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Li H, Xie J, Song J, Jin C, Xin H, Pan X, Ke J, Yuan Y, Shen H, Ning G. CRCS: An automatic image processing pipeline for hormone level analysis of Cushing's disease. Methods 2024; 222:28-40. [PMID: 38159688 DOI: 10.1016/j.ymeth.2023.12.003] [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: 11/08/2023] [Revised: 12/01/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024] Open
Abstract
Due to the abnormal secretion of adreno-cortico-tropic-hormone (ACTH) by tumors, Cushing's disease leads to hypercortisonemia, a precursor to a series of metabolic disorders and serious complications. Cushing's disease has high recurrence rate, short recurrence time and undiscovered recurrence reason after surgical resection. Qualitative or quantitative automatic image analysis of histology images can potentially in providing insights into Cushing's disease, but still no software has been available to the best of our knowledge. In this study, we propose a quantitative image analysis-based pipeline CRCS, which aims to explore the relationship between the expression level of ACTH in normal cell tissues adjacent to tumor cells and the postoperative prognosis of patients. CRCS mainly consists of image-level clustering, cluster-level multi-modal image registration, patch-level image classification and pixel-level image segmentation on the whole slide imaging (WSI). On both image registration and classification tasks, our method CRCS achieves state-of-the-art performance compared to recently published methods on our collected benchmark dataset. In addition, CRCS achieves an accuracy of 0.83 for postoperative prognosis of 12 cases. CRCS demonstrates great potential for instrumenting automatic diagnosis and treatment for Cushing's disease.
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Affiliation(s)
- Haiyue Li
- Institute of Image Processing and Pattern Recognition, Shanghai Jiao Tong University, and Key Laboratory of System Control and Information Processing, Ministry of Education of China, Shanghai 200240, China
| | - Jing Xie
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, China
| | - Jialin Song
- The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiao Tong University, Xi'an 710049, China
| | - Cheng Jin
- Medical Robot Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Hongyi Xin
- University of Michigan - Shanghai Jiao Tong University Joint Institute Shanghai Jiao Tong University, Shanghai 200240, China
| | - Xiaoyong Pan
- Institute of Image Processing and Pattern Recognition, Shanghai Jiao Tong University, and Key Laboratory of System Control and Information Processing, Ministry of Education of China, Shanghai 200240, China
| | - Jing Ke
- Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Ye Yuan
- Institute of Image Processing and Pattern Recognition, Shanghai Jiao Tong University, and Key Laboratory of System Control and Information Processing, Ministry of Education of China, Shanghai 200240, China
| | - Hongbin Shen
- Institute of Image Processing and Pattern Recognition, Shanghai Jiao Tong University, and Key Laboratory of System Control and Information Processing, Ministry of Education of China, Shanghai 200240, China.
| | - Guang Ning
- State Key Laboratory of Medical Genomes, National Clinical Research Center for Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Laboratory of Endocrinology and Metabolism, Institute of Health Sciences, Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS) & Shanghai Jiao Tong University School of Medicine (SJTUSM), Shanghai, China.
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Martini ML, Ransom RC, Rechberger JS, O'Keeffe D, Young W, Atkinson JLD, Meyer FB, Rinaldo L, Carlstrom L, Cloft HJ, Van Gompel J. Angiographic cross-filling between inferior petrosal sinuses and alteration of adrenocorticotropic hormone sampling results for tumor localization in Cushing disease. J Neurosurg 2024; 140:386-392. [PMID: 37877973 DOI: 10.3171/2023.6.jns2320] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/06/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Inferior petrosal sinus (IPS) sampling (IPSS) is a diagnostic procedure used to guide diagnostic localization of imaging-negative adrenocorticotropic hormone (ACTH)-secreting pituitary microadenomas. However, the efficacy of IPSS has been suboptimal at accurately lateralizing the adenoma, reducing surgical cure rates and leading to unintended pituitary dysfunction due to the added exploration. One rationale for the occasional imprecision is the existence of additional petrosal sinus collateral channels that connect the IPS bilaterally, which may lead to false localization results during sampling. The aim of this study was to explore a potential connection between normal anatomical variation in the angioarchitecture of the IPSs and the ACTH results obtained in subsequent IPSS tests. METHODS A retrospective review was performed on all cases between 1998 and 2013 involving patients at a single institution who underwent IPSS for radiographically equivocal pituitary microadenomas. Cases were reviewed for tumor laterality noted on either operative or pathology reports, as well as the presence of angiographic evidence of cross-filling between the sinuses. In addition, ACTH levels from the right and left IPSs were documented at baseline and at 2, 5, and 10 minutes after corticotropin-releasing hormone (CRH) administration. A ratio of the change in ACTH levels measured at the time of maximal response (10 minutes) versus the levels measured at the initial response (2 minutes) was computed for each patient and compared between patients by their angiographic cross-filling status. RESULTS There were 41 patients with a histopathologically confirmed right- or left-sided ACTH-secreting pituitary microadenoma who underwent preoperative IPSS. Among these patients, 28 (68%) showed angiographic evidence of cross-filling between the IPSs, and 13 showed no cross-filling. On average, ACTH levels increased by a factor of 3.91 ± 0.77 in the contralateral IPS in patients with angiographic cross-filling, compared with a factor increase of only 1.80 ± 0.27 in patients without cross-filling (p = 0.014). In comparison, ACTH levels increased by a factor of 2.01 ± 0.57 in the ipsilateral IPS in patients with cross-filling, and by 8.78 ± 7.30 in those without cross-filling (p = 0.373). CONCLUSIONS The presence of angiographic cross-filling, suggestive of a greater degree of vascular channel networking between the right and left IPS, is a significant factor influencing the measured rates of change of ACTH in IPSS and may impact the specificity of this test to accurately determine microadenoma laterality in the preoperative setting.
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Affiliation(s)
| | | | | | - Derek O'Keeffe
- 2Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - William Young
- 2Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
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Cote DJ, Peterson R, Zada G. Commentary: Endoscopic Endonasal Transsphenoidal Resection for MRI-Negative Cushing Disease With 2 Separate Functioning Pituitary Adenomas Neuroendocrine Tumors: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:245. [PMID: 37976144 DOI: 10.1227/ons.0000000000001005] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- David J Cote
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
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Shinya Y, Hong S, Choby GW, Bancos I, Giannini C, Van Gompel JJ. Endoscopic Endonasal Transsphenoidal Resection for MRI-Negative Cushing Disease With 2 Separate Functioning Pituitary Adenomas Neuroendocrine Tumors: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:243-244. [PMID: 37850934 DOI: 10.1227/ons.0000000000000965] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Sukwoo Hong
- Department of Neurologic Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Garret W Choby
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Irina Bancos
- Department of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester , Minnesota , USA
| | - Caterina Giannini
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester , Minnesota , USA
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester , Minnesota , USA
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Белая ЖЕ, Голоунина ОО, Ситкин ИИ, Рожинская ЛЯ, Дегтярев МВ, Трухина ДА, Бондаренко ЕВ, Лапшина АМ, Мамедова ЕО, Пржиялковская ЕГ, Вакс ВВ, Мельниченко ГА, Мокрышева НГ, Дедов ИИ. [Diagnostic value of bilateral inferior petrosal sinus sampling in various modifications and methods of radiation and radionuclide imaging in the diagnosis and differential diagnosis of ACTH-dependent endogenous hypercortisolism]. Probl Endokrinol (Mosk) 2024; 69:4-16. [PMID: 38311990 PMCID: PMC10848181 DOI: 10.14341/probl13299] [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] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/30/2023] [Accepted: 06/16/2023] [Indexed: 02/06/2024]
Abstract
AIM To analyze the diagnostic performance of bilateral inferior petrosal sinus sampling (BIPSS) with desmopressin as a stimulation agent and prolactin measurements to control catheter position with or without the ACTH/prolactin normalized ratio calculation in the differential diagnosis of ACTH-dependent endogenous hypercortisolism, and the diagnostics performance of ectopic ACTH-syndrome (EAS) visualization. MATERIALS AND METHODS A single-center diagnostic study with a retrospective analysis of the data was carried out. The study included patients with ACTH-dependent endogenous hypercorticism with no visualization of pituitary adenoma on MRI or adenoma sizes less than 6 mm. All patients underwent BIPSS with and without calculation of the ACTH/prolactin normalized ratio. Visualization of an EAS included pituitary MRI (to exclude EAS), whole-body CT scan with contrast, and somatostatin receptor scintigraphy with 99mTc-Tectrotide and CT (99mTc-Tectrotide SPECT). The final verification was based on immunohistochemical confirmation of the tumor or stable remission of Cushing's disease (CD) after surgical treatment. Statistical data processing was carried out by using IBM SPSS Statistics 23. Confidence intervals were calculated using the JavaStat online calculator. RESULTS 230 BIPSS were performed in 228 patients (166 women, 62 men), of which 178 patients were verified as CD and 50 cases were EAS of various localization. The effectiveness of catheterization of petrosal sinuses was 96.9%. The sensitivity of BIPSS without ACTH/prolactin ratio calculation (n=70) was 95.9% (95% CI 86.3-98.9), specificity was 92% (95% CI 75.0-97.8), for the BIPSS with additional determination of ACTH/prolactin-normalized ratio (n=51) - 97.3% (95% CI 86.2-99.5) and 93.8% (95% CI 71.7-98.9), respectively. The use of the MRI method for this sample of patients had a sensitivity of 60.2% (95% CI 52.6-67.5), specificity of 59.2% (95% CI 44.2-73.0), the total body CT with contrast has a sensitivity of 74% (95% CI 59.7-85.4), specificity of 100% (95% CI 97.95-100). The diagnostic accuracy for 99mTc-Tectrotide SPECT in NET visualization has a sensitivity of 73.3% (95% CI 44.9-92.2), specificity of 100% (95% CI 95.3-100). CONCLUSION BIPSS with desmopressin stimulation and prolactin measurements to control catheter position, as well as the additional calculation of the ACTH/prolactin-normalized ratio, is an optimal method for the differential diagnosis of EAS. Patients who are identified an EAS on BIPSS may be further referred for 99mTc-Tectrotide SPECT and CT for tumor visualization.
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Affiliation(s)
- Ж. Е. Белая
- Национальный медицинский исследовательский центр эндокринологии
| | - О. О. Голоунина
- Национальный медицинский исследовательский центр эндокринологии
| | - И. И. Ситкин
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. Я. Рожинская
- Национальный медицинский исследовательский центр эндокринологии
| | - М. В. Дегтярев
- Национальный медицинский исследовательский центр эндокринологии
| | - Д. А. Трухина
- Национальный медицинский исследовательский центр эндокринологии
| | | | - А. М. Лапшина
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. О. Мамедова
- Национальный медицинский исследовательский центр эндокринологии
| | | | - В. В. Вакс
- Great Western Hospitals NHS Foundation Trust
| | | | - Н. Г. Мокрышева
- Национальный медицинский исследовательский центр эндокринологии
| | - И. И. Дедов
- Национальный медицинский исследовательский центр эндокринологии
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Ishida A, Kaneko K, Minamimoto R, Hotta M, Inoshita N, Takano K, Yamada S. Clinical decision-making based on 11C-methionine PET in recurrent Cushing's disease with equivocal MRI findings. J Neurosurg 2023; 139:1671-1680. [PMID: 37410630 DOI: 10.3171/2023.5.jns23179] [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: 02/17/2023] [Accepted: 05/09/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Diagnosis and accurate localization of recurrent tumors in Cushing's disease (CD) are challenging, especially after multiple transsphenoidal surgeries (TSSs) or radiosurgery. Even experts face difficulties in detecting these recurrent tumors, and a favorable surgical outcome is not guaranteed. In this report, the authors aimed to determine the usefulness of 11C-methionine positron emission tomography (MET-PET) for evaluating patients with recurrent CD with inconclusive magnetic resonance imaging (MRI) lesions and to develop a treatment protocol for these cases. METHODS In this retrospective study of patients with recurrent CD in the period between April 2018 and December 2022, the authors assessed the usefulness of MET-PET in determining whether equivocal MRI findings were recurrent tumors or postsurgical cavities and deciding further treatment options. All patients had undergone at least one TSS, and most had undergone multiple TSSs and had pathologically confirmed corticotroph tumors with hypercortisolemia. RESULTS Overall, 15 patients with recurrent CD (10 females and 5 males) were included, all of whom had undergone MET-PET. All patients had been subjected to multiple treatments, including TSSs or radiosurgeries. Their MRI scans demonstrated less-enhanced lesions that were not confirmed as recurrences even with cutting-edge MRI because they could not be distinguished from postsurgical changes with confidence. MET uptake was positive in 8 patients (9 examinations) and negative in 7. Following MET-PET, repeat TSS was performed in 5 patients. Corticotroph tumors were identified in all 5 patients, even though one of them had negative MET uptake. The MET uptake precisely identified a tumor location on the opposite side of the MRI-suspected lesion in 2 patients. Meanwhile, patients with negative uptake and mild hypercortisolism were only observed. Nonsurgical options were also used in other patients: temozolomide (TMZ) was administered in 2 patients owing to a prior history of multiple TSSs and radiosurgery and the drug-resistant nature of the disease. TMZ was highly effective in these patients; their Cushing's symptoms ameliorated, and their adrenocorticotropic hormone and cortisol levels continued to decline. Interestingly, MET uptake disappeared following TMZ treatment. CONCLUSIONS MET-PET is extremely useful for confirming equivocal lesions on MRI in patients with recurrent CD and for deciding further treatment options. The authors propose a novel protocol based on MET-PET results for treating patients with relapsing CD in whom the recurrent tumors cannot be confirmed with MRI.
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Affiliation(s)
- Atsushi Ishida
- 1Hypothalamic and Pituitary Center, Moriyama Memorial Hospital, Tokyo
| | - Koichiro Kaneko
- 2Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, Tokyo
| | - Ryogo Minamimoto
- 3Department of Radiology, Division of Nuclear Medicine, National Center for Global Health and Medicine, Tokyo
| | - Masatoshi Hotta
- 3Department of Radiology, Division of Nuclear Medicine, National Center for Global Health and Medicine, Tokyo
| | | | - Koji Takano
- 5Endocrinology, Moriyama Memorial Hospital, Tokyo, Japan
| | - Shozo Yamada
- 1Hypothalamic and Pituitary Center, Moriyama Memorial Hospital, Tokyo
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Feng Z, Zhang H, Zhou T, Yu X, Zhang Y, Yan X. Dynamic functional connectivity changes associated with psychiatric traits and cognitive deficits in Cushing's disease. Transl Psychiatry 2023; 13:308. [PMID: 37798280 PMCID: PMC10556150 DOI: 10.1038/s41398-023-02615-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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 09/17/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023] Open
Abstract
Cushing's disease is a rare neuroendocrine disorder with excessive endogenous cortisol, impaired cognition, and psychiatric symptoms. Evidence from resting-state fMRI revealed the abnormalities of static brain connectivity in patients with Cushing's disease (CD patients). However, it is unknown whether the CD patients' dynamic functional connectivity would be abnormal and whether the dynamic features are associated with deficits in cognition and psychopathological symptoms. Here, we evaluated 50 patients with Cushing's disease and 57 healthy participants by using resting-state fMRI and dynamic functional connectivity (dFNC) approach. We focused on the dynamic features of default mode network (DMN), salience network (SN), and central executive network (CEN) because these are binding sites for the cognitive-affective process, as well as vital in understanding the pathophysiology of psychiatric disorders. The dFNC was further clustered into four states by k-mean clustering. CD patients showed more dwell time in State 1 but less time in State 4. Intriguingly, group differences in dwell time in these two states can explain the cognitive deficits of CD patients. Moreover, the inter-network connections between DMN and SN and the engagement time in State 4 negatively correlated with anxiety and depression but positively correlated with cognitive performance. Finally, the classifier trained by the dynamic features of these networks successfully classified CD patients from healthy participants. Together, our study revealed the dynamic features of CD patients' brains and found their associations with impaired cognition and emotional symptoms, which may open new avenues for understanding the cognitive and affective deficits induced by Cushing's disease.
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Affiliation(s)
- Zhebin Feng
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, PR China
| | - Haitao Zhang
- Department of Respiratory Medicine, Anhui Provincial Children's Hospital, Hefei, Anhui, PR China
| | - Tao Zhou
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, PR China
| | - Xinguang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, PR China
- Neurosurgery Institute, Chinese PLA General Hospital, Beijing, PR China
| | - Yanyang Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, PR China.
- Neurosurgery Institute, Chinese PLA General Hospital, Beijing, PR China.
| | - Xinyuan Yan
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA.
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Castle-Kirszbaum M, Amukotuwa S, Fuller P, Goldschlager T, Gonzalvo A, Kam J, Kow CY, Shi MD, Stuckey S. MRI for Cushing Disease: A Systematic Review. AJNR Am J Neuroradiol 2023; 44:311-316. [PMID: 36759141 PMCID: PMC10187804 DOI: 10.3174/ajnr.a7789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 10/11/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND MR imaging is key in the diagnostic work-up of Cushing disease. The sensitivity of MR imaging in Cushing disease is not known nor is the prognostic significance of "MR imaging-negative" disease. PURPOSE Our aim was to determine the overall sensitivity and prognostic significance of MR imaging localization of Cushing disease. DATA SOURCES We performed a systematic review of the MEDLINE and PubMed databases for cohort studies reporting the sensitivity of MR imaging for the detection of adenomas in Cushing disease. STUDY SELECTION This study included 57 studies, comprising 5651 patients. DATA ANALYSIS Risk of bias was assessed using the methodological index for non-randomized studies criteria. Meta-analysis of proportions and pooled subgroup analysis were performed. DATA SYNTHESIS Overall sensitivity was 73.4% (95% CI, 68.8%-77.7%), and the sensitivity for microadenomas was 70.6% (66.2%-74.6%). There was a trend toward greater sensitivity in more recent studies and with the use of higher-field-strength scanners. Thinner-section acquisitions and gadolinium-enhanced imaging, particularly dynamic sequences, also increased the sensitivity. The use of FLAIR and newer 3D spoiled gradient-echo and FSE sequences, such as spoiled gradient-echo sequences and sampling perfection with application-optimized contrasts by using different flip angle evolutions, may further increase the sensitivity but appear complementary to standard 2D spin-echo sequences. MR imaging detection conferred a 2.63-fold (95% CI, 2.06-3.35-fold) increase in remission for microadenomas compared with MR imaging-negative Cushing disease. LIMITATIONS Pooled analysis is limited by heterogeneity among studies. We could not account for variation in image interpretation and tumor characteristics. CONCLUSIONS Detection on MR imaging improves the chances of curative resection of adenomas in Cushing disease. The evolution of MR imaging technology has improved the sensitivity for adenoma detection. Given the prognostic importance of MR imaging localization, further effort should be made to improve MR imaging protocols for Cushing disease.
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Affiliation(s)
- M Castle-Kirszbaum
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | | | - P Fuller
- Endocrinology (P.F.)
- Hudson Institute (P.F.), Melbourne, Australia
| | - T Goldschlager
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | - A Gonzalvo
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - J Kam
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - C Y Kow
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
| | - M D Shi
- Barwon Health (M.D.S.), Geelong, Australia
| | - S Stuckey
- Department of Radiology (S.S.), Peter MacCallum Cancer Centre, Melbourne, Australia
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Mao JN, Yan HY, Chen JY, Yan CL, Li P, Jin W, Hang CH. Comparison of the preoperative diagnostic accuracy of BIPSS versus MRI for Cushing disease: a single-centre experience. BMC Endocr Disord 2023; 23:42. [PMID: 36793008 PMCID: PMC9933337 DOI: 10.1186/s12902-023-01277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/19/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Cushing disease (CD) arises due to a pituitary corticotroph adenoma, which is the most common cause of Cushing syndrome (CS). Bilateral inferior petrosal sinus sampling (BIPSS) is a safe method for differentiating CD from ectopic adrenocorticotropic hormone (ACTH)-dependent CS. Enhanced high-resolution magnetic resonance imaging (MRI) can localize tiny pituitary lesions. The aim of this study was to compare the preoperative diagnostic accuracy of BIPSS versus MRI for CD in CS patients. We performed a retrospective study of patients who underwent BIPSS and MRI between 2017 and 2021. Low- and high-dose dexamethasone suppression tests were performed. Blood samples were collected simultaneously from the right and left catheter and femoral vein before and after desmopressin stimulation. MRI images were obtained, and endoscopic endonasal transsphenoidal surgery (EETS) was performed in confirmed CD patients. Dominant sides of ACTH secretion during BIPSS and MRI were compared with surgical findings. RESULTS Twenty-nine patients underwent BIPSS and MRI. CD was diagnosed in 28 patients, 27 of whom received EETS. Localizations of microadenomas by MRI and BIPSS agreed with the EETS findings in 96% and 93% of the cases, respectively. BIPSS and EETS were successfully performed on all patients. CONCLUSION BIPSS was the most accurate method (gold standard) for establishing a preoperative diagnosis of pituitary-dependent CD and was more sensitive than MRI in diagnosing microadenoma. High-resolution MRI with enhancement had an advantage over BIPSS in microadenoma lateralization diagnostics. The combined use of MRI and BIPSS could improve the preoperative diagnosis accuracy in ACTH-dependent CS patients.
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Affiliation(s)
- Jian-Nan Mao
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, People's Republic of China
| | - Hui-Ying Yan
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, People's Republic of China
| | - Jie-Yu Chen
- Department of Neuropathology, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, People's Republic of China
| | - Chao-Long Yan
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, People's Republic of China
| | - Ping Li
- Department of Endocrinology, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, People's Republic of China.
| | - Wei Jin
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, People's Republic of China.
| | - Chun-Hua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, People's Republic of China.
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Bessiène L, Moutel S, Lataud M, Jouinot A, Bonnet-Serrano F, Guibourdenche J, Villa C, Baussart B, Gaillard S, Barat M, Dohan A, Bertagna X, Dousset B, Bertherat J, Assié G. Corticotroph tumor progression speed after adrenalectomy. Eur J Endocrinol 2022; 187:797-807. [PMID: 36206174 DOI: 10.1530/eje-22-0536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/06/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES After bilateral adrenalectomy in Cushing's disease, corticotroph tumor progression occurs in one-third to half of patients. However, progression speed is variable, ranging from slow to rapid. The aim was to explore corticotroph progression speed, its consequences and its risk factors. DESIGN A retrospective single-center observational study. METHODS In total,103 patients with Cushing's disease who underwent bilateral adrenalectomy between 1990 and 2020 were included. Clinical, biological, histological and MRI features were collected. Median duration of follow-up after bilateral adrenalectomy was 9.31 years. RESULTS In total,44 patients progressed (43%). Corticotroph tumor progression speed ranged from 1 to 40.7 mm per year. Progression speed was not different before and after bilateral adrenalectomy (P = 0.29). In univariate analyses, predictive factors for rapid corticotroph tumor progression included the severity of Cushing's disease before adrenalectomy as the cause of adrenalectomy, high ACTH in the year following adrenalectomy and high Ki67 immunopositivity in the tumor. During follow-up, early morning ACTH absolute variation was associated with corticotroph tumor progression speed (P-value = 0.001). ACTH measurement after dynamic testing did not improve this association. CONCLUSION After adrenalectomy, corticotroph progression speed is highly variable and manageable with MRI and ACTH surveillance. Progression speed does not seem related to bilateral adrenalectomy but rather to intrinsic properties of highly proliferative and secreting tumors.
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Affiliation(s)
- Laura Bessiène
- Department of Endocrinology, Hôpital Cochin, Reference and Competence Center Rare Adrenal Diseases and for Rare Pituitary Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sandrine Moutel
- Department of Endocrinology, Hôpital Cochin, Reference and Competence Center Rare Adrenal Diseases and for Rare Pituitary Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marine Lataud
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anne Jouinot
- Department of Endocrinology, Hôpital Cochin, Reference and Competence Center Rare Adrenal Diseases and for Rare Pituitary Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Fidéline Bonnet-Serrano
- Department of Hormonology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Jean Guibourdenche
- Department of Hormonology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Chiara Villa
- Department of Pathological Cytology and Anatomy, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Bertrand Baussart
- Department of Neurosurgery, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Maxime Barat
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Anthony Dohan
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Xavier Bertagna
- Department of Endocrinology, Hôpital Cochin, Reference and Competence Center Rare Adrenal Diseases and for Rare Pituitary Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Bertrand Dousset
- Department of Visceral and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology, Hôpital Cochin, Reference and Competence Center Rare Adrenal Diseases and for Rare Pituitary Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
| | - Guillaume Assié
- Department of Endocrinology, Hôpital Cochin, Reference and Competence Center Rare Adrenal Diseases and for Rare Pituitary Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, CNRS UMR8104, INSERM U1016, Institut Cochin, F-75014, Paris, France
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11
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Bashari WA, Gillett D, MacFarlane J, Powlson AS, Kolias AG, Mannion R, Scoffings DJ, Mendichovszky IA, Jones J, Cheow HK, Koulouri O, Gurnell M. Modern imaging in Cushing's disease. Pituitary 2022; 25:709-712. [PMID: 35666391 PMCID: PMC9587975 DOI: 10.1007/s11102-022-01236-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Accepted: 05/19/2022] [Indexed: 01/18/2023]
Abstract
Management of Cushing's disease is informed by dedicated imaging of the sella and parasellar regions. Although magnetic resonance imaging (MRI) remains the investigation of choice, a significant proportion (30-50%) of corticotroph tumours are so small as to render MRI indeterminate or negative when using standard clinical sequences. In this context, alternative MR protocols [e.g. 3D gradient (recalled) echo, with acquisition of volumetric data] may allow detection of tumors that have not been previously visualized. The use of hybrid molecular imaging (e.g. 11C-methionine positron emission tomography coregistered with volumetric MRI) has also been proposed as an additional modality for localizing microadenomas.
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Affiliation(s)
- W A Bashari
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D Gillett
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - J MacFarlane
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - A S Powlson
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - A G Kolias
- Department of Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - R Mannion
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D J Scoffings
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - I A Mendichovszky
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - J Jones
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - H K Cheow
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - O Koulouri
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - M Gurnell
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
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12
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Nasi-Kordhishti I, Grimm F, Giese S, Lörincz KN, Bender B, Honegger J. The importance of MRI quality and reader's experience for detecting an adenoma in Cushing's disease. Eur J Endocrinol 2022; 187:349-359. [PMID: 35895719 DOI: 10.1530/eje-22-0180] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 02/27/2022] [Accepted: 06/28/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In Cushing's disease (CD), detection of an adenoma by MRI is challenging. The aim of this study is to compare real-life MRI in the initial diagnostic workup of CD with high-quality MRI performed in a tertiary center for pituitary diseases. DESIGN AND METHODS We retrospectively analyzed 139 patients with CD who underwent primary transsphenoidal surgery (TSS) in our department and had both an MRI conducted at a different institution (external MRI; extMRI) and an MRI conducted at our institution (internal MRI; intMRI). Preoperative interpretation of MRI was performed independently by an external radiologist (extRAD), an internal neuroradiologist (intRAD) and a pituitary surgeon (SURG). Intraoperative detection of an adenoma and endocrinological remission provided proof of the true adenoma localization in 105 patients. RESULTS Interpretation of extMRI by extRAD and SURG was concordant in only 64% (89/139) of cases, while 74.1% (103/139) concordance was observed for interpretation of intMRI by intRAD and SURG. Based on extMRI, the true localization of the adenoma was correctly predicted in only 46.7% of the patients by extRAD and in 65.7% by SURG. In contrast, the sensitivity to correctly identify the adenoma on intMRI was 80.0% for intRAD and 94.3% for SURG. CONCLUSION Both the quality of MRI and the reader's experience are paramount for detection of microadenomas in CD. Every effort should be made to perform high-quality initial MRI according to current standards and to ensure rating by an expert in pituitary imaging.
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Affiliation(s)
| | - Florian Grimm
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
| | - Sabrina Giese
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
| | | | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls-University, Tübingen, Germany
| | - Jürgen Honegger
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
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13
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Bonneville JF, Potorac I, Petrossians P, Tshibanda L, Beckers A. Pituitary MRI in Cushing's disease - an update. J Neuroendocrinol 2022; 34:e13123. [PMID: 35352410 DOI: 10.1111/jne.13123] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 11/27/2022]
Abstract
Pituitary MRI is essential in the diagnosis of ACTH-dependent Cushing's syndrome, but its results are inconsistent. The demonstration of a sellar image compatible with the diagnosis of corticotropinoma varies from 40% to 90%, depending on the centre where the imaging is performed. In fact, the expertise of the neuroradiologist, use of a Tesla 3.0 MRI and choice of sequences are fundamental. The T2 and 3D gradient echo sequences after gadolinium injection are the most informative and today allow the detection of macro- and microadenomas in almost all cases. The diagnosis of numerous picoadenomas (<3-4 mm) is more challenging. The 2D and 3D spin echo or delayed T1 SE or FLAIR sequences after gadolinium can be used as a complement or to confirm a suspicious image. Characterization of corticotropinomas remains problematic. However, the correct assessment of so-called incidentalomas by recognizing artifacts, anatomical variants and frequent Rathke's cleft cysts eliminates around 90% of the incidentalomas that mimic pituitary adenomas, as repetitively reported in the literature. For the time being, there is reason to believe that hybrid imaging combining PET and MRI such as 11C-methionine PET coregistered with volumetric MRI will solve the diagnosis of corticotropinomas in the near future.
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Affiliation(s)
- Jean-François Bonneville
- Department of Medical Imaging, Centre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
| | - Iulia Potorac
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
| | - Patrick Petrossians
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
| | - Luaba Tshibanda
- Department of Medical Imaging, Centre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
| | - Albert Beckers
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
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14
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Jiang H, Li Z, Yang W, Sun Y, Yan F, Sun Q, Wei H, Bian L. Region-specific disturbed iron redistribution in Cushing's disease measured by magnetic resonance imaging-based quantitative susceptibility mapping. Clin Endocrinol (Oxf) 2022; 97:81-90. [PMID: 35170794 DOI: 10.1111/cen.14692] [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: 11/23/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cushing's disease (CD) is most common endogenous Cushing's syndrome. This study aimed to assess iron alternations in deep grey matter in CD. DESIGN A cross-sectional study was performed. PATIENTS In this study, 48 active CD patients, 39 remitted CD patients and 52 healthy control (HC) subjects underwent magnetic resonance imaging. MEASUREMENTS Quantitative susceptibility mapping (QSM). RESULTS Decreased susceptibility values were found in the bilateral putamen, caudate, red nucleus, subthalamic nucleus and pulvinar nuclei of the thalamus (TL-PLV) in active and remitted patients with CD compared with HCs. Interestingly, in remitted patients with CD, altered susceptibility values were significantly correlated with altered brain volumes in TL-PLV, while TL-PLV may play an essential role as a general regulatory hub for adaptive and flexible cognition. CONCLUSION Chronic exposure to hypercortisolism may be related to iron distribution and significantly correlated with altered brain volumes and clinical features in patients with CD.
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Affiliation(s)
- Hong Jiang
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, Rui Jin Lu Wan Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenghao Li
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjie Yang
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuhao Sun
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fuhua Yan
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingfang Sun
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, Rui Jin Lu Wan Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongjiang Wei
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
| | - Liuguan Bian
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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15
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Sharifi G, Amin AA, Sabahi M, Echeverry NB, Dilmaghani NA, Mousavinejad SA, Valizadeh M, Davoudi Z, Adada B, Borghei-Razavi H. MRI-negative Cushing's Disease: Management Strategy and Outcomes in 15 Cases Utilizing a Pure Endoscopic Endonasal Approach. BMC Endocr Disord 2022; 22:154. [PMID: 35676664 PMCID: PMC9178868 DOI: 10.1186/s12902-022-01069-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cushing's disease (CD) is among the most common etiologies of hypercortisolism. Magnetic resonance imaging (MRI) is often utilized in the diagnosis of CD, however, up to 64% of adrenocorticotropic hormone (ACTH)-producing pituitary microadenomas are undetectable on MRI. We report 15 cases of MRI negative CD who underwent surgical resection utilizing a purely endoscopic endonasal approach. METHODS Endoscopic endonasal transsphenoidal surgery (EETS) was performed on 134 CD cases by a single surgeon. Fifteen cases met inclusion criteria: no conclusive MRI studies and no previous surgical treatment. Data collected included signs/symptoms, pre- and post-operative hormone levels, and complications resulting from surgical or medical management. Data regarding tumor diameter, location, and tumor residue/recurrence was obtained from both pre- and post-operative MRI. Immunohistochemistry was performed to assess for tumor hormone secretion. RESULTS Aside from a statistically significant difference (P = 0.001) in histopathological results between patients with negative and positive MRI, there were no statistically significant difference between these two groups in any other demographic or clinical data point. Inferior petrosal sinus sampling (IPSS) with desmopressin (DDAVP®) administration was performed on the 15 patients with inconclusive MRIs to identify the origin of ACTH hypersecretion via a central/peripheral (C/P) ratio. IPSS in seven, five and three patients showed right, left, and central side lateralization, respectively. With a mean follow-up of 5.5 years, among MRI-negative patients, 14 (93%) and 12 patients (80%) achieved early and long-term remission, respectively. In the MRI-positive cohort, over a mean follow-up of 4.8 years, 113 patients (94.9%) and 102 patients (85.7%) achieved initial and long-term remission, respectively. CONCLUSIONS Surgical management of MRI-negative/inconclusive Cushing's disease is challenging scenario requiring a multidisciplinary approach. An experienced neurosurgeon, in collaboration with a dedicated endocrinologist, should identify the most likely location of the adenoma utilizing IPSS findings, followed by careful surgical exploration of the pituitary to identify the adenoma.
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Affiliation(s)
- Guive Sharifi
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Arsalan Amin
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadmahdi Sabahi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Nikolas B Echeverry
- Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Nader Akbari Dilmaghani
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Otolaryngology, Head and Neck Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Mousavinejad
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Valizadeh
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Davoudi
- Department of Endocrinology, Loghman Hakim Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Director of Minimally Invasive Cranial and Pituitary Surgery Program, Research Director of Neuroscience Institute, Cleveland Clinic Florida Region, 2950 Cleveland Clinic Blvd. Weston, Cleveland, FL, 33331, USA.
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16
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Янар ЭА, Маказан НВ, Карева МА, Воронцов АВ, Владимирова ВП, Безлепкина ОБ, Петеркова ВА. Course of Cushing`s disease and treatment outcomes in correlation with pituitary MRI in children. Probl Endokrinol (Mosk) 2022; 68:93-104. [PMID: 35841173 PMCID: PMC9762535 DOI: 10.14341/probl12854] [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] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cushing's disease (CD) is a rare disorder of a persistent cortisol excess caused by ACTH-secreting pituitary tumor (corticotropinoma). Transsphenoidal surgery (TSS) is a treatment of choice for СD, which effectiveness range is from 70 to 90%. Recurrence rate after successful treatment is about 25%. If surgical treatment is unsuccessful or recurrence appear, radiation treatment is the next therapeutic option, which effectiveness range is also 90%, but the hypopituitarism rate as side effect of treatment is higher. Preoperative predictors of remission and recurrence are still unexplored what leads to further investigations. AIM Analysis of remission and recurrence rates of pediatric CD after successful treatment according to preoperative MRI and therapeutic option. MATERIALS AND METHODS We conducted a retrospective analysis of 90 pediatric patients with CD who were observed between 1992 and 2020 at the Endocrinology Research Centre. RESULTS The most common clinical symptoms of CD were weight gain [94%] and growth retardation [72%]. Pituitary tumor was detected on radiological imaging in 53/90 patients [59%], there were no signs of visible adenoma in 37/90 of patients [41%]. 63 of 90 patients underwent TSS (70%), 27 patients underwent radiosurgery (30%). Remission rate after TSS was 71% [45/63], after radiosurgery - 85% [23/27]. There were no significant differences in remission rates after radical treatment according to preoperative MRI results (P=0.21 after TSS and P=0.87 after radiosurgery, х2 analysis). Recurrence after successful treatment was diagnosed in 10 patients. There were no significant differences in time to recurrence according to preoperative MRI results (P=0.055, х2 analysis). Time to recurrence was statistically different after TSS compared to radiosurgery (P=0.007, Kaplan-Meier analysis) and in the group with developed adrenal insufficiency in the early postoperative period (P=0.04, Kaplan-Meier analysis). Analysis of side effect of treatment showed that the frequency of growth hormone and gonadotrophin deficiency was statistically higher after radiosurgery (р<0.01, Kruskel-Wallis ANOVA test). Diabetes insipidus was diagnosed only after TSS. CONCLUSION Results of our study didn`t allow to use MRI-results as predictor of effectiveness treatment in pediatric CD. Therapeutic option has an impact on time to recurrence, not on recurrence rates. The frequency of growth hormone and gonadotrophin deficiency was statistically higher after radiosurgery compared to TSS. Further studies are needed to identify predictors of remission and recurrence in CD.>< 0.01, Kruskel-Wallis ANOVA test). Diabetes insipidus was diagnosed only after TSS. CONCLUSION Results of our study didn`t allow to use MRI-results as predictor of effectiveness treatment in pediatric CD. Therapeutic option has an impact on time to recurrence, not on recurrence rates. The frequency of growth hormone and gonadotrophin deficiency was statistically higher after radiosurgery compared to TSS. Further studies are needed to identify predictors of remission and recurrence in CD.
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Affiliation(s)
- Э. А. Янар
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. В. Маказан
- Национальный медицинский исследовательский центр эндокринологии
| | - М. А. Карева
- Национальный медицинский исследовательский центр эндокринологии
| | - А. В. Воронцов
- Национальный медицинский исследовательский центр эндокринологии
| | | | | | - В. А. Петеркова
- Национальный медицинский исследовательский центр эндокринологии
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17
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Koh CH, Khan DZ, Digpal R, Layard Horsfall H, Ali AMS, Baldeweg SE, Bouloux PM, Dorward NL, Drake WM, Evanson J, Grieve J, Stoyanov D, Korbonits M, Marcus HJ. The clinical outcomes of imaging modalities for surgical management Cushing's disease - A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2022; 13:1090144. [PMID: 36714581 PMCID: PMC9880448 DOI: 10.3389/fendo.2022.1090144] [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: 11/05/2022] [Accepted: 12/23/2022] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Cushing's disease presents major diagnostic and management challenges. Although numerous preoperative and intraoperative imaging modalities have been deployed, it is unclear whether these investigations have improved surgical outcomes. Our objective was to investigate whether advances in imaging improved outcomes for Cushing's disease. METHODS Searches of PubMed and EMBASE were conducted. Studies reporting on imaging modalities and clinical outcomes after surgical management of Cushing's disease were included. Multilevel multivariable meta-regressions identified predictors of outcomes, adjusting for confounders and heterogeneity prior to investigating the effects of imaging. RESULTS 166 non-controlled single-arm studies were included, comprising 13181 patients over 44 years.The overall remission rate was 77.0% [CI: 74.9%-79.0%]. Cavernous sinus invasion (OR: 0.21 [CI: 0.07-0.66]; p=0.010), radiologically undetectable lesions (OR: 0.50 [CI: 0.37-0.69]; p<0.0001), previous surgery (OR=0.48 [CI: 0.28-0.81]; p=0.008), and lesions ≥10mm (OR: 0.63 [CI: 0.35-1.14]; p=0.12) were associated with lower remission. Less stringent thresholds for remission was associated with higher reported remission (OR: 1.37 [CI: 1.1-1.72]; p=0.007). After adjusting for this heterogeneity, no imaging modality showed significant differences in remission compared to standard preoperative MRI.The overall recurrence rate was 14.5% [CI: 12.1%-17.1%]. Lesion ≥10mm was associated with greater recurrence (OR: 1.83 [CI: 1.13-2.96]; p=0.015), as was greater duration of follow-up (OR: 1.53 (CI: 1.17-2.01); p=0.002). No imaging modality was associated with significant differences in recurrence.Despite significant improvements in detection rates over four decades, there were no significant changes in the reported remission or recurrence rates. CONCLUSION A lack of controlled comparative studies makes it difficult to draw definitive conclusions. Within this limitation, the results suggest that despite improvements in radiological detection rates of Cushing's disease over the last four decades, there were no changes in clinical outcomes. Advances in imaging alone may be insufficient to improve surgical outcomes. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42020187751.
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Affiliation(s)
- Chan Hee Koh
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
- Department of Neurosurgery, Royal Stoke University Hospital, Stoke, United Kingdom
- *Correspondence: Chan Hee Koh,
| | - Danyal Z. Khan
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Ronneil Digpal
- Department of Neurosurgery, University Hospital Southampton, Southampton, United Kingdom
| | - Hugo Layard Horsfall
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Ahmad M. S. Ali
- Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom
| | - Stephanie E. Baldeweg
- Department of Diabetes and Endocrinology, University College Hospital, London, United Kingdom
- Centre for Obesity & Metabolism, Department of Experimental & Translational Medicine, Division of Medicine, University College London, London, United Kingdom
| | - Pierre-Marc Bouloux
- Centre for Neuroendocrinology University College London Medical School, London, United Kingdom
| | - Neil L. Dorward
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - William M. Drake
- Centre for Endocrinology, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Jane Evanson
- Department of Radiology, Barts Health NHS Trust, London, United Kingdom
| | - Joan Grieve
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Márta Korbonits
- Centre for Endocrinology, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Hani J. Marcus
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
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18
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Tatsi C, Bompou ME, Flippo C, Keil M, Chittiboina P, Stratakis CA. Paediatric patients with Cushing disease and negative pituitary MRI have a higher risk of nonremission after transsphenoidal surgery. Clin Endocrinol (Oxf) 2021; 95:856-862. [PMID: 34431123 PMCID: PMC10913091 DOI: 10.1111/cen.14560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/05/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Diagnostic workup of Cushing disease (CD) involves imaging evaluation of the pituitary gland, but in many patients no tumour is visualised. The aim of this study is to describe the association of magnetic resonance imaging (MRI) findings with the postoperative course of paediatric and adolescent patients with CD. PATIENTS Patients with a diagnosis of CD at less than 21 years of age with MRI evaluation of the pituitary before first transsphenoidal surgery were included. MEASUREMENTS Clinical, imaging and biochemical data were analysed. RESULTS One hundred and eighty-six patients with paediatric or adolescent-onset CD were included in the study. Of all patients, 127 (68.3%) had MRI findings consistent with pituitary adenoma, while the remaining had negative or inconclusive MRI. Patients with negative MRI were younger in age and had lower morning cortisol and adrenocorticotropin levels. Of 181 patients with data on postoperative course, patients with negative MRI had higher odds of not achieving remission after the first surgery (odds ratio = 2.6, 95% confidence intervals [CIs] = 1.1-6.0) compared to those with positive MRI. In patients with remission after first transsphenoidal surgery, long-term recurrence risk was not associated with the detection of a pituitary adenoma in the preoperative MRI (hazard risk = 2.1, 95% CI = 0.7-5.8). CONCLUSIONS Up to one-third of paediatric and adolescent patients with CD do not have a pituitary tumour visualised in MRI. A negative MRI is associated with higher odds of nonremission after surgery; however, if remission is achieved, long-term risk for recurrence is not associated with the preoperative MRI findings.
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Affiliation(s)
- Christina Tatsi
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA
| | - Maria E. Bompou
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA
| | - Chelsi Flippo
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA
| | - Meg Keil
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA
| | - Prashant Chittiboina
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, Bethesda, Maryland, USA
| | - Constantine A. Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA
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19
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Cui M, Zhou T, Feng S, Liu X, Wang F, Zhang Y, Yu X. Altered microstructural pattern of white matter in Cushing's disease identified by automated fiber quantification. Neuroimage Clin 2021; 31:102770. [PMID: 34332193 PMCID: PMC8339293 DOI: 10.1016/j.nicl.2021.102770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/26/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022]
Abstract
A growing body of evidence suggests that altered brain structure plays a crucial role in the pathogenesis of neuropsychological abnormalities induced by hypercortisolism in patients with Cushing's disease. While most studies mainly focus on gray matter, white matter structure has been largely overlooked. In the current study, we conducted a cross-sectional diffusion tensor imaging study on 58 patients with Cushing's disease and 54 matched healthy individuals to profile the microstructural pattern using automated fiber quantification and investigate its association with neuroendocrine and neuropsychological deficits. The study revealed that microstructural pattern showed a widespread mean diffusivity, radial diffusivity increase, fractional anisotropy decrease and partial axial diffusivity increase among tracts notably in corpus callosum forceps, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, superior longitudinal fasciculus, uncinate fasciculus and arcuate fasciculus, while within the same tract abnormalities localized to specific positions. Moreover, compromised microstructural pattern of white matter in specific tracts and locations along the trajectory were associated with ACTH and cortisol concentration and cognitive decline in patients with Cushing's disease. Collectively, our study elucidates the form of white matter pathology induced by hypercortisolism and its association with cognitive decline which may provide further targets for early identification and intervention of Cushing's disease.
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Affiliation(s)
- Mengchu Cui
- Medical School of Chinese PLA, Beijing, PR China; Department of Neurosurgery, The First Medical Centre, Chinese PLA General Hospital, Beijing, PR China
| | - Tao Zhou
- Department of Neurosurgery, The First Medical Centre, Chinese PLA General Hospital, Beijing, PR China
| | - Shiyu Feng
- Department of Neurosurgery, The First Medical Centre, Chinese PLA General Hospital, Beijing, PR China
| | - Xinyun Liu
- Department of Radiology, The First Medical Centre, Chinese PLA General Hospital, Beijing, PR China
| | - Fuyu Wang
- Department of Neurosurgery, The First Medical Centre, Chinese PLA General Hospital, Beijing, PR China
| | - Yanyang Zhang
- Department of Neurosurgery, The First Medical Centre, Chinese PLA General Hospital, Beijing, PR China.
| | - Xinguang Yu
- Department of Neurosurgery, The First Medical Centre, Chinese PLA General Hospital, Beijing, PR China.
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20
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Zhang Y, Zhou T, Feng S, Wang W, Liu H, Wang P, Sha Z, Yu X. The chronic effect of cortisol on orchestrating cerebral blood flow and brain functional connectivity: evidence from Cushing's disease. Metabolism 2021; 115:154432. [PMID: 33197455 DOI: 10.1016/j.metabol.2020.154432] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cortisol has long been considered to play a crucial role in the pathogenesis of stress-related disorders. Cushing's disease (CD) provides an excellent "hyperexpression model" to investigate the chronic effects of cortisol on brain physiology and cognition. Previous studies have shown that cortisol is associated with neurophysiological alterations in animal models, which has also been examined by neural activity and cerebral blood flow (CBF) in human studies. However, the manner in which cortisol affects the coupling between brain activity and metabolic demand remains largely unknown. METHODS Here we used functional magnetic resonance imaging and arterial-spin-labeling imaging to investigate neurophysiological coupling by examining the ratio of CBF and functional connectivity strength (FCS) in 100 participants (47 CD patients and 53 healthy controls). RESULTS The results showed that CD was associated with lower CBF-FCS coupling predominantly in regions involving cognitive processing, such as the left dorsolateral prefrontal cortex and precuneus, as well as greater CBF-FCS coupling in subcortical structures, including the bilateral thalamus, right putamen, and hippocampus (P < 0.05, false discovery rate corrected). Moreover, regions with disrupted CBF-FCS coupling were associated with cortisol dosage and cognitive decline in CD patients. CONCLUSIONS Together, these findings elucidate the effect of cortisol excess on cerebral microenvironment regulation and associated cognitive disturbances in the human brain.
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Affiliation(s)
- Yanyang Zhang
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, PR China
| | - Tao Zhou
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, PR China
| | - Shiyu Feng
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, PR China
| | - Wenxin Wang
- Department of Radiology, The First Medical Center of Chinese PLA General Hospital, Beijing, PR China
| | - Hailong Liu
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, PR China
| | - Peng Wang
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, PR China
| | - Zhiqiang Sha
- Department of Psychiatry, Western Psychiatric Institute and Clinic, , University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Xinguang Yu
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, PR China.
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21
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Rak B, Maksymowicz M, Pękul M, Zieliński G. Clinical, Biological, Radiological Pathological and Immediate Post-Operative Remission of Sparsely and Densely Granulated Corticotroph Pituitary Tumors: A Retrospective Study of a Cohort of 277 Patients With Cushing's Disease. Front Endocrinol (Lausanne) 2021; 12:672178. [PMID: 34135861 PMCID: PMC8202403 DOI: 10.3389/fendo.2021.672178] [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: 02/25/2021] [Accepted: 04/30/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Cushing's disease is the most common cause of endogenous hypercortisolemia due to a corticotroph pituitary tumor. Up-to-date there is no reliable biomarker of invasiveness among corticotroph tumors, while it is well established in the literature that sparsely granulated somatotroph tumors are characterized by poorer prognosis. The aim of the study was to correlate multiple data including clinical, biochemical, radiological, and pathological findings (including granulation pattern) as well as immediate post-operative remission status among patients operated on due to corticotroph tumors. METHODS We enrolled all patients consecutively operated on for planned transsphenoidal neurosurgery due to corticotroph PitNETs in years 2010-2018. We excluded from analysis silent corticotroph tumors, plurihormonal PitNETs, and the Crooke's cell adenomas. RESULTS We recorded 348 hormonally active corticotroph PitNETs. The results of the analysis showed the female predominance 79.88% (n = 278), with the mean age of Cushing's disease occurrence 43.27 years of age. The mean time from the first signs and symptoms to the operation was 2 years. The women were diagnosed earlier (20-40 years of age vs. 50-60 years of age among men). We performed a detailed analysis of 277 cases classified by granularity pattern as DG or SG corticotroph PitNETs. Densely granulated tumors (DG) occurred four times more frequently than sparsely granulated (SG) (n = 225 vs. n = 52), at similar age (mean 42.94; median 40 vs. mean 45.46; median 45.5; p = 0.3896), but were characterized by lower Knosp's scale grades (p = 0.0147*), smaller preoperative tumors' volumes measured at MRI, and more commonly exhibited lower Ki-67 labeling index (<3%) (p = 0.0168*). What is more, DG adenomas more frequently achieved an immediate remission status (measured as postoperative cortisol concentration <2 µg/dl; p = 0.0180*), and the mean postoperative cortisol concentration in DG group was lower than in SG group (mean 5.375 µg/dl vs. 10.47 µg/dl; median 2.49 µg/dl vs. 6.52 µg/dl; p = 0.0028**). CONCLUSIONS Our study indicates that DG corticotroph adenomas occurred at younger age, more commonly were microadenomas as compared to SG tumors, less frequently had invasive features in comparison to SG corticotroph adenomas (p = 0.0019**), and more commonly achieved an immediate postsurgical hormonal remission (p = 0.0180*). We highlight the need for an accurate differentiation of DG and SG subtypes in the pathomorphological diagnosis of corticotropic tumors, especially in invasive PitNETs.
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Affiliation(s)
- Beata Rak
- Department of Internal Diseases and Endocrinology, Public Central Teaching Hospital, Medical University of Warsaw, and the Laboratory of Experimental Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Maria Maksymowicz
- Department of Pathology and Laboratory Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Monika Pękul
- Department of Pathology and Laboratory Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
- *Correspondence: Grzegorz Zieliński,
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22
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Bauduin SEEC, van der Pal Z, Pereira AM, Meijer OC, Giltay EJ, van der Wee NJA, van der Werff SJA. Cortical thickness abnormalities in long-term remitted Cushing's disease. Transl Psychiatry 2020; 10:293. [PMID: 32826851 PMCID: PMC7443132 DOI: 10.1038/s41398-020-00980-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 05/31/2020] [Accepted: 06/02/2020] [Indexed: 01/06/2023] Open
Abstract
Long-term remitted Cushing's disease (LTRCD) patients commonly continue to present persistent psychological and cognitive deficits, and alterations in brain function and structure. Although previous studies have conducted gray matter volume analyses, assessing cortical thickness and surface area of LTRCD patients may offer further insight into the neuroanatomical substrates of Cushing's disease. Structural 3T magnetic resonance images were obtained from 25 LTRCD patients, and 25 age-, gender-, and education-matched healthy controls (HCs). T1-weighted images were segmented using FreeSurfer software to extract mean cortical thickness and surface area values of 68 cortical gray matter regions and two whole hemispheres. Paired sample t tests explored differences between the anterior cingulate cortex (ACC; region of interest), and the whole brain. Validated scales assessed psychiatric symptomatology, self-reported cognitive functioning, and disease severity. After correction for multiple comparisons, ROI analyses indicated that LTRCD-patients showed reduced cortical thickness of the left caudal ACC and the right rostral ACC compared to HCs. Whole-brain analyses indicated thinner cortices of the left caudal ACC, left cuneus, left posterior cingulate cortex, right rostral ACC, and bilateral precuneus compared to HCs. No cortical surface area differences were identified. Cortical thickness of the left caudal ACC and left cuneus were inversely associated with anxiety symptoms, depressive symptoms, and disease duration, although certain associations did not persist after correction for multiple testing. In six of 68 regions examined, LTRCD patients had reduced cortical thickness in comparison to HCs. Cortical thickness of the left caudal ACC was inversely associated with disease duration. This suggests that prolonged and excessive exposure to glucocorticoids may be related to cortical thinning of brain structures involved in emotional and cognitive processing.
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Affiliation(s)
- S E E C Bauduin
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands.
| | - Z van der Pal
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - A M Pereira
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - O C Meijer
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - E J Giltay
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - N J A van der Wee
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - S J A van der Werff
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
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23
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Chaudhary K, Chandy D, Agrawal V, Dhawale A, Nagaonkar S. Spinal Epidural Lipomatosis with Osteoporotic Vertebral Fractures Presenting as Acute Thoracic Myelopathy in a 33-Year-Old Man with Cushing Disease. World Neurosurg 2020; 142:136-141. [PMID: 32634631 DOI: 10.1016/j.wneu.2020.06.212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 05/28/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Steroid-related spinal epidural lipomatosis (SEL) is a well-known condition most commonly encountered in patients taking chronic steroid medications. Endogenous Cushing syndrome is a rare cause of SEL. The authors report an unusual presentation of acute thoracic myelopathy due to SEL with osteoporotic vertebral compression fractures in a patient with Cushing disease. CASE DESCRIPTION A 33-year-old man presented with thoracic myelopathy due to SEL and multiple vertebral compression fractures. He had Cushingoid clinical features, and investigations revealed a pituitary microadenoma as the cause of hypercortisolism. The diagnosis was missed on multiple occasions before the onset of paraparesis. The patient was treated with urgent thoracic laminoplasty followed by transsphenoidal surgery on the same day. Although normalization of the serum cortisol levels was delayed by 6 months, he had a complete neurologic recovery and remains symptom free at 2 years follow-up. CONCLUSIONS This is a rare presentation of Cushing disease and has been reported only twice before in the 1990s. This case highlights the need to keep a high degree of suspicion for development of thoracic myelopathy in a patient with Cushing syndrome who develops thoracic compression fractures associated with SEL. Early recognition of this clinical association and addressing the primary endocrine problem urgently could have prevented spinal cord involvement and the subsequent spine surgery. This scenario is also documented in previous published case reports of this association where the diagnosis of Cushing syndrome has been revealed retrospectively after the development of neurologic symptoms.
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Affiliation(s)
- Kshitij Chaudhary
- Department of Orthopaedics and Spine Surgery, Sir HN Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India.
| | - David Chandy
- Department of Endocrinology, Sir HN Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India
| | - Vivek Agrawal
- Department of Neurosurgery, Sir HN Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India
| | - Arjun Dhawale
- Department of Orthopaedics and Spine Surgery, Sir HN Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India
| | - Smita Nagaonkar
- Department of Otolaryngology, Sir HN Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India
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Jiang H, Can-Xin X, Pan SJ, Na-Ying H, Sun YH, Yan FH, Bian LG, Liu C, Sun QF. The aging-liked alterations in Cushing's disease: A neurite orientation dispersion and density imaging (NODDI) study. J Neurol Sci 2020; 413:116769. [PMID: 32169741 DOI: 10.1016/j.jns.2020.116769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 02/22/2020] [Accepted: 03/03/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE Glucocorticoid (GC) is probably related to biological aging, but the exact mechanism remains unknown. Cushing's disease (CD) could represent a unique human model for examining the effects of prolonged exposure to hypercortisolism and its relationship with aging. Thus, we studied the alterations of neurites in CD patients with Neurite orientation dispersion and density imaging (NODDI). METHODS CD patients (n = 15) and healthy control subjects (n = 15) were included in this study. Orientation dispersion index (Odi), neurite density index (Ndi), partial fraction of free water (fiso), partial fraction of extracellular water (fec) were examined in a cross-sectional analysis. RESULTS Significant altered NODDI parameters were found in CD patients. Some of these alterations were correlated with current age. Additionally, increased dendritic density was found in cerebellar of CD patients. CONCLUSION Hypercortisolism relative reductions of the dendritic density were correlated with current age in several regions of CD patients. Our study enhances the understanding of the link between the aging and GC.
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Affiliation(s)
- Hong Jiang
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xu Can-Xin
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Si-Jian Pan
- Department of Stereotactic and Functional Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - He Na-Ying
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yu-Hao Sun
- Department of Stereotactic and Functional Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Fu-Hua Yan
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Liu-Guan Bian
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Chang Liu
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, Center for Information in Medicine, University of Electronic Science and Technology of China, Chengdu 610054, China; College of Information Technology and Engineering, Chengdu University, Chengdu 610106, China; College of Computer Science, Sichuan Normal University, Chengdu, Sichuan 610066, China.
| | - Qing-Fang Sun
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; Department of Neurosurgery, Rui-Jin Lu-Wan Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
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25
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Cheng H, Gao L, Hou B, Feng F, Guo X, Wang Z, Feng M, Xing B, Fan Y. Reversibility of cerebral blood flow in patients with Cushing's disease after surgery treatment. Metabolism 2020; 104:154050. [PMID: 31863780 PMCID: PMC6938712 DOI: 10.1016/j.metabol.2019.154050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 09/30/2019] [Revised: 11/29/2019] [Accepted: 12/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Cushing's disease (CD) patients have metabolic abnormalities in the brain caused by excessive exposure to endogenous cortisol. However, the reversibility of brain metabolism of CD patients after treatment remains largely unknown. METHODS This study recruited 50 CD patients seeking treatment and 34 matched normal controls (NCs). The patients were treated with Transsphenoidal Adenomectomy (TSA) and reexamined 3 months later. Cerebral blood flow (CBF) of the patients was assessed using 3D pseudo-continuous arterial spin labelling (PCASL) imaging before the treatment and at the 3-month follow-up and were compared with CBF measure of the NCs using a whole-brain voxelwise group comparison method. For remitted patients, their CBF measures and hormone level measures, including adrenocorticotropic hormone (ACTH), 24-hour urinary free cortisol (24hUFC) and serum cortisol, were compared before and after the treatment. Finally, a correlation analysis was carried out to explore the relationship between changes of CBF and hormone level measures of the remitted CD patients. RESULTS After the treatment, 45 patients reached remission. Compared with the NCs, the CD patients before the treatment exhibited significantly reduced CBF in cortical regions, including occipital lobe, parietal lobe, superior/middle/inferior temporal gyrus, superior/middle/inferior frontal gyrus, orbitofrontal cortex, precentral gyrus, middle/posterior cingulate gyrus, and rolandic operculum, as well as significantly increased CBF in subcortical structures, including caudate, pallidum, putamen, limbic lobe, parahippocampal gyrus, hippocampus, thalamus, and amygdala (p < 0.01, false discovery rate corrected). For the remitted patients, the change in CBF before and after the treatment displayed a spatial pattern similar to the difference between the NCs and the CD patients before the treatment, and no significant difference in CBF was observed between the NCs and the remitted CD patients after the treatment. The changes of 24hUFC were significantly correlated with the changes of averaged CBF within the subcortical region in the remitted patients (p = 0.01). CONCLUSIONS Our findings demonstrate that the brain metabolic abnormalities of CD patients are reversible when their hormone level changes towards normal after surgery treatment.
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Affiliation(s)
- Hewei Cheng
- Department of Biomedical Engineering, School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing, PR China; Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA; Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Lu Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China; China Pituitary Disease Registry Center, China Pituitary Adenoma Specialist Council, Beijing, PR China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China; China Pituitary Disease Registry Center, China Pituitary Adenoma Specialist Council, Beijing, PR China
| | - Zihao Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China; China Pituitary Disease Registry Center, China Pituitary Adenoma Specialist Council, Beijing, PR China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China; China Pituitary Disease Registry Center, China Pituitary Adenoma Specialist Council, Beijing, PR China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China; China Pituitary Disease Registry Center, China Pituitary Adenoma Specialist Council, Beijing, PR China.
| | - Yong Fan
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA; Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Zhao Y, Liang W, Cai F, Wu Q, Wang Y. Fluconazole for Hypercortisolism in Cushing's Disease: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2020; 11:608886. [PMID: 33391186 PMCID: PMC7774647 DOI: 10.3389/fendo.2020.608886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/12/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cushing's disease is associated with an increased risk of pulmonary fungal infection, which could be a relative contraindication for pituitary adenoma excision surgery. CASE We report a case of a patient with Cushing's disease and pulmonary Cryptococcus neoformans. A 48-year-old woman was admitted to our hospital because of moon face and edema. Laboratory and radiological findings suggested a diagnosis of Cushing's disease and pulmonary cryptococcus infection. Fluconazole 400 mg per day was administered intravenously and continued orally for 3 months. Both cryptococcus infection and hypercortisolism relieved and transsphenoidal resection was performed. CONCLUSION Cushing's disease can be effectively treated with fluconazole to normalize cortisol concentration prior to pituitary surgery. Fluconazole is an alternative treatment especially in Cushing's disease patients with cryptococcal pneumonia.
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Affiliation(s)
- Yiming Zhao
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Weiwei Liang
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Cai
- Department of Neurosurgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Qun Wu
- Department of Neurosurgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Yongjian Wang
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Yongjian Wang,
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Abstract
PURPOSE To explore the incidence of double pituitary adenomas in a tertiary center for pituitary surgery and asses their clinical, imaging and histopathological features. METHODS The medical records of the patients operated on for pituitary tumors at the Department of Neurosurgery of Military Institute of Medicine in Warsaw, Poland between the years 2003 and 2018 were retrospectively analyzed. Among the 3270 treated patients, the diagnosis of double pituitary adenoma was established in 22 patients. Clinical, laboratory, detailed histopathological and diagnostics imaging data were collected and analyzed. RESULTS There were 21 cases of synchronous and one case of asynchronous double pituitary adenoma. The main clinical finding was acromegaly (12/22) followed by Cushing's disease (3/22). The diagnosis of synchronous double pituitary adenoma was suspected in the preoperative MRI in 11 patients. In the remaining patients the diagnosis of contiguous double pituitary adenoma was confirmed in the histopathological examination. There was no predilection for gender and the mean observation time was 74.2 months. In one case of Cushing's disease the occurrence of double pituitary adenoma led to the initial failure of achieving hormonal remission. One patient presented with double pituitary adenomas as a manifestation of Carney complex. CONCLUSIONS Double pituitary adenoma is a rare entity that can pose a significant challenge especially in the setting of Cushing's disease. Careful inspection of preoperative MRI and diagnostic work-up before transsphenoidal surgery and thorough histopathological microscopic examinations with immunohistochemical staining for all pituitary hormones is essential for establishing the diagnosis of double pituitary adenoma.
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Affiliation(s)
- Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
| | - Emir Ahmed Sajjad
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland.
| | - Maria Maksymowicz
- Department of Pathology and Laboratory Diagnostics, M. Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - Monika Pękul
- Department of Pathology and Laboratory Diagnostics, M. Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - Andrzej Koziarski
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
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Stroud A, Zhang J, McCormack A. Diagnosing Cushing's disease in the context of chronic kidney disease: a case report and literature review. Eur J Endocrinol 2019; 181:K29-K35. [PMID: 31382242 DOI: 10.1530/eje-19-0326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/05/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The diagnosis of Cushing's disease (CD) is particularly challenging in patients with chronic kidney disease (CKD) due to abnormalities of the hypothalamo-pituitary-adrenal axis associated with the latter. This case report presents discrepant biochemical findings in a patient with CKD who was subsequently diagnosed with CD, and outlines principles which may guide the definitive diagnosis of CD in this context. METHODS The case of a patient with Stage 4 CKD who underwent transsphenoidal surgery for pituitary-dependent CD is presented. A literature review was conducted to identify similar cases and characterise features of hypothalamo-pituitary-adrenal axis dysfunction in CKD. RESULTS The patient discussed herein presented with markedly elevated plasma adrenocorticotrophic hormone (ACTH) due to a pituitary macroadenoma, with normal 24-h urine free cortisol (24-UFC) but abnormal overnight dexamethasone suppression testing and elevated midnight salivary cortisol. He experienced biochemical remission after undergoing transsphenoidal adenomectomy. A literature review revealed that CKD can be associated with elevated serum cortisol, reduced UFC and elevated plasma ACTH. Only four other cases of CD being diagnosed in a patient with CKD have been published. The loss of a circadian rhythm of cortisol secretion was the most common feature among all cases. CONCLUSIONS To establish a definitive diagnosis of CD in the context of pre-existing CKD, the absence of circadian rhythms of cortisol and ACTH is a more sensitive indicator than 24-UFC and low-dose dexamethasone suppression testing.
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Affiliation(s)
- Anna Stroud
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - John Zhang
- St Vincent's Hospital, Sydney, Australia
| | - Ann McCormack
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
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Pivonello R, Arnaldi G, Scaroni C, Giordano C, Cannavò S, Iacuaniello D, Trementino L, Zilio M, Guarnotta V, Albani A, Cozzolino A, Michetti G, Boscaro M, Colao A. The medical treatment with pasireotide in Cushing's disease: an Italian multicentre experience based on "real-world evidence". Endocrine 2019; 64:657-672. [PMID: 30968338 PMCID: PMC6551343 DOI: 10.1007/s12020-018-1818-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [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: 08/03/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022]
Abstract
A phase III study has demonstrated that 6-month pasireotide treatment induced disease control with good safety in 15-26% of patients with Cushing's disease (CD). The aim of the current study was to evaluate the 6-month efficacy and safety of pasireotide treatment according to the real-world evidence. Thirty-two CD patients started pasireotide at the dose of 600 µg twice a day (bid) and with the chance of up-titration to 900 µg bid, or down-titration to 450 or 300 µg bid, on the basis of urinary cortisol (UC) levels or safety. Hormonal, clinical and metabolic parameters were measured at baseline and at 3-month and 6-month follow-up, whereas tumour size was evaluated at baseline and at 6-month follow-up. At baseline, 31 patients had very mild to moderate disease and 1 patient had very severe disease. Five (15.6%) patients discontinued treatment for adverse events; the remaining 27 patients (26 with very mild to moderate disease and 1 with very severe disease), reached 6-month follow-up. Considering the group of patients with very mild to moderate disease, responsiveness, defined by the normalization (<1 the upper limit of normal range, ULN) or near normalization (>1 and ≤1.1 ULN) of UC levels, was registered in 21 patients (full control in 19 and near control in 2), corresponding to 67.7% and 80.8% according to an "intention-to-treat" or "per-protocol" methodological approach, respectively. Weight, body mass index, waist circumference, as well as total and LDL-cholesterol significantly decreased, whereas fasting plasma glucose and glycated haemoglobin significantly increased. Hyperglycaemia was documented in 81.2%, whereas gastrointestinal disturbances in 40.6% of patients. In conclusion, in the real-life clinical practice, pasireotide treatment normalizes or nearly normalizes UC in at least 68% of patients with very mild to moderate disease, with consequent improvement in weight, visceral adiposity and lipid profile, despite the occurrence or deterioration of diabetes in the majority of cases, confirming the usefulness of this treatment in patients with milder disease and without uncontrolled diabetes.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Carla Scaroni
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Carla Giordano
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Salvo Cannavò
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Laura Trementino
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marialuisa Zilio
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Valentina Guarnotta
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Adriana Albani
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Sperimentale, Università "La Sapienza", Roma, Italy
| | - Grazia Michetti
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marco Boscaro
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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Fukuhara N, Inoshita N, Yamaguchi-Okada M, Tatsushima K, Takeshita A, Ito J, Takeuchi Y, Yamada S, Nishioka H. Outcomes of three-Tesla magnetic resonance imaging for the identification of pituitary adenoma in patients with Cushing's disease. Endocr J 2019; 66:259-264. [PMID: 30760659 DOI: 10.1507/endocrj.ej18-0458] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pituitary adenoma has been reported to be detectable in only 36-63% of Cushing's disease (CD) patients by magnetic resonance imaging (MRI). In this study, we investigate the outcomes and problems associated with tumor identification using 3-Tesla (3-T) MRI, which provides clearer images than ≤1.5-T MRI, in 115 patients who were initially diagnosed with CD. Before surgery, 31 macroadenomas (27%) and 54 microadenomas (47%) were identified by 3-T MRI, but pituitary adenoma was invisible on MRI in the remaining 30 cases (26%). The smallest tumor diameter amenable to a definitive diagnosis was 2 mm, and spoiled gradient-echo was the best sequence for diagnosing microadenomas. In 14 of 30 cases of MRI-invisible CD, the pituitary adenoma was identified during surgery. Nine of these 14 tumors that developed from outside the pituitary gland were retrospectively identified on MRI by comparison with surgical findings. The remaining 16 cases of MRI-invisible CD in which the pituitary adenoma was not identified during surgery involved partial hypophysectomy. Seven cases were hormonally remitted, but another nine cases experienced persistent disease after surgery. The sensitivity and specificity of the pituitary adenoma diagnosis in CD patients after the introduction of 3-T MRI were 80% and 100%, respectively. However, the sensitivity decreased to 72% when macroadenomas were excluded. Some adenomas associated with CD are still undetectable on 3-T MRI due to tumor size, location and intensity. However, sensitivity can be improved by monitoring tumors that develop outside the pituitary gland.
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Affiliation(s)
- Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
| | - Naoko Inoshita
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Pathology, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Mitsuo Yamaguchi-Okada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Keita Tatsushima
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Akira Takeshita
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Junko Ito
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Yasuhiro Takeuchi
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Shozo Yamada
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
- Department of Neurosurgery, Tokyo Neurological Center Hospital, Tokyo 134-0088, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 105-8470, Japan
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Afshari A, Keil M, Lyssikatos C, Belyavskaya E, Valdés N, Chowdhry FA, Parsa K, Ardeshirpour Y, Pursley R, Khare S, Kainerstorfer JM, Chittiboina P, Lodish MB, Mazzuchi TA, Gandjbakhche AH, Stratakis CA. Optical Imaging Technology: A Useful Tool to Identify Remission in Cushing Disease After Surgery. Horm Metab Res 2019; 51:120-126. [PMID: 30602178 PMCID: PMC6753582 DOI: 10.1055/a-0801-8917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We recently reported the use of optical imaging technology to quantify facial plethora in endogenous Cushing syndrome (CS). In the present study, we studied a larger cohort of patients with Cushing disease (CD) and examined water content fraction as well as blood volume fraction as bio-optic markers for determining the efficacy of this methodology as a predictor of lasting remission after surgery for CS. We imaged 49 patients before and after transsphenoidal surgery (TSS) for Cushing disease (CD); 22 patients were also seen at 3-6 months, and 13 patients 12 months post-operatively. On all patients, we used multi-spectral imaging (MSI) to evaluate hemodynamic distributions as well as water content at a specific area of the face. We found a decrease in blood volume fraction after vs. before surgical treatment in the tested facial area in 37 of the 40 patients, as determined with biochemical markers (p<0.001). All patients that were followed up for up to 12 months showed the same decrease from preoperative values and they remained in remission from CD. We conclude that MSI can be used for the evaluation of remission from CD, at least in the immediate post-operative period and up to one year after surgery. The use of this technology can supplement biochemical and other testing for the evaluation of the various treatment modalities available for patients with CD.
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Affiliation(s)
- Ali Afshari
- Section on Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Margaret Keil
- Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Elena Belyavskaya
- Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Nuria Valdés
- Service of Endocrinology and Nutrition, Hospital Universitario Central de Asturias, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - Fatima A. Chowdhry
- Section on Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Kian Parsa
- Section on Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Yasaman Ardeshirpour
- Section on Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Randall Pursley
- Section on Signal Processing & Instrumentation, Computational Biosciences and Engineering Laboratory, Office of Intramural Research (OIR), Center for Information Technology (CIT), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Siddharth Khare
- Section on Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jana M. Kainerstorfer
- Assistant Professor of Biomedical Engineering, College of Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Prashant Chittiboina
- Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Maya B. Lodish
- Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Thomas A. Mazzuchi
- Professor and Department Chair of Engineering Management $ System Engineering Department, Engineering and Applied Science School, George Washington University, Washington, DC, USA
| | - Amir H. Gandjbakhche
- Section on Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Constantine A. Stratakis
- Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
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32
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Kochar IS, Ramachandran S, Sethi A. A variable course of Cushing's disease in a 7 year old: diagnostic dilemma. J Pediatr Endocrinol Metab 2018; 31:1285-1288. [PMID: 30312168 DOI: 10.1515/jpem-2018-0133] [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: 03/22/2018] [Accepted: 08/06/2018] [Indexed: 11/15/2022]
Abstract
Background Cushing's syndrome (CS) or hypercortisolism results from disruption of the hypothalamus-pituitary-adrenal (HPA) axis with the resultant increase in the circulating serum and urinary cortisol levels and lack of cortisol circadian rhythm. The resultant effects cause the physical manifestation of hypercortisolism. The appearance of Cushing's disease in children is insidious, the most common features being growth failure, obesity, early puberty and facial appearance. Case presentation We report a case of a 7-year-old male with a very unusual course of the disease, which could have led to diagnostic delays.
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Affiliation(s)
| | - Smita Ramachandran
- Fellow Pediatric Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
| | - Aashish Sethi
- Fellow Pediatric Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
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33
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Guo W, Li F, Zhu C, Wang B, Wang K, Dai C, Jia H, Wei H, He Q, Cui J, Yuan M, Tang S, Liu W, Zhu T, Gao Z, Zheng F, Ma Z, Qu H, Zhu M. Effect of hypercortisolism on bone mineral density and bone metabolism: A potential protective effect of adrenocorticotropic hormone in patients with Cushing's disease. J Int Med Res 2018; 46:492-503. [PMID: 28851260 PMCID: PMC6011297 DOI: 10.1177/0300060517725660] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 07/13/2017] [Indexed: 12/11/2022] Open
Abstract
Objective To investigate the effects of Cushing's disease (CD) and adrenal-dependent Cushing's syndrome (ACS) on bone mineral density (BMD) and bone metabolism. Methods Data were retrospectively collected for 55 patients with hypercortisolism (CD, n = 34; ACS n = 21) from January 1997 to June 2014. BMD was examined in all patients, and bone turnover markers were tested in some patients. Healthy controls (n = 18) were also recruited. Results The lumbar spine and femoral neck BMD were significantly lower in the ACS and CD groups than in the control group. Lumbar BMD was significantly lower in the ACS than CD group. The collagen breakdown product (CTX) concentrations were significantly higher while the osteocalcin and procollagen type I N-terminal propeptide (PINP) concentrations were significantly lower in the ACS and CD groups than in the control group. The PINP concentration was significantly lower while the CTX concentration was significantly higher in the ACS than CD group. In the CD group only, lumbar BMD and serum adrenocorticotropic hormone had a significant positive correlation. Conclusions Bone turnover markers indicated suppressed osteoblast and enhanced osteoclast activities. PINP and CTX changes might indicate bone mass deterioration. Adrenocorticotropic hormone might be protective for lumbar BMD in patients with CD.
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Affiliation(s)
- Weihong Guo
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Fengao Li
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Chonggui Zhu
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Baoping Wang
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Kunling Wang
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Chenlin Dai
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Hongwei Jia
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Hongyan Wei
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Qing He
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Jin Cui
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Menghua Yuan
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Shaofang Tang
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Wei Liu
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Tiehong Zhu
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Zhihong Gao
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Fangqiu Zheng
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Zhongshu Ma
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
| | - Huiqi Qu
- Department of Paediatrics, Division of Endocrinology, McGill University Health Centre Research Institute, Decarie Boulevard, Montréal, Québec, Canada
| | - Mei Zhu
- Department of Endocrinology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, China
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Jiang H, Ren J, He NY, Liu C, Sun YH, Jian FF, Bian LG, Shen JK, Yan FH, Pan SJ, Sun QF. Volumetric magnetic resonance imaging analysis in patients with short-term remission of Cushing's disease. Clin Endocrinol (Oxf) 2017; 87:367-374. [PMID: 28543178 DOI: 10.1111/cen.13381] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 03/02/2017] [Revised: 04/30/2017] [Accepted: 05/03/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The data on patients with short-term remission of Cushing's disease (CD) might provide information that is not available from previous long-term remission studies. We aimed to investigate structural changes in the brain in these patients and to examine whether these changes were associated with clinical characteristics. DESIGN A cross-sectional study was performed. METHODS Thirty-four patients with CD (14 with CD in short-term remission and 20 with active CD) and 34 controls matched for age, sex and education underwent clinical evaluation and magnetic resonance imaging brain scans. Biometric measurements, disease duration and remission duration data were collected. Grey matter volumes in the whole brain were examined using voxel-based morphometry (VBM). RESULTS No differences were observed in the grey matter volumes of the medial frontal gyrus (MFG) and cerebellum between the patients with remitted CD and healthy controls, whereas patients with active CD had smaller grey matter volumes in these two regions compared with controls and patients with remitted CD. Furthermore, significant correlations were found between remission time and grey matter values in these regions in short-term remission patients with CD. Additionally, greater grey matter volumes in the bilateral caudate of short-term remission patients with CD were observed. CONCLUSIONS Trends for structural restoration were found in CD patients with short-term remission. This finding was associated with the number of days elapsed since curative surgery and the current age of the patients. This study enhances our understanding of potential reversibility after the resolution of hypercortisolism in CD patients.
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Affiliation(s)
- Hong Jiang
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Ren
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Na-Ying He
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chang Liu
- College of Information Science and Engineering, Chengdu University, Chengdu, China
| | - Yu-Hao Sun
- Department of Stereotactic and Functional Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang-Fang Jian
- Department of Endocrinology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liu-Guan Bian
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Kang Shen
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fu-Hua Yan
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Si-Jian Pan
- Department of Stereotactic and Functional Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing-Fang Sun
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Affiliation(s)
- Cherng Jye Seow
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore.
| | - William Francis Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minn
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Kiefer FW, Winhofer Y, Iacovazzo D, Korbonits M, Wolfsberger S, Knosp E, Trautinger F, Höftberger R, Krebs M, Luger A, Gessl A. PRKAR1A mutation causing pituitary-dependent Cushing disease in a patient with Carney complex. Eur J Endocrinol 2017; 177:K7-K12. [PMID: 28522647 DOI: 10.1530/eje-17-0227] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/18/2017] [Indexed: 02/02/2023]
Abstract
CONTEXT Carney complex (CNC) is an autosomal dominant condition caused, in most cases, by an inactivating mutation of the PRKAR1A gene, which encodes for the type 1 alpha regulatory subunit of protein kinase A. CNC is characterized by the occurrence of endocrine overactivity, myxomas and typical skin manifestations. Cushing syndrome due to primary pigmented nodular adrenocortical disease (PPNAD) is the most frequent endocrine disease observed in CNC. CASE DESCRIPTION Here, we describe the first case of a patient with CNC and adrenocorticotropic hormone (ACTH)-dependent Cushing disease due to a pituitary corticotroph adenoma. Loss-of-heterozygosity analysis of the pituitary tumour revealed loss of the wild-type copy of PRKAR1A, suggesting a role of this gene in the pituitary adenoma development. CONCLUSION PRKAR1A loss-of-function mutations can rarely lead to ACTH-secreting pituitary adenomas in CNC patients. Pituitary-dependent disease should be considered in the differential diagnosis of Cushing syndrome in CNC patients.
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Affiliation(s)
- Florian W Kiefer
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Yvonne Winhofer
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Donato Iacovazzo
- Centre for Endocrinology, Barts and The London School of Medicine, Queen Mary University of London, London, UK
| | - Márta Korbonits
- Centre for Endocrinology, Barts and The London School of Medicine, Queen Mary University of London, London, UK
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Franz Trautinger
- Department of Dermatology and Venereology, Karl Landsteiner University of Health Sciences, St Pölten, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Krebs
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Anton Luger
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alois Gessl
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Vitale G, Tortora F, Baldelli R, Cocchiara F, Paragliola RM, Sbardella E, Simeoli C, Caranci F, Pivonello R, Colao A. Pituitary magnetic resonance imaging in Cushing's disease. Endocrine 2017; 55:691-696. [PMID: 27435590 DOI: 10.1007/s12020-016-1038-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 06/24/2016] [Indexed: 11/26/2022]
Abstract
Adrenocorticotropin-secreting pituitary tumor represents about 10 % of pituitary adenomas and at the time of diagnosis most of them are microadenomas. Transsphenoidal surgery is the first-line treatment of Cushing's disease and accurate localization of the tumor within the gland is essential for selectively removing the lesion and preserving normal pituitary function. Magnetic resonance imaging is the best imaging modality for the detection of pituitary tumors, but adrenocorticotropin-secreting pituitary microadenomas are not correctly identified in 30-50 % of cases, because of their size, location, and enhancing characteristics. Several recent studies were performed with the purpose of better localizing the adrenocorticotropin-secreting microadenomas through the use in magnetic resonance imaging of specific sequences, reduced contrast medium dose and high-field technology. Therefore, an improved imaging technique for pituitary disease is mandatory in the suspect of Cushing's disease. The aims of this paper are to present an overview of pituitary magnetic resonance imaging in the diagnosis of Cushing's disease and to provide a magnetic resonance imaging protocol to be followed in case of suspicion adrenocorticotropin-secreting pituitary adenoma.
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Affiliation(s)
- Giovanni Vitale
- Department of Clinical Sciences and Community Health (DISCCO), University of Milan, Milan, Italy.
- Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano IRCCS, Milan, Italy.
| | - Fabio Tortora
- Dipartimento Medico-Chirurgico di Internistica Clinica e Sperimentale "F. Magrassi e A. Lanzara", Second University of Naples, Naples, Italy
| | - Roberto Baldelli
- UOSD Endocrinologia, Istituto Nazionale Tumori "Regina Elena" -Roma, Rome, Italy
| | - Francesco Cocchiara
- Endocrinology, Department of Internal Medicine and Medical Specialities (DiMI), IRCCS AOU San Martino-IST, University of Genova, Genova, Italy
| | | | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Ferdinando Caranci
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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Jiang H, He NY, Sun YH, Jian FF, Bian LG, Shen JK, Yan FH, Pan SJ, Sun QF. Altered spontaneous brain activity in Cushing's disease: a resting-state functional MRI study. Clin Endocrinol (Oxf) 2017; 86:367-376. [PMID: 27859451 DOI: 10.1111/cen.13277] [Citation(s) in RCA: 16] [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: 08/23/2016] [Revised: 10/21/2016] [Accepted: 11/04/2016] [Indexed: 01/23/2023]
Abstract
CONTEXT AND OBJECTIVE Cushing's disease (CD) provides a unique and naturalist model for studying the influence of hypercortisolism on the human brain and the reversibility of these effects after resolution of the condition. This cross-sectional study used resting-state fMRI (rs-fMRI) to investigate the altered spontaneous brain activity in CD patients and the trends for potential reversibility after the resolution of the hypercortisolism. We also aim to determine the relationship of these changes with clinical characteristics and cortisol levels. SUBJECTS AND METHODS Active CD patients (n = 18), remitted CD patients (n = 14) and healthy control subjects (n = 22) were included in this study. Amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) values were calculated to represent spontaneous brain activity. RESULTS Our study resulted in three major findings: (i) active CD patients showed significantly altered spontaneous brain activity in the posterior cingulate cortex (PCC)/precuneus (PCu), occipital lobe (OC)/cerebellum, thalamus, right postcentral gyrus (PoCG) and left prefrontal cortex (PFC); (ii) trends for partial restoration of altered spontaneous brain activity after the resolution hypercortisolism were found in several brain regions; and (iii) active CD patients showed a significant correlation between cortisol levels and ALFF/ReHo values in the PCC/PCu, a small cluster in the OC and the right IPL. CONCLUSIONS This study provides a new approach to investigating brain function abnormalities in patients with CD and enhances our understanding of the effect of hypercortisolism on the human brain. Furthermore, our explorative potential reversibility study of patients with CD may facilitate the development of future longitudinal studies.
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Affiliation(s)
- Hong Jiang
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Na-Ying He
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Hao Sun
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang-Fang Jian
- Department of Endocrinology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liu-Guan Bian
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Kang Shen
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fu-Hua Yan
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Si-Jian Pan
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing-Fang Sun
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, Rui-Jin Lu-Wan Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Abstract
The purpose of this study was to review therapeutic outcomes and comorbidities of patients with Cushing's disease (CD) in a single center. We conducted a retrospective study of 33 patients with CD undergoing transsphenoidal surgery from January 2007 to February 2014 (27 females and 6 males, median age 38 years, range 18-71 years). The diagnosis of Cushing's syndrome was established on the basis of the patient's history, characteristic clinical features, and laboratory data including an elevated 24-h urinary free cortisol level, lack of serum cortisol suppression after dexamethasone suppression tests and an elevated midnight cortisol level. In 28/33 patients, the tumor was visualized on MR of the sellar region, while in 5 it was diagnosed using an inferior petrosal sinus sampling. Out of the 33 patients, 10 had macroadenoma and the remaining 23 had microadenoma. Twenty-one patients (63.6%) had hypertension, 17 (51.5%) dyslipidemia, and 7 (21.2%) had type 2 diabetes or impaired glucose tolerance. The median follow-up period was 28 months. Remission after transsphenoidal surgery was achieved in 78.8% of patients, while 7 patients failed to achieve disease remission. Those patients were treated with second-line treatment modalities (second operation, radiotherapy, bilateral adrenalectomy, and/or ketoconazole). One patient rejected all the treatment modalities after surgery. Cumulative remission after all the treatment modalities was achieved in 87.9% patients. Patients with Cushing's disease should be managed in centers with much experience due to high patient load. In our Center, the remission of the disease has been achieved in 78.8% of the patients following transsphenoidal surgery. Multimodal treatment which included radiotherapy and medical treatment led to biochemical remission of the disease in 87.9% of patients.
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Affiliation(s)
- Mirsala Solak
- Department of Endocrinology, Center of Neuroendocrinology Zagreb, University Hospital Center, Zagreb, Croatia.
| | - Ivana Kraljevic
- Department of Endocrinology, Center of Neuroendocrinology Zagreb, University Hospital Center, Zagreb, Croatia
| | - Tina Dusek
- Department of Endocrinology, Center of Neuroendocrinology Zagreb, University Hospital Center, Zagreb, Croatia
| | - Ante Melada
- Department of Neurosurgery, Center of Neuroendocrinology Zagreb, University Hospital Center, Zagreb, Croatia
| | | | - Vjerislav Peterkovic
- Department of Neurosurgery, Center of Neuroendocrinology Zagreb, University Hospital Center, Zagreb, Croatia
| | - David Ozretic
- Department of Radiology, University Hospital Center, Zagreb, Croatia
| | - Darko Kastelan
- Department of Endocrinology, Center of Neuroendocrinology Zagreb, University Hospital Center, Zagreb, Croatia
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Koulouri O, Steuwe A, Gillett D, Hoole AC, Powlson AS, Donnelly NA, Burnet NG, Antoun NM, Cheow H, Mannion RJ, Pickard JD, Gurnell M. A role for 11C-methionine PET imaging in ACTH-dependent Cushing's syndrome. Eur J Endocrinol 2015; 173:M107-20. [PMID: 26245763 DOI: 10.1530/eje-15-0616] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/05/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We report our experience of functional imaging with (11)C-methionine positron emission tomography-computed tomography (PET-CT) co-registered with 3D gradient echo (spoiled gradient recalled (SPGR)) magnetic resonance imaging (MRI) in the investigation of ACTH-dependent Cushing's syndrome. DESIGN Twenty patients with i) de novo Cushing's disease (CD, n=10), ii) residual or recurrent hypercortisolism following first pituitary surgery (±radiotherapy; n=8) or iii) ectopic Cushing's syndrome (n=2) were referred to our centre for functional imaging studies between 2010 and 2015. Six of the patients with de novo CD and five of those with persistent/relapsed disease had a suspected abnormality on conventional MRI. METHODS All patients underwent (11)C-methionine PET-CT. For pituitary imaging, co-registration of PET-CT images with contemporaneous SPGR MRI (1 mm slice thickness) was performed, followed by detailed mapping of (11)C-methionine uptake across the sella in three planes (coronal, sagittal and axial). This allowed us to determine whether suspected adenomas seen on structural imaging exhibited focal tracer uptake on functional imaging. RESULTS In seven of ten patients with de novo CD, asymmetric (11)C-methionine uptake was observed within the sella, which co-localized with the suspected site of a corticotroph microadenoma visualised on SPGR MRI (and which was subsequently confirmed histologically following successful transsphenoidal surgery (TSS)). Focal (11)C-methionine uptake that correlated with a suspected abnormality on pituitary MRI was seen in five of eight patients with residual or recurrent Cushing's syndrome following first TSS (and pituitary radiotherapy in two cases). Two patients elected to undergo repeat TSS with histology confirming a corticotroph tumour in each case. In two patients with the ectopic ACTH syndrome, (11)C-methionine was concentrated in sites of distant metastases, with minimal uptake in the sellar region. CONCLUSIONS (11)C-methionine PET-CT can aid the detection of ACTH-secreting tumours in Cushing's syndrome and facilitate targeted therapy.
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Affiliation(s)
- Olympia Koulouri
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Andrea Steuwe
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Daniel Gillett
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Andrew C Hoole
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Andrew S Powlson
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Neil A Donnelly
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Neil G Burnet
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Nagui M Antoun
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Heok Cheow
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Richard J Mannion
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - John D Pickard
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
| | - Mark Gurnell
- Metabolic Research Laboratories Wellcome Trust-MRC Institute of Metabolic Science Departments of Nuclear Medicine Medical Physics Otolaryngology Oncology Neuroradiology Neurosurgery National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge & Addenbrooke's Hospital, Box 289, Hills Road, Cambridge CB2 0QQ, UK
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Lampropoulos KI, Samonis G, Nomikos P. Factors influencing the outcome of microsurgical transsphenoidal surgery for pituitary adenomas: a study on 184 patients. Hormones (Athens) 2013; 12:254-64. [PMID: 23933694 DOI: 10.14310/horm.2002.1409] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Evaluation of factors influencing the outcome of microsurgical transsphenoidal surgery in patients harbouring pituitary adenomas as well as of the efficacy and safety of this procedure. DESIGN A total of 184 consecutive patients with pituitary adenomas, undergoing microsurgical transsphenoidal resection of their lesions from March 2004 to June 2011, were prospectively studied. Extent of tumour resection and disease remission were defined according to recently established radiological and hormonal consensus criteria. RESULTS The study included 97 nonfunctioning and 87 functioning adenomas. A gross-total removal, as documented on postoperative imaging, was achieved in 67.4% of all patients. Residual tumour after surgery was detected in 37.1% of patients with nonfunctioning adenomas. The remission rates for patients with functioning adenomas, as documented by the last endocrinological evaluation, were 54.9% for growth hormone-secreting, 69.5% for adrenocorticotropin hormone-secreting, 72.7% for prolactin-secreting and 100% for thyroid-stimulating hormone-secreting, with two recurrences in patients with Cushing's disease. Multivariate analysis showed that factors influencing surgical outcome were cavernous sinus invasion, large tumour diameter (≥25 mm) and reoperation for the nonfunctioning adenomas, and cavernous sinus invasion as well as large tumour diameter (≥25 mm) for the functioning adenomas. In the latter cohort, predictors for endocrinological remission were maximum tumour diameter (≤20 mm) and reoperation. Postoperative complications were present in 3.3% of the cases. One patient developed epistaxis, two hemorrhage at the surgical field, one postoperative rhinorrhea, one postoperative permanent diabetes insipidus and one postoperative panhypopituitarism. CONCLUSIONS Microsurgical transsphenoidal surgery is an effective and safe treatment in all patients with pituitary adenomas, except for prolactinomas responsive to medical therapy.
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Affiliation(s)
- Kostas I Lampropoulos
- Department of Neurosurgery and Gamma Knife Radiosurgery, Hygeia Hospital, Marousi, Athens, Greece.
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Därr R, Zöphel K, Eisenhofer G, Abolmaali N, Gastmeier J, Wieczorek K, Jelinek V, Kamvissi V, Bornstein SR, Hofbauer LC. Combined use of 68Ga-DOTATATE and 18F-FDG PET/CT to localize a bronchial carcinoid associated with ectopic ACTH syndrome. J Clin Endocrinol Metab 2012; 97:2207-8. [PMID: 22529105 DOI: 10.1210/jc.2012-1402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Roland Därr
- Division of Endocrinology, Department of Medicine III, Dresden Technical University Medical Center, Fetscherstrasse 74, 01307 Dresden, Germany
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Sun Y, Sun Q, Fan C, Shen J, Zhao W, Guo Y, Su T, Wang W, Ning G, Bian L. Diagnosis and therapy for Cushing's disease with negative dynamic MRI finding: a single-centre experience. Clin Endocrinol (Oxf) 2012; 76:868-76. [PMID: 22050513 DOI: 10.1111/j.1365-2265.2011.04279.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Most patients with Cushing's disease (CD) will have evidence of an adenoma on high-resolution magnetic resonance imaging (MRI). However, a significant minority of patients with CD and biochemical hypercortisolaemia have no visible adenoma on MRI. The purpose of this study was to evaluate the diagnostic value of preoperative biochemical assessment and accuracy of MRI findings on surgical outcome. DESIGN Retrospective data set analyses. PATIENTS AND MEASUREMENT: The clinical, endocrinological, histopathological and surgical outcomes of 24 consecutive CD patients with negative MRI findings were compared with those of 95 consecutive age- and sex-matched CD patients with pituitary adenomas on MRI. RESULTS The total remission rate was 86.6%. Among all patients, 87 had concordant positive endocrine tests and underwent neurosurgery, while bilateral inferior petrosal sinus sampling (BIPSS) was performed in 12 and 50 other patients with negative and positive MRI, respectively. A pituitary adenoma, confirmed by pathological examination, was found in 83.3% and 93.6% of patients with negative and positive MRI, respectively. The remission rate was not different between patients with negative and positive MRI (87.5 % and 86.3%, respectively; P > 0.05) or between patients who did not undergo BIPSS with negative MRI and patients with positive MRI (P > 0.05). The remission rate of patients who underwent BIPSS with negative MRI was not different from those not undergoing BIPSS (P > 0.05). The recurrence rate was higher, although not statistically different, in patients with negative MRI compared to positive ones. CONCLUSIONS Based on the findings outlined, MRI-negative CD may be a surgically remediable syndrome, with a pathophysiological basis that primarily involves a pituitary cause of the hypercortisolaemia.
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Affiliation(s)
- Yuhao Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Clayton RN, Raskauskiene D, Reulen RC, Jones PW. Mortality and morbidity in Cushing's disease over 50 years in Stoke-on-Trent, UK: audit and meta-analysis of literature. J Clin Endocrinol Metab 2011; 96:632-42. [PMID: 21193542 DOI: 10.1210/jc.2010-1942] [Citation(s) in RCA: 236] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Pituitary ACTH-dependent Cushing's disease (CD) is uncommon, and there are very limited data on long-term mortality. OBJECTIVE The aim was to summarize what is known about mortality in ACTH-dependent CD, to report on our own data, and to provide a meta-analysis of six other reports that addressed mortality of CD. DESIGN AND METHODS Vital status of 60 CD patients was recorded as of December 31, 2009, and the standardized mortality ratio (SMR) was calculated and compared with the general population of England and Wales, United Kingdom. A meta-analysis of SMRs from seven studies (including ours) was performed for overall mortality in CD. Where reported (four studies), a similar meta-analysis was performed for those patients whose hypercortisolism was in remission after treatment compared to those patients from the same center with persistent disease. RESULTS 1. From Stoke-on-Trent, 51 of 60 patients were female, median age at diagnosis was in the range of 36-46 yr, and median follow-up was 15 yr. There were 13 deaths, nine due to cardiovascular disease. Overall SMR for the whole cohort was 4.8 (95% confidence interval, 2.8-8.3) (P < 0001). SMR for vascular disease was 13.8 (7.2-36.5) (P < 0001). For persistent disease (n = 6), SMR was 16 (6.7-38.4) vs. remission (n = 54) SMR of 3.3 (1.7-6.7); after adjustment for age and sex, relative risk of death for persistent disease was 10.7 (2.3-48.6) (P = 0.002). Hypertension and diabetes mellitus were associated with significantly worse survival. 2. Using a random effects model meta-analysis revealed an overall (remission plus persistent disease) SMR of 2.2 (1.45-3.41) (P < 0.001). Pooled SMR was 1.2 (0.45-3.2) (P = not significant) for patients in remission and 5.5 (2.7-11.3) (P = 0.001) for patients with persistent disease. Persistence of disease, older age at diagnosis, and presence of hypertension and diabetes are the main determinants of mortality. CONCLUSIONS Overall mortality in CD is double that of the general population. However, patients with CD in remission fare much better than those with persistence of hypercortisolism, and they appear not to have an increased mortality rate. Hypertension and diabetes mellitus are risk factors for worse outcome. Because diagnosis and treatment of patients are at a young age, much longer follow-up of patients in remission is required before one can be confident that their mortality outcome is no different from that of the general population, especially because cardiovascular risk factors may persist after successful biochemical control of the disease.
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Affiliation(s)
- R N Clayton
- Department of Endocrinology, University Hospital of North Staffordshire, Stoke-on-Trent ST4 7PX, Staffordshire, United Kingdom.
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Savage MO, Dias RP, Chan LF, Afshar F, Plowman NP, Matson M, Grossman AB, Storr HL. Diagnosis and treatment of Cushing's disease in children. Endocr Dev 2009; 17:134-145. [PMID: 19955763 DOI: 10.1159/000262535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Cushing's disease (CD) is rare in the paediatric age range, but presents a diagnostic and therapeutic challenge. Most paediatric endocrinologists have limited experience managing children or adolescents with CD and thus benefit from close consultation with adult colleagues. A diagnostic protocol for investigation is required which broadly follows the model for adult patients. Treatment strategies for CD are described and critically appraised. The management of paediatric CD patients after cure also presents challenges for optimizing growth, bone health, reproduction and body composition from childhood into and during adult life.
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Bayram NA, Ersoy R, Aydin C, Gul K, Keles T, Topaloglu O, Durmaz T, Bozkurt E, Cakir B. Assessment of left ventricular functions by tissue Doppler echocardiography in patients with Cushing's disease. J Endocrinol Invest 2009; 32:248-52. [PMID: 19542743 DOI: 10.1007/bf03346461] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To verify whether tissue Doppler imaging (TDI) could contribute to a better understanding of the natural history of cardiomyopathy in active Cushing's disease (CD), through its enhanced sensitivity to diastolic dysfunction, and identifying preliminary regional signs of systolic dysfunction before the appearance of clinical symptoms of cardiac pathologies. METHODS Eleven women with newly diagnosed CD and 32 control cases, purposely matched for gender, age, body mass index and co-incidental diseases were enrolled in this study. Echocardiographic examinations were assessed by conventional echocardiography and tissue Doppler imaging. The peak systolic velocity (S'm), early diastolic myocardial peak velocity (E'm), late diastolic myocardial peak velocity (A'm), isovolumic acceleration (IVA), myocardial pre-contraction time (PCT'm), myocardial contraction time (CT'm) and myocardial relaxation time (RT'm) were measured at septal and lateral mitral anulus. RESULTS In TDI, E'm and, E'm/A'm ratio were significantly lower, and PCT'm/CT'm ratio was higher, S'm, A'm, peak early diastole/E'm ratio, PCT'm, and isovolumetric myocardial relaxation time values were similar at lateral and septal anulus in patients with CD than controls (p>0.05). Lateral and septal anulus IVA were significantly lower in patients with CD than the control group (p<0.05). Correlation analysis showed that IVA time at lateral anulus correlated positively with S'm at lateral anulus (r=0.58; p=0.002) and IVA time at septal anulus correlated positively with S'm at septal anulus (r=0.51; p=0.008). CONCLUSION Our study confirms that patients with CD have impaired diastolic function. More importantly, we also demonstrated an impairment of myocardial systolic function in patients with CD by TDI. We recommend using TDI in addition to conventional echocardiography parameters for the cardiovascular risk assessment of patients with Cushing' syndrome.
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Affiliation(s)
- N A Bayram
- Department of Cardiology, Ankara Ataturk Education and Research Hospital, Ankara, Turkey
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Jehle S, Walsh JE, Freda PU, Post KD. Selective use of bilateral inferior petrosal sinus sampling in patients with adrenocorticotropin-dependent Cushing's syndrome prior to transsphenoidal surgery. J Clin Endocrinol Metab 2008; 93:4624-32. [PMID: 18796519 PMCID: PMC2626443 DOI: 10.1210/jc.2008-0979] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Few data are available on the selective use of bilateral inferior petrosal sinus sampling (BIPSS) in the presurgical evaluation of patients with ACTH-dependent Cushing's syndrome, so we investigated whether its use only in patients without a clear adenoma on magnetic resonance imaging and/or inconsistent biochemical testing affected remission and long-term outcome after surgery in patients with Cushing's disease (CD). SETTING This was a retrospective review of patients treated for CD by one pituitary neurosurgeon at tertiary medical centers in New York City. PATIENTS A total of 193 consecutive adult patients who underwent initial transsphenoidal surgery (TS) for presumed CD between 1987 and 2005 were included. MAIN OUTCOME MEASURES We examined preoperative pituitary imaging and biochemical data, results of BIPSS and surgical pathology, and outcome based on biochemical tests after initial TS and long term after subsequent therapies. RESULTS Remission rate after the first TS was 80.8% overall, 79.1% in the BIPSS group (n = 105), and 83.0% in the No-BIPSS group (n = 88). Recurrences occurred in 13.5% after the first TS at a mean of 4.8 +/- 3.5 yr (range, 0.7-12.4 yr) with no difference between BIPSS and No-BIPSS groups. Long-term remission was achieved after surgeries and radiotherapy in 85% (86.7% of BIPSS group, 83.0% of No-BIPSS group). CD was ultimately confirmed in all but one patient in each group. CONCLUSIONS Selective use of BIPSS in the preoperative evaluation of patients with presumed CD did not lead to misdiagnosis in the No-BIPSS group or adversely affect remission rates or long-term outcome.
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Affiliation(s)
- Sigrid Jehle
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, New York 10029, USA
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Aldasouqi SA, Kosuri K, Mattewal A, Gossain VV. Visual vignette. Endocr Pract 2007; 13:429. [PMID: 17669724 DOI: 10.4158/ep.13.4.429] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Saleh A Aldasouqi
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
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Kwon HS, Kim SI, Yoo SJ, Yoon KH, Lee KW, Kang MW, Son HY, Kang SK, Cha BY. Adrenal tuberculosis in Cushing's disease with bilateral macronodular adrenocortical hyperplasia. Endocr J 2006; 53:219-23. [PMID: 16618981 DOI: 10.1507/endocrj.53.219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cushing's disease is a disorder of hypercortisolism caused by a pituitary micro- or macro-adenoma. Most patients with Cushing's disease have a bilateral adrenal enlargement, which depends on the duration of the disease, as a result of the long standing ACTH stimulation of both adrenal glands. However, in macronodular adrenocortical hyperplasia (MNH) that is caused by Cushing's disease, if the MNH gains autonomy, a bilateral adrenalectomy, as well as the removal of pituitary adenoma, is often essential. We encountered a patient diagnosed with Cushing's disease with bilateral adrenal tuberculosis simulating MNH. She had taken anti-tuberculosis medications one year prior to admission due to spinal tuberculosis. Sellar MRI revealed a pituitary macroadenoma, but adrenal CT showed enlargement in both adrenal glands that appeared to be MNH. A hormonal study and bilateral inferior petrosal sinus sampling revealed Cushing's disease. Therefore, she underwent trans-sphenoidal surgery of the pituitary mass. The pituitary surgery was successful and the serum cortisol returned to normal range. However, the adrenal mass rapidly enlarged after removing the pituitary tumor without showing evidence of a recurrence or adrenal autonomy of hypercortisolism. Accordingly, a laparoscopic left adrenalectomy was performed to examine the nature of the mass. The resected left adrenal gland was pathologically determined to have a lesion of tuberculosis with some part of the intact cortex. So we assumed that the cause of rapid adrenal enlargement might be due to adrenal tuberculosis. In summary, to the best of our knowledge, this is the first case of Cushing's disease coexisting with both adrenal tuberculosis simulating a bilateral MNH.
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Affiliation(s)
- Hyuk-Sang Kwon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea
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