin biopsies were obtained from abdominal region before and a year after treatment in patients with CS and once from healthy volunteers. Total RNA was isolated from the skin biopsy samples and the real-time PCR system was used to determine the expression levels of 23 genes in the skin biopsy. RESULTS Skin expression levels of HAS 1, 2 and 3 mRNAs were lower and COL1A2, COL2A1, COL3A1 mRNAs were higher in patients with CS than in normal controls. MMP-9, TIMP-1 and elastin mRNA expression levels were similar in two groups. Skin IL-1β mRNA expression level was significantly higher in patients with CS. None of these parameters changed significantly 12 months after treatment. Patients with CS showed higher skin GH and HSD11B1 mRNA expressions and lower GHR and IGF-1R mRNA expression compared to control. Expression levels of IGF-1, GR and HSD11B2 mRNA were similar in two groups. None of these parameters changed significantly 12 months after treatment. CONCLUSION CS is associated with increased expression levels of skin COL1A2, COL2A1, COL3A1 mRNAs (which are correlated with increased expression level of skin GH mRNA). Decreased skin HAS may cause decreased synthesis of HA that contributes to thinning of skin in CS. Increased local inflammatory cytokine and HSD11B1 mRNAs may be related to the acne formation in CS. Treatment of CS was not able to reverse these changes and ongoing changes were detected after treatment.
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Affiliation(s)
- Z Karaca
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - S Taheri
- Erciyes University Genome and Stem Cell Institution, Kayseri, Turkey
| | - S T Firat
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - M Borlu
- Department of Dermatology, Erciyes University Medical School, Kayseri, Turkey
| | - G Zararsiz
- Department of Biostatistics, Erciyes University Medical School, Kayseri, Turkey
| | - E Mehmetbeyoglu
- Erciyes University Genome and Stem Cell Institution, Kayseri, Turkey
| | - A Sezgin Caglar
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - A Hacioglu
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - F Tanriverdi
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - K Unluhizarci
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - F Kelestimur
- Department of Endocrinology, Yeditepe University Medical School, Istanbul, Turkey.
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Vogel F, Braun LT, Rubinstein G, Zopp S, Künzel H, Strasding F, Albani A, Riester A, Schmidmaier R, Bidlingmaier M, Quinkler M, Deutschbein T, Beuschlein F, Reincke M. Persisting Muscle Dysfunction in Cushing's Syndrome Despite Biochemical Remission. J Clin Endocrinol Metab 2020; 105:dgaa625. [PMID: 32882010 PMCID: PMC7538105 DOI: 10.1210/clinem/dgaa625] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/31/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Glucocorticoid-induced myopathy is a characteristic symptom of endogenous Cushing's syndrome (CS). Its long-term outcome is largely unknown. OBJECTIVE To evaluate long-term muscle function following the remission of endogenous CS. STUDY DESIGN Observational longitudinal cohort study. SETTING Tertiary care hospitals and a specialized outpatient clinic. PATIENTS As part of the prospective multicenter German Cushing's Registry, we assessed muscle strength in patients with overt endogenous CS. We studied the patients at the time of diagnosis (n = 88), after 6 months (n = 69), and thereafter annually, following surgical remission over a period of up to 4 years (1 year: n = 55; 2 years: n = 34; 3 years: n = 29; 4 years: n = 22). Muscle function was evaluated by hand grip strength and by chair rising test. RESULTS Grip strength was decreased to 83% of normal controls (100%) at the time of diagnosis. It further decreased to 71% after 6 months in remission (P ≤ 0.001) and showed no improvement during further follow-up compared with baseline. Chair rising test performance improved initially (8 seconds at baseline vs 7 seconds after 6 months, P = 0.004) but remained at this reduced level thereafter (7 seconds after 3 years vs 5 seconds in controls, P = 0.038). In multivariate analysis, we identified, as predictors for long-term muscle dysfunction, age, waist-to-hip ratio, and hemoglobin A1c at baseline. Furthermore, muscle strength during follow-up was strongly correlated with quality of life. CONCLUSION This study shows that CS-associated myopathy does not spontaneously resolve during remission. This calls for action to identify effective interventions to improve muscle dysfunction in this setting.
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Affiliation(s)
- Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Heike Künzel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Finn Strasding
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Adriana Albani
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Anna Riester
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Ralf Schmidmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Martin Bidlingmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | | | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
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