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Ritzel K, Fazel J, August L, Fedtke V, Nowak E, Vogel F, Braun L, Zopp S, Then C, Künzel H, Reisch N, Zimmermann P, Thorsteinsdottir J, Schopohl J, Bidlingmaier M, Beuschlein F, Reincke M, Rubinstein G. Biochemical Control in Cushing's syndrome: Outcomes of the treatment in a large single center cohort. J Clin Endocrinol Metab 2024:dgae337. [PMID: 38767080 DOI: 10.1210/clinem/dgae337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/22/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Normalization of hypercortisolism is essential to reduce morbidity and mortality in patients with Cushing's syndrome (CS). The aim of this analysis was to assess biochemical control rates in patients with Cushing's disease (CD), ectopic Cushing's syndrome (ECS) and adrenal Cushing's syndrome (ACS). METHODS Patients with confirmed CS (n= 296) treated in a single tertiary care center were retrospectively analysed (185 CD, 27 ECS, 84 uni- and bilateral ACS). RESULTS Firstline treatment led to biochemical control in 82% of the patients. Time to biochemical control (median, IQR) was longer in CD (11.0 weeks, 5.6-29.8; p< 0.05) than in ACS (7.7 weeks, 4.1-17.1) and ECS (5.6 weeks, 4.1-23.3). Disease persistence or recurrence after first-line therapy was observed more often in CD (24% and 18%; p< 0.05) than in ECS (15% and 15%) and ACS (6% and 4%). Total time in hypercortisolism since diagnosis was significantly shorter in patients with CD diagnosed since 2013, after specialized patient care was implemented, compared to patients diagnosed before 2013 (13.5 weeks, vs. 26.1 weeks; p< 0.0070). Control of hypercortisolism at last follow up (76 months, 38-163) was achieved in 94% of patients with ACS, 100% of patients with ECS and 92% of patients with CD. CONCLUSIONS Biochemical control can be achieved in most patients with different subtypes of CS within a reasonable time frame. Control of hypercortisolism has improved over time.
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Affiliation(s)
- Katrin Ritzel
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Julia Fazel
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Leah August
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Vanessa Fedtke
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Elisabeth Nowak
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Frederick Vogel
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Leah Braun
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Stephanie Zopp
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Cornelia Then
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Heike Künzel
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Nicole Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | - Petra Zimmermann
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich
| | | | - Jochen Schopohl
- Department of Medicine IV, LMU University Hospital, LMU Munich
| | | | - Felix Beuschlein
- Department of Medicine IV, LMU University Hospital, LMU Munich
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zürich (USZ), and University of Zurich (UZH), Switzerland
- The LOOP Zurich - Medical Research Center, Zurich, Switzerland
| | - Martin Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich
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Braun LT, Osswald A, Zopp S, Rubinstein G, Vogel F, Riester A, Honegger J, Eisenhofer G, Constantinescu G, Deutschbein T, Quinkler M, Elbelt U, Künzel H, Nowotny HF, Reisch N, Hartmann MF, Beuschlein F, Pons-Kühnemann J, Reincke M, Wudy SA. Delineating endogenous Cushing's syndrome by GC-MS urinary steroid metabotyping. EBioMedicine 2024; 99:104907. [PMID: 38128413 PMCID: PMC10776922 DOI: 10.1016/j.ebiom.2023.104907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Diagnosing Cushing's syndrome (CS) is highly complex. As the diagnostic potential of urinary steroid metabolome analysis by gas chromatography-mass spectrometry (GC-MS) in combination with systems biology has not yet been fully exploited, we studied a large cohort of patients with CS. METHODS We quantified daily urinary excretion rates of 36 steroid hormone metabolites. Applying cluster analysis, we investigated a control group and 168 patients: 44 with Cushing's disease (CD) (70% female), 18 with unilateral cortisol-producing adrenal adenoma (83% female), 13 with primary bilateral macronodular adrenal hyperplasia (PBMAH) (77% female), and 93 ruled-out CS (73% female). FINDINGS Cluster-Analysis delineated five urinary steroid metabotypes in CS. Metabotypes 1, 2 and 3 revealing average levels of cortisol and adrenal androgen metabolites included patients with exclusion of CS or and healthy controls. Metabotype 4 reflecting moderately elevated cortisol metabolites but decreased DHEA metabolites characterized the patients with unilateral adrenal CS and PBMAH. Metabotype 5 showing strong increases both in cortisol and DHEA metabolites, as well as overloaded enzymes of cortisol inactivation, was characteristic of CD patients. 11-oxygenated androgens were elevated in all patients with CS. The biomarkers THS, F, THF/THE, and (An + Et)/(11β-OH-An + 11β-OH-Et) correctly classified 97% of patients with CS and 95% of those without CS. An inverse relationship between 11-deoxygenated and 11-oxygenated androgens was typical for the ACTH independent (adrenal) forms of CS with an accuracy of 95%. INTERPRETATION GC-MS based urinary steroid metabotyping allows excellent identification of patients with endogenous CS and differentiation of its subtypes. FUNDING The study was funded by the Else Kröner-Fresenius-Stiftung and the Eva-Luise-und-Horst-Köhler-Stiftung.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Straße 3, Tübingen 72076, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, Dresden 01307, Germany; Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, Dresden 01307, Germany
| | - Georgiana Constantinescu
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, Dresden 01307, Germany
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany; Medicover Oldenburg MVZ, Elisenstr. 12, Oldenburg 26122, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, Berlin 10627, Germany
| | - Ulf Elbelt
- Division of Medicine B, University Hospital Ruppin-Brandenburg, Brandenburg Medical School, Fehrbelliner Str. 38, Neuruppin 16816, Germany; Endokrinologikum Berlin MVZ, Friedrichstraße 76, Berlin 10117, Germany; Medical Department, Division of Psychosomatic Medicine, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Hanna F Nowotny
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Michaela F Hartmann
- Division of Pediatric Endocrinology & Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Feulgenstr. 10-12, Giessen 35392, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitäts-Spital Zürich (USZ) und Universität Zürich (UZH), Raemistrasse 100, Zürich CH-8091, Switzerland
| | - Jörn Pons-Kühnemann
- Medical Statistics, Institute of Medical Informatics, Justus Liebig University Giessen, Rudolf-Buchheim-Str. 6, Giessen D-35392, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany
| | - Stefan A Wudy
- Division of Pediatric Endocrinology & Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Feulgenstr. 10-12, Giessen 35392, Germany.
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Nowak E, Vogel F, Albani A, Braun L, Rubinstein G, Zopp S, Ritzel K, Beuschlein F, Theodoropoulou M, Reincke M. Diagnostic challenges in cyclic Cushing's syndrome: a systematic review. Lancet Diabetes Endocrinol 2023:S2213-8587(23)00150-X. [PMID: 37429301 DOI: 10.1016/s2213-8587(23)00150-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 07/12/2023]
Abstract
Cyclic Cushing's syndrome is a subentity of Cushing's syndrome in which phases of biochemical hypercortisolism (peaks) are followed by spontaneous periods of physiological or even hypocortisolaemic cortisol secretion (troughs). To identify common features of cyclic Cushing's syndrome, we systematically reviewed single case reports and case series in MEDLINE from database inception to Oct 10, 2022, and identified 707 articles, of which 149 articles were assessed for eligibility and 118 articles (covering 212 cases) were included in the analysis. Pituitary tumours accounted for 67% of cases of cyclic Cushing's syndrome (n=143), ectopic tumours for 17% (n=36), and adrenal tumours for 11% (n=23). Occult tumours accounted for 2% of cases (n=4), and 3% of cases were unclassified (n=6). We compared the clinical symptoms and comorbidities of patients with cyclic Cushing's syndrome with those of patients with non-cyclic Cushing's syndrome and observed no major difference. In adrenocorticotropic hormone (ACTH)-dependent cyclic Cushing's syndrome, bilateral inferior petrosal sinus sampling had a positive (ie, true pituitary) and negative (ie, true ectopic) predictive value of 100% when performed during periods of hypercortisolism, versus a positive predictive value of 73% and a negative predictive value of 86% when performed, irrespective of cortisolaemic status. Overall, 6% of patients (n=12) with cyclic Cushing's syndrome had unnecessary surgery due to misclassification. Remission rates were significantly lower and the time to remission significantly longer in patients with cyclic Cushing's syndrome compared with patients with non-cyclic Cushing's syndrome (p<0·001). Variations in biochemical test results due to unpredictable cycle duration and frequency might cause diagnostic challenges resulting in misdiagnoses and missed diagnoses.
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Affiliation(s)
- Elisabeth Nowak
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Frederick Vogel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Adriana Albani
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Leah Braun
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - German Rubinstein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stephanie Zopp
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Katrin Ritzel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Felix Beuschlein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany; Department of Endocrinology, Diabetology, and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
| | | | - Martin Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany.
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Lotan D, Park R, Rubinstein G, Moeller C, DeFilippis E, Oh K, Slomovich S, Oren D, Lin E, Clerkin K, Latif F, Colombo P, Yuzefpolskaya M, Topkara V, Kim J, Majure D, Sayer G, Jonathan W, Uriel N. The Utility and Characteristics of Cardiovascular Magnetic Resonance Imaging in Suspected Chronic Allograft Rejection. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Moeller C, Rubinstein G, Lotan D, Oren D, Clerkin K, Raikhelkar J, Colombo P, Leahy N, Fried J, Takeda K, Naka Y, Topkara V, Yuzefpolskaya M, Sayer G, Uriel N. Validation of the Heartmate 3 Survival Risk Score in a Large Left Ventricular Assist Device Center. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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6
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Rubinstein G, Lotan D, Moeller C, Slomovich S, Oren D, Fried J, Clerkin K, Topkara V, Raikhelkar J, Oh K, Takeda K, Naka Y, Kaku Y, Colombo P, Yuzefpolskaya M, Latif F, Sayer G, Uriel N. The Hemodynamic Effects of Pump Speed Adjustments in Patients with Heartmate 3 Left Ventricular Assist Device. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Moeller C, Oren D, DeFilippis E, Lotan D, Rubinstein G, Mehlman Y, Raja A, Slomovich S, Fried J, Raikhelkar J, Lin E, Oh K, Lee S, Topkara V, Majure D, Latif F, Sayer G, Uriel N, Clerkin K. Donor-Derived Cell-Free DNA in Heart Transplant Recipients with Coronary Allograft Vasculopathy. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Moeller C, Oren D, Rubinstein G, Lotan D, Slomovich S, Clerkin K, Fried J, Raikhelkar J, Mehlman Y, Lin E, Lee S, Kleet A, Oh K, Topkara V, DeFilippis E, Majure D, Latif F, Uriel N, Sayer G. Clinical Utility of Donor Derived Cell-Free DNA in the Multiorgan Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Mehlman Y, Lotan D, Rubinstein G, Moeller C, Oren D, Slomovich S, Latif F, Lee S, Oh K, Lin E, Raikhelkar J, Clerkin K, Fried J, Yuzefpolskaya M, DeFilippis E, Colombo P, Topkara V, Lewis M, Sayer G, Axsom K, Uriel N. Donor-Derived Cell-Free DNA in Heart Transplant Recipients with a History of Congenital Heart Disease. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Oren D, Moeller C, Rubinstein G, Lotan D, DeFilippis E, Mehlman Y, Raja A, Slomovich S, Clerkin K, Fried J, Raikhelkar J, Lin E, Oh K, Lee S, Topkara V, Latif F, Majure D, Sayer G, Uriel N. Evaluation of Donor Derived Cell-Free DNA in ABO Mismatched Heart Transplant Patients. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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McLeod J, Rosenblum H, Kennel P, Lotan D, Rubinstein G, Moeller C, Theodoropoulos K, Raikhelkar J, Clerkin K, Sayer G, Kaku Y, Takeda K, Uriel N, Fried J. Use of Extracorporeal Membrane Oxygenation in Ranolazine Overdose. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Lotan D, Rubinstein G, Moeller C, Slomovich S, Oren D, DeFilippis E, Raikhelkar J, Clerkin K, Fried J, Majure D, Naka Y, Kaku Y, Takeda K, Oh K, Lin E, Lee S, Topkara V, Colombo P, Yuzefpolskaya M, Latif F, Sayer G, Uriel N, Miroslav S. The Effect of Preservation Modality on Myocardial Injury - A Single Blinded Study. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Lotan D, Moeller C, Rubinstein G, Rosenblum H, DeFilippis E, Clerkin K, Raikhelkar J, Batra J, Oh K, Lin E, Fried J, Latif F, Kennel P, McLeod J, Colombo P, Lee S, Topkara V, Yuzefpolskaya M, Sayer G, Uriel N. Against All Odds - Transplanting Against 100% Reactive Antibodies and the Role of Non-Invasive Monitoring. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Slomovich S, Rubinstein G, Moeller C, Lotan D, Mehlman Y, Donald E, Batra J, Oren D, Oh K, Clerkin K, Fried J, DeFilippis E, Topkara V, Kleet A, Colombo P, Yuzefpolskaya M, Lin E, Lee S, Majure D, Latif F, Sayer G, Uriel N, Raikhelkar J. Donor-Derived Cell-Free DNA in Cancer Survivors Following Heart Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Rubinstein G, Lotan D, Moeller C, Slomovich S, Oren D, Mehlman Y, DeFilippis E, Lin E, Raikhelkar J, Clerkin K, Donald E, Oh K, Kleet A, Majure D, Lee S, Topkara V, Colombo P, Latif F, Yuzefpolskaya M, Sayer G, Uriel N. Donor-Derived Cell-Free DNA in Heart Transplant Recipients Bridged with Left Ventricular Assist Device. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Oren D, Moeller C, Lotan D, Rubinstein G, Slomovich S, Fried J, Raikhelkar J, Oh K, Topkara V, DeFilippis E, Colombo P, Yuzefpolskaya M, Lin E, Lee S, Latif F, Sayer G, Uriel N, Clerkin K. Donor-Derived Cell-Free Dna in Heart Transplant Recipients with Microvascular Cardiac Allograft Vasculopathy. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Lotan D, Moeller C, Rubinstein G, Oren D, Mehlman Y, Slomovich S, Aishwarya R, DeFilippis E, Fried J, Clerkin K, Raikhelkar J, Oh K, Lin E, Lee S, Colombo P, Kleet A, Yuzefpolskaya M, Topkara V, Latif F, Sayer G, Uriel N. Persistently Elevated Donor-Derived Cell-Free DNA in Heart Transplant Recipients. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Lotan D, Rubinstein G, Moeller C, Oren D, Slomovich S, Mehlman Y, DeFilippis E, Rosenblum H, Raikhelkar J, Clerkin K, Fried J, Oh K, Lin E, Lee S, Topkara V, Latif F, Colombo P, Yuzefpolskaya M, Sayer G, Uriel N. The Effect of Persistently Elevated Dd-Cfdna with De-Novo Donor Specific Antibody on Heart Transplant Recipients Outcomes. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Feldkamp L, Müller L, Deutschbein T, Detomas M, Hahner S, Strasburger CJ, Künzel H, Oßwald A, Braun L, Rubinstein G, Reincke M, Quinkler M, Kienitz T. Glucocorticoid receptor polymorphism BclI with increased glucocorticoid sensitivity has a positive influence on Quality of Life in Endogenous Cushing's syndrome in remission. Eur J Endocrinol 2023; 188:366-374. [PMID: 36995896 DOI: 10.1093/ejendo/lvad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/09/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
CONTEXT Patients with endogenous Cushing's syndrome (CS) may suffer from a wide range of neuropsychiatric symptoms leading to impaired quality of life (QoL). OBJECTIVE Glucocorticoid receptor (GR) polymorphisms are associated with increased (BclI and N363S) or decreased (A3669G and ER22/23EK) GR sensitivity. HYPOTHESIS GR genotypes may modulate and affect QoL and recovery after remission differently via GR sensitivity. METHODS 295 patients with endogenous CS (81 active, 214 in remission) from 3 centers of the German Cushing's Registry were included for the cross-sectional analysis. All subjects were assessed with three questionnaires (CushingQoL, Tuebingen CD-25, SF-36). For the longitudinal part 120 patients of them were analyzed at baseline and after 1.5 ± 0.9 yrs of follow-up. DNA samples were obtained from peripheral blood leukocytes for GR genotyping. RESULTS Patients in remission scored significantly better than patients with active CS in the CushingQoL questionnaire and in the SF-36 sub-categories physical and social functioning, role-physical, bodily pain and vitality. In cross-sectional analysis, no differences in QoL between minor allele and wildtype carriers were detected for all polymorphisms in active or cured CS. In longitudinal analysis, however, carriers with BclI minor allele showed significant improvement in SF-36 sub-categories vitality (p = 0.038) and mental health (p = 0.013) compared to wildtype carriers (active CS at baseline vs. CS in remission at follow-up). The outcome of the two questionnaires CushingQoL and Tuebingen CD-25 improved significantly in both wildtype and minor allele carriers. CONCLUSION BclI minor allele carriers initially had the lowest QoL but recovered better from impaired QoL than wildtype carriers.
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Affiliation(s)
- Lara Feldkamp
- Endocrinology in Charlottenburg, 10627 Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Lisa Müller
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | | | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Oßwald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Tina Kienitz
- Endocrinology in Charlottenburg, 10627 Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
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20
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Vogel F, Braun L, Zopp S, Nowak E, Schreiner J, Benz I, Rubinstein G, Künzel H, Ritzel K, Kroiss M, Honegger J, Beuschlein F, Schilbach K, Teupser D, Bidlingmaier M, Reincke M. Low-grade inflammation during the glucocorticoid withdrawal phase in patients with Cushing's syndrome. Eur J Endocrinol 2023; 188:375-384. [PMID: 36971260 DOI: 10.1093/ejendo/lvad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/05/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023]
Abstract
CONTEXT Endogenous Cushing's syndrome (CS) leads to profound immunosuppression. Successful surgery induces biochemical remission and reversal of immunosuppression, which is characterized by clinical signs of glucocorticoid withdrawal and associated with increased susceptibility to infections and thromboembolic complications. OBJECTIVE We hypothesized that the glucocorticoid withdrawal phase is characterized by low-grade inflammation that may be related to patient-relevant outcomes. PATIENTS AND METHODS In this retrospective observational study, we analyzed longitudinal data from 80 patients with CS prospectively enrolled in the German Cushing's registry between 2012 and 2021. All enrolled patients underwent successful surgery. In a second step, a case control study was performed in 25 of the patients with age-, gender- and BMI-matched control patients in whom hypercortisolism was excluded. Analyses included the inflammatory markers C-reactive protein and interleukin-6, as well as body composition, muscle function testing and quality of life questionnaires. The patients were studied during active CS and in the postoperative remission phase 1, 3, 6, 12 and 24 months after surgery. RESULTS Compared to the preoperative phase and matched controls, patients with CS had increased systemic inflammatory markers in the early remission phase. One month following surgery, median (IQR) C-reactive protein was 0.48 mg/dL (0.14; 0.90) vs. 0.10 mg/dL (0.06; 0.39) during active CS (p ≤ 0.001). Similarly, interleukin-6 one month after surgery was 7.2 pg/mL (3.3; 11.7) vs. 1.7 pg/mL (1.5; 2.5) during active CS (p ≤ 0.001). Obesity and HbA1c were associated with increased inflammation levels. This proinflammatory state lasted until one year following surgery. Moreover, inflammatory markers during early remission showed an inverse correlation with long-term muscle function. CONCLUSION The glucocorticoid withdrawal phase is associated with a low-grade inflammatory state, which is particularly pronounced in obese and hyperglycemic patients and related to lower muscle function.
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Affiliation(s)
- Frederick Vogel
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Leah Braun
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Stephanie Zopp
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Elisabeth Nowak
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Jochen Schreiner
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Irina Benz
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - German Rubinstein
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Heike Künzel
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Katrin Ritzel
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Matthias Kroiss
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Jürgen Honegger
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Felix Beuschlein
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich (USZ) und Universität Zürich (UZH), Zurich, Switzerland
| | | | - Daniel Teupser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | | | - Martin Reincke
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
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21
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Braun LT, Vogel F, Rubinstein G, Zopp S, Nowak E, Constantinescu G, Masjkur J, Detomas M, Pamporaki C, Altieri B, Deutschbein T, Quinkler M, Beuschlein F, Reincke M. Lack of sensitivity of diagnostic Cushing-scores in Germany: a multicenter validation. Eur J Endocrinol 2023; 188:6979714. [PMID: 36651158 DOI: 10.1093/ejendo/lvac016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Endogenous Cushing's syndrome (CS) is a severe condition, often diagnosed at a late stage. To reduce mortality, early diagnosis plays an important role. Two screening tools for early identification of patients with CS have been developed in multicentric cohorts, but have not yet been validated in cohorts with different geographic backgrounds. DESIGN We validated the Spanish score published by Leon-Justel et al. in 2016 and the Italian score by Parasiliti-Caprino et al. published in 2021 in our cohort. METHODS In the multicentric German Cushing registry, patients with confirmed and expected but ruled out Cushing's syndrome are prospectively diagnosed and followed up. We validated both scores in a cohort of 458 subjects: 176 patients with confirmed CS and 282 patients with suspected, but finally excluded CS. RESULTS Using the Spanish score, 17.5% of our patients with proven CS biochemical screening would not have been recommended. This concerned patients with pituitary CS (22%) and with adrenal CS (10%). On the contrary, only 14% of patients without CS would have received a recommendation for biochemical screening. Using the Italian score, 29% of patients with proven CS were classified into the low-risk classes not recommended for biochemical screening. This mostly affected patients with adrenal (31%) and pituitary CS (30%). About 12% of subjects without CS would have received a biochemical screening recommendation. CONCLUSIONS Both scores had limited sensitivity and high specificity in a German validation cohort. Further research is necessary to develop a screening score, which is effective in different healthcare systems and ethnicities.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
| | - Elisabeth Nowak
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
| | - Georgiana Constantinescu
- Department of Internal Medicine III, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden 01307, Germany
| | - Jimmy Masjkur
- Department of Internal Medicine III, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden 01307, Germany
| | - Mario Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg 97080, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden 01307, Germany
| | - Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg 97080, Germany
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg 97080, Germany
- Medicover Oldenburg MVZ, Oldenburg 26122, Germany
| | | | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich (USZ) und Universität Zürich (UZH), Zürich 8091, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
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22
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Braun LT, Vogel F, Zopp S, Marchant Seiter T, Rubinstein G, Berr CM, Künzel H, Beuschlein F, Reincke M. Whom Should We Screen for Cushing Syndrome? The Endocrine Society Practice Guideline Recommendations 2008 Revisited. J Clin Endocrinol Metab 2022; 107:e3723-e3730. [PMID: 35730067 PMCID: PMC9387700 DOI: 10.1210/clinem/dgac379] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Cushing syndrome (CS) is a rare and serious disease with high mortality. Patients are often diagnosed late in the course of the disease. OBJECTIVE This work investigated whether defined patient populations should be screened outside the at-risk populations defined in current guidelines. METHODS As part of the prospective German Cushing registry, we studied 377 patients with suspected CS. The chief complaint for CS referral was documented. Using urinary free cortisol, late-night salivary cortisol, and the 1-mg dexamethasone suppression test as well as long-term clinical observation, CS was confirmed in 93 patients and ruled out for the remaining 284. RESULTS Patients were referred for 18 key symptoms, of which 5 were more common in patients with CS than in those in whom CS was ruled out: osteoporosis (8% vs 2%; P = .02), adrenal incidentaloma (17% vs 8%, P = 0.01), metabolic syndrome (11% vs 4%; P = .02), myopathy (10% vs 2%; P < .001), and presence of multiple symptoms (16% vs 1%; P < .001). Obesity was more common in patients in whom CS was ruled out (30% vs 4%, P < .001), but recent weight gain was prominent in those with CS. A total of 68 of 93 patients with CS (73%) had typical chief complaints, as did 106 of 284 of patients with ruled-out CS status (37%) according to the Endocrine Society practice guideline 2008. CONCLUSION The 2008 Endocrine Society Practice guideline for screening and diagnosis of CS defined at-risk populations that should undergo testing. These recommendations are still valid in 2022.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - Thomas Marchant Seiter
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - Christina M Berr
- Department of Endocrinology, I. Medical Clinic, University Hospital, University of Augsburg, 86156 Augsburg, Germany
| | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich (USZ) und Universität Zürich (UZH), 8091 Zurich, Switzerland
| | - Martin Reincke
- Correspondence: Martin Reincke, MD, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstraße 5, 80336 Munich, Germany.
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Rubinstein G, Osswald A, Braun LT, Vogel F, Kroiss M, Pilz S, Deniz S, Aigner L, Knösel T, Bertherat J, Bouys L, Ladurner R, Riester A, Bidlingmaier M, Beuschlein F, Reincke M. The role of adrenal venous sampling (AVS) in primary bilateral macronodular adrenocortical hyperplasia (PBMAH): a study of 16 patients. Endocrine 2022; 76:434-445. [PMID: 35274284 PMCID: PMC9068666 DOI: 10.1007/s12020-022-03020-z] [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] [Received: 11/05/2021] [Accepted: 02/16/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Primary bilateral macronodular adrenocortical hyperplasia (PBMAH) is a rare cause of ACTH-independent Cushing's syndrome. Current guidelines recommend bilateral adrenalectomy for PBMAH, but several studies showed clinical effectiveness of unilateral adrenalectomy despite bilateral disease in selected patients. Our aim was to evaluate the gain of information which can be obtained through adrenal venous sampling (AVS) based cortisol lateralization ratios for guidance of unilateral adrenalectomy. DESIGN We performed a retrospective analysis of 16 patients with PBMAH and clinical overt cortisol secretion in three centers METHODS: Selectivity of adrenal vein sampling during AVS was defined as a gradient of cortisol or a reference adrenal hormone ≥2.0 between adrenal and peripheral vein. Lateralization was assumed if the dominant to non-dominant ratio of cortisol to reference hormone was ≥4.0. RESULTS AVS was technically successful in all patients based on absolute cortisol levels and in 13 of 16 patients (81%) based on reference hormone levels. Lateralization was documented in 8 of 16 patients. In patients with lateralization, in 5 of 8 cases this occurred toward morphologically larger adrenals, while in 3 patients lateralization was present in bilaterally identical adrenals. The combined volume of adrenals correlated positively with urinary free cortisol, suggesting that adrenal size is the dominant determinant of cortisol secretion. CONCLUSIONS In this study the gain of information through AVS for unilateral adrenalectomy was limited in patients with PBMAH and marked adrenal asymmetry.
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Affiliation(s)
- German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Theresa Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Matthias Kroiss
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University of Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Pilz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Sinan Deniz
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, München, Germany
| | - Laura Aigner
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, München, Germany
- Department for Diagnostic and Interventional Radiology and Neuroradiology, Klinikverbund Allgäu, Kempten, Germany
| | - Thomas Knösel
- Pathologisches Institut, Klinikum der Universität München, München, Deutschland
| | - Jérôme Bertherat
- Université de Paris, 75006, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, 75014, Paris, France
| | - Lucas Bouys
- Université de Paris, 75006, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, 75014, Paris, France
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich (USZ) and Universität Zürich (UZH), Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
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Braun LT, Vogel F, Zopp S, Rubinstein G, Schilbach K, Künzel H, Beuschlein F, Reincke M. Diurnal Salivary Cortisol Profiles in Patients with Cushing's Syndrome. Exp Clin Endocrinol Diabetes 2022; 130:434-438. [PMID: 35038761 DOI: 10.1055/a-1719-5381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Quantification of salivary cortisol is one of the highly sensitive and specific screening parameters for Cushing's syndrome (CS). However, only late-night salivary cortisol is part of the standard screening procedure. In this study, we aimed to analyze salivary cortisol day profiles in patients with different types of CS to test whether specific patterns might be relevant for diagnosis and subtyping. MATERIAL AND METHODS Among 428 patients including those with confirmed Cushing's syndrome (N=111, of those 75 with Cushing's disease, 27 patients with adrenal CS and nine patients with ectopic CS), autonomous cortisol secretion (N=39) or exclusion of CS (control group, N=278) salivary cortisol was measured five times a day. RESULTS At each of the five time points, salivary cortisol was significantly higher in patients with CS compared to the control group (p≤0.001). Using the entire profile instead of one single salivary cortisol at 11 p.m. improved diagnostic accuracy (85 vs. 91%) slightly. Patients with ACTH-dependent CS had higher salivary cortisol levels than patients with adrenal CS. Also, morning cortisol was significantly higher in patients with ectopic CS than in patients with Cushing's disease (p=0.04). Nevertheless, there was a strong overlap between diurnal profiles, and the diagnostic yield for subtyping was low. DISCUSSION The study results show that using diurnal salivary cortisol profiles for CS diagnosis results in a limited increase in diagnostic accuracy. With significant differences between Cushing subtypes, cortisol profiles are not useful in everyday clinical practice for subtyping of CS.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany.,Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
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25
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Zhang R, Rubinstein G, Vetrivel S, Kunz S, Vogel F, Bouys L, Bertherat J, Kroiss M, Deniz S, Osswald A, Knösel T, Bidlingmaier M, Sbiera S, Reincke M, Riester A. Steroid profiling using liquid chromatography mass spectrometry during adrenal vein sampling in patients with primary bilateral macronodular adrenocortical hyperplasia. Front Endocrinol (Lausanne) 2022; 13:1079508. [PMID: 36561559 PMCID: PMC9763872 DOI: 10.3389/fendo.2022.1079508] [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: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Adrenal vein sampling (AVS) is not a routine procedure in patients with primary bilateral macronodular adrenocortical hyperplasia (PBMAH), but has been used to determine lateralization of cortisol secretion in order to guide decision of unilateral adrenalectomy. Our aim was to characterize the steroid fingerprints in AVS samples of patients with PBMAH and hypercortisolism and to identify a reference hormone for AVS interpretation. METHOD Retrospectively, we included 17 patients with PBMAH from the German Cushing's registry who underwent AVS. 15 steroids were quantified in AVS and peripheral blood samples using LC-MS/MS. We calculated lateralization indices and conversion ratios indicative of steroidogenic enzyme activity to elucidate differences between individual adrenal steroidomes and in steroidogenic pathways. RESULTS Adrenal volume was negatively correlated with peripheral cortisone (r=0.62, p<0.05). 24-hour urinary free cortisol correlated positively with peripheral androgens (rDHEA=0.57, rDHEAS=0.82, rA=0.73, rT=0.54, p<0.05). DHEA was found to be a powerful reference hormone with high selectivity index, which did not correlate with serume cortisol and has a short half-life. All investigated steroids showed lateralization in single patients indicating the heterogenous steroid secretion pattern in patients with PBMAH. The ratios of corticosterone/aldosterone (catalyzed by CYP11B2), androstenedione/dehydroepiandrosterone (catalyzed by HSD3B2) and cortisone/cortisol (catalyzed by HSD11B2) in adrenal vein samples were higher in smaller adrenals (p<0.05). ARMC5 mutation carriers (n=6) showed lower androstenedione/17-hydroxyprogesterone and higher testosterone/androstenedione (p<0.05) ratios in peripheral blood, in line with lower peripheral androstenedione concentrations (p<0.05). CONCLUSION Steroid profiling by LC-MS/MS led us to select DHEA as a candidate reference hormone for cortisol secretion. Lateralization and different steroid ratios showed that each steroid and all three steroidogenic pathways may be affected in PBMAH patients. In patients with germline ARMC5 mutations, the androgen pathway was particularly dysregulated.
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Affiliation(s)
- Ru Zhang
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Sharmilee Vetrivel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Sonja Kunz
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Lucas Bouys
- Institut Cochin, Université Paris-Cité, Paris, France
| | | | - Matthias Kroiss
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Sinan Deniz
- Klinik und Poliklinik für Radiologie, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Thomas Knösel
- Pathologisches Institut, Ludwig-Maximilians-University, Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Silviu Sbiera
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
- *Correspondence: Anna Riester,
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26
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Braun LT, Zopp S, Vogel F, Honegger J, Rubinstein G, Schilbach K, Künzel H, Beuschlein F, Reincke M. Signs, symptoms and biochemistry in recurrent Cushing disease: a prospective pilot study. Endocrine 2021; 73:762-766. [PMID: 33871792 PMCID: PMC8325659 DOI: 10.1007/s12020-021-02719-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | | | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Germany.
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Heger E, Rubinstein G, Braun LT, Zopp S, Honegger J, Seidensticker M, Reincke M, Oßwald A. Chemosensory dysfunction in Cushing's syndrome. Endocrine 2021; 73:674-681. [PMID: 33821391 PMCID: PMC8325648 DOI: 10.1007/s12020-021-02707-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Cushing's syndrome (CS) can lead to structural changes in the brain and cognitive impairment, but chemosensory function has not been investigated yet. The aim was to analyze sense of smell and taste in patients with CS and explore the effect of therapy. METHODS The study cohort comprised 20 patients with florid CS treated between 2018 and 2020 in the outpatient clinic of the LMU Munich. We compared these 20 patients with CS to 40 healthy subjects matched for age, sex, and smoking status. Patients' sense of smell and taste was examined at diagnosis and 3 months after successful therapeutic surgery leading to clinical and biochemical remission. Odor threshold, discrimination, and identification were measured with "Sniffin' Sticks", taste was measured with "Taste Strips". Perceived sense of smell and taste was retrieved via a questionnaire. RESULTS Patients with florid CS had significantly reduced smell (total smell score 30.3 vs. 34.4, p < 0.0005) and taste scores (9.5 vs. 12.0, p < 0.0005) compared to controls and significantly more frequently hyposmia (55 vs. 2.5%, p < 0.0005), hypogeusia (40 vs. 0%, p < 0.0005), and self-reported chemosensory impairment (60 vs. 0%, p < 0.0005). Three months after successful surgery, CS patients showed significant improvement of odor threshold (8.1 vs. 7.0, p < 0.0005), odor discrimination (12.0 vs. 11.0, p = 0.003), total smell score (33.4 vs. 30.3, p < 0.0005), and taste (11.5 vs. 9.5, p = 0.003). CONCLUSIONS Chemosensory dysfunction is a novel and clinically relevant feature of CS.
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Affiliation(s)
- Elena Heger
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, München, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, München, Germany
| | - Leah T Braun
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, München, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, München, Germany
| | - Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Tübingen, Germany
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, Ludwig-Maximilians-Universität, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, München, Germany
| | - Andrea Oßwald
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, München, Germany.
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Vogel F, Braun L, Rubinstein G, Zopp S, Benedix S, Schneider H, Ritzel K, Schilbach K, Schmidmaier R, Beuschlein F, Bidlingmaier M, Reincke M. Patients with low IGF-I after curative surgery for Cushing's syndrome have an adverse long-term outcome of hypercortisolism-induced myopathy. Eur J Endocrinol 2021; 184:813-821. [PMID: 33830940 DOI: 10.1530/eje-20-1285] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/07/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Glucocorticoid excess leads to muscle atrophy and weakness in patients with endogenous Cushing's syndrome. Insulin-like growth factor I (IGF-I) is known to have protective effects on muscle loss. We hypothesized that individual serum IGF-I concentrations might be predictive for long-term myopathy outcome in Cushing's syndrome. PATIENTS AND METHODS In a prospective longitudinal study of 31 patients with florid Cushing's syndrome, we analyzed IGF-I and IGF binding protein 3 (IGFBP 3) concentrations at the time of diagnosis and following surgical remission over a period of up to 3 years. We assessed muscle strength by grip strength measurements using a hand grip dynamometer and muscle mass by bio-impedance measurements. FINDINGS Individual serum IGF-I concentrations in the postoperative phase were strongly predictive of long-term grip strength outcome (rs = 0.696, P ≤ 0.001). Also, lower IGF-I concentrations were associated with a lower muscle mass after 3 years (rs = 0.404, P = 0.033). While patients with high IGF-I s.d. scores (SDS; >1.4) showed an improvement in grip strength within the follow-up period (P = 0.009), patients with lower IGF-I SDS (≤-0.4) had a worse outcome with persisting muscle dysfunction. In contrast, preoperative IGF-I concentrations during the florid phase of Cushing's syndrome did not predict long-term muscle function outcome (rs = 0.285, P = 0.127). CONCLUSION Lower individual IGF-I concentrations 6 months after curative surgery for Cushing's syndrome are associated with adverse long-term myopathy outcome and IGF-I might be essential for muscle regeneration in the early phase after correction of hypercortisolism.
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Affiliation(s)
- Frederick Vogel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Sarina Benedix
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Holger Schneider
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Ralf Schmidmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Bayern, Germany
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Reincke M, Albani A, Assie G, Bancos I, Brue T, Buchfelder M, Chabre O, Ceccato F, Daniele A, Detomas M, Di Dalmazi G, Elenkova A, Findling J, Grossman AB, Gomez-Sanchez CE, Heaney AP, Honegger J, Karavitaki N, Lacroix A, Laws ER, Losa M, Murakami M, Newell-Price J, Pecori Giraldi F, Pérez-Rivas LG, Pivonello R, Rainey WE, Sbiera S, Schopohl J, Stratakis CA, Theodoropoulou M, van Rossum EFC, Valassi E, Zacharieva S, Rubinstein G, Ritzel K. Corticotroph tumor progression after bilateral adrenalectomy (Nelson's syndrome): systematic review and expert consensus recommendations. Eur J Endocrinol 2021; 184:P1-P16. [PMID: 33444221 PMCID: PMC8060870 DOI: 10.1530/eje-20-1088] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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: 09/21/2020] [Accepted: 01/12/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Corticotroph tumor progression (CTP) leading to Nelson's syndrome (NS) is a severe and difficult-to-treat complication subsequent to bilateral adrenalectomy (BADX) for Cushing's disease. Its characteristics are not well described, and consensus recommendations for diagnosis and treatment are missing. METHODS A systematic literature search was performed focusing on clinical studies and case series (≥5 patients). Definition, cumulative incidence, treatment and long-term outcomes of CTP/NS after BADX were analyzed using descriptive statistics. The results were presented and discussed at an interdisciplinary consensus workshop attended by international pituitary experts in Munich on October 28, 2018. RESULTS Data covered definition and cumulative incidence (34 studies, 1275 patients), surgical outcome (12 studies, 187 patients), outcome of radiation therapy (21 studies, 273 patients), and medical therapy (15 studies, 72 patients). CONCLUSIONS We endorse the definition of CTP-BADX/NS as radiological progression or new detection of a pituitary tumor on thin-section MRI. We recommend surveillance by MRI after 3 months and every 12 months for the first 3 years after BADX. Subsequently, we suggest clinical evaluation every 12 months and MRI at increasing intervals every 2-4 years (depending on ACTH and clinical parameters). We recommend pituitary surgery as first-line therapy in patients with CTP-BADX/NS. Surgery should be performed before extrasellar expansion of the tumor to obtain complete and long-term remission. Conventional radiotherapy or stereotactic radiosurgery should be utilized as second-line treatment for remnant tumor tissue showing extrasellar extension.
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Affiliation(s)
- Martin Reincke
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
| | - Adriana Albani
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
| | - Guillaume Assie
- Department of Endocrinology, Université de Paris, Institut Cochin, INSERM, CNRS, Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic Minnesota, Diabetes, Metabolism, Nutrition, Rochester, Minnesota, USA
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), Institut MarMaRa and Endocrinology Department, Conception Hospital, Assistance Publique-Hôpitaux de Marseille (APHM), Marseille, France
| | - Michael Buchfelder
- Universitätsklinikum Erlangen, Neurochirurgische Klinik, Erlangen, Germany
| | - Olivier Chabre
- CHU Grenoble-Alpes, Unit of Endocrinology, Pavillon des Ecrins, Grenoble, France
| | - Filippo Ceccato
- Department of Medicine, University of Padova, Padova, Veneto, Italy
| | - Andrea Daniele
- Department of Medicine, University of Padova, Padova, Veneto, Italy
| | - Mario Detomas
- Division of Endocrinology and Diabetology, Department of Internal Medicine, University of Würzburg, Wurzburg, Bayern, Germany
| | - Guido Di Dalmazi
- Department of Medical and Surgical Sciences, Endocrinology and Diabetes Prevention and Care Unit, University of Bologna, S. Orsola Policlinic, Bologna, Italy
| | - Atanaska Elenkova
- Department of Endocrinology, Medical University Sofia, Sofia, Bulgaria
| | - James Findling
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Menomonee Falls, Wisconsin, USA
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Centre for Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, UK
| | - Celso E Gomez-Sanchez
- Department of Pharmacology and Toxicology and Medicine, Endocrine Service, G.V. Montgomery VA Medical Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Anthony P Heaney
- Division of Endocrinology, Medical Director, Pituitary & Neuroendocrine Tumor Program, UCLA School of Medicine, Los Angeles, California, USA
| | - Juergen Honegger
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andre Lacroix
- Division of Endocrinology, Department of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Edward R Laws
- Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marco Losa
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Masanori Murakami
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - John Newell-Price
- Dept of Oncology and Metabolism, The Medical School University of Sheffield, Sheffield, UK
| | - Francesca Pecori Giraldi
- Department of Clinical Sciences & Community Health, University of Milan Neuroendocrinology Research Laboratory, Instituto Auxologico Italiano IRCCS, Milan, Italy
| | - Luis G Pérez-Rivas
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - William E Rainey
- Departments of Molecular & Integrative Physiology and Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Silviu Sbiera
- Division of Endocrinology and Diabetology, Department of Internal Medicine, University of Würzburg, Wurzburg, Bayern, Germany
| | - Jochen Schopohl
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
| | - Constantine A Stratakis
- Section on Genetics & Endocrinology Eunice Kennedy Shriver National Insitute of Child Health & Human Development (NICHD) National Institute of Health (NIH), NIH Clinical Research Center, Bethesda, Maryland, USA
| | - Marily Theodoropoulou
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Sabina Zacharieva
- Department of Endocrinology, Medical University Sofia, Sofia, Bulgaria
| | - German Rubinstein
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
| | - Katrin Ritzel
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany
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Vogel F, Braun L, Rubinstein G, Zopp S, Oßwald A, Schilbach K, Schmidmaier R, Bidlingmaier M, Reincke M. Metformin and Bone Metabolism in Endogenous Glucocorticoid Excess: An Exploratory Study. Front Endocrinol (Lausanne) 2021; 12:765067. [PMID: 34777259 PMCID: PMC8578886 DOI: 10.3389/fendo.2021.765067] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Glucocorticoid excess exhibits multiple detrimental effects by its catabolic properties. Metformin was recently suggested to protect from adverse metabolic side-effects of glucocorticoid treatment. Whether metformin is beneficial in patients with endogenous glucocorticoid excess has not been clarified. OBJECTIVE To evaluate the phenotype in patients with endogenous Cushing's syndrome (CS) treated with metformin at the time of diagnosis. PATIENTS AND METHODS As part of the German Cushing's Registry we selected from our prospective cohort of 96 patients all 10 patients who had been on pre-existing metformin treatment at time of diagnosis (CS-MET). These 10 patients were matched for age, sex and BMI with 16 patients without metformin treatment (CS-NOMET). All patients had florid CS at time of diagnosis. We analyzed body composition, metabolic parameters, bone mineral density and bone remodeling markers, muscle function and quality of life. RESULTS As expected, diabetes was more prevalent in the CS-MET group, and HbA1c was higher. In terms of comorbidities and the degree of hypercortisolism, the two groups were comparable. We did not observe differences in terms of muscle function or body composition. In contrast, bone mineral density in metformin-treated patients was superior to the CS-NOMET group at time of diagnosis (median T-Score -0.8 versus -1.4, p = 0.030). CS-MET patients showed decreased β-CTX levels at baseline (p = 0.041), suggesting reduced bone resorption under metformin treatment during glucocorticoid excess. CONCLUSION This retrospective cohort study supports potential protective effects of metformin in patients with endogenous glucocorticoid excess, in particular on bone metabolism.
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Vogel F, Braun LT, Rubinstein G, Zopp S, Künzel H, Strasding F, Albani A, Riester A, Schmidmaier R, Bidlingmaier M, Quinkler M, Deutschbein T, Beuschlein F, Reincke M. Persisting Muscle Dysfunction in Cushing's Syndrome Despite Biochemical Remission. J Clin Endocrinol Metab 2020; 105:dgaa625. [PMID: 32882010 PMCID: PMC7538105 DOI: 10.1210/clinem/dgaa625] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/31/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Glucocorticoid-induced myopathy is a characteristic symptom of endogenous Cushing's syndrome (CS). Its long-term outcome is largely unknown. OBJECTIVE To evaluate long-term muscle function following the remission of endogenous CS. STUDY DESIGN Observational longitudinal cohort study. SETTING Tertiary care hospitals and a specialized outpatient clinic. PATIENTS As part of the prospective multicenter German Cushing's Registry, we assessed muscle strength in patients with overt endogenous CS. We studied the patients at the time of diagnosis (n = 88), after 6 months (n = 69), and thereafter annually, following surgical remission over a period of up to 4 years (1 year: n = 55; 2 years: n = 34; 3 years: n = 29; 4 years: n = 22). Muscle function was evaluated by hand grip strength and by chair rising test. RESULTS Grip strength was decreased to 83% of normal controls (100%) at the time of diagnosis. It further decreased to 71% after 6 months in remission (P ≤ 0.001) and showed no improvement during further follow-up compared with baseline. Chair rising test performance improved initially (8 seconds at baseline vs 7 seconds after 6 months, P = 0.004) but remained at this reduced level thereafter (7 seconds after 3 years vs 5 seconds in controls, P = 0.038). In multivariate analysis, we identified, as predictors for long-term muscle dysfunction, age, waist-to-hip ratio, and hemoglobin A1c at baseline. Furthermore, muscle strength during follow-up was strongly correlated with quality of life. CONCLUSION This study shows that CS-associated myopathy does not spontaneously resolve during remission. This calls for action to identify effective interventions to improve muscle dysfunction in this setting.
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Affiliation(s)
- Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Heike Künzel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Finn Strasding
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Adriana Albani
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Anna Riester
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Ralf Schmidmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Martin Bidlingmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | | | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
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Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
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Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
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Braun LT, Fazel J, Zopp S, Benedix S, Osswald-Kopp A, Riester A, Rubinstein G, Seidensticker M, Beuschlein F, Drey M, Bidlingmaier M, Schmidmaier R, Reincke M. The Effect of Biochemical Remission on Bone Metabolism in Cushing's Syndrome: A 2-Year Follow-Up Study. J Bone Miner Res 2020; 35:1711-1717. [PMID: 32315096 DOI: 10.1002/jbmr.4033] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/01/2020] [Accepted: 04/13/2020] [Indexed: 12/16/2022]
Abstract
Endogenous Cushing's syndrome (CS) is a rare cause of secondary osteoporosis. The long-term consequences for bone metabolism after successful surgical treatment remain largely unknown. We assessed bone mineral density and fracture rates in 89 patients with confirmed Cushing's syndrome at the time of diagnosis and 2 years after successful tumor resection. We determined five bone turnover markers at the time of diagnosis, 1 and 2 years postoperatively. The bone turnover markers osteocalcin, intact procollagen-IN-propeptide (PINP), alkaline bone phosphatase, CTX-I, and TrAcP 5b were measured in plasma or serum by chemiluminescent immunoassays. For comparison, 71 sex-, age-, and body mass index (BMI)-matched patients in whom Cushing's syndrome had been excluded were studied. None of the patients received specific osteoanabolic treatment. At time of diagnosis, 69% of the patients had low bone mass (mean T-score = -1.4 ± 1.1). Two years after successful surgery, the T-score had improved in 78% of patients (mean T-score 2 years postoperatively -1.0 ± 0.9). The bone formation markers osteocalcin and intact PINP were significantly decreased at time of diagnosis (p ≤ 0.001 and p = 0.03, respectively), and the bone resorption marker CTX-I and TrAcP 5b increased. Postoperatively, the bone formation markers showed a three- to fourfold increase 1 year postoperatively, with a moderate decline thereafter. The bone resorption markers showed a similar but less pronounced course. This study shows that the phase immediately after surgical remission from endogenous CS is characterized by a high rate of bone turnover resulting in a striking net increase in bone mineral density in the majority of patients. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Julia Fazel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Sarina Benedix
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Andrea Osswald-Kopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany.,Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Michael Drey
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Ralf Schmidmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
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Rubinstein G, Osswald A, Hoster E, Losa M, Elenkova A, Zacharieva S, Machado MC, Hanzu FA, Zopp S, Ritzel K, Riester A, Braun LT, Kreitschmann-Andermahr I, Storr HL, Bansal P, Barahona MJ, Cosaro E, Dogansen SC, Johnston PC, Santos de Oliveira R, Raftopoulos C, Scaroni C, Valassi E, van der Werff SJA, Schopohl J, Beuschlein F, Reincke M. Time to Diagnosis in Cushing's Syndrome: A Meta-Analysis Based on 5367 Patients. J Clin Endocrinol Metab 2020; 105:5609009. [PMID: 31665382 DOI: 10.1210/clinem/dgz136] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/24/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Signs and symptoms of Cushing's syndrome (CS) overlap with common diseases, such as the metabolic syndrome, obesity, osteoporosis, and depression. Therefore, it can take years to finally diagnose CS, although early diagnosis is important for prevention of complications. OBJECTIVE The aim of this study was to assess the time span between first symptoms and diagnosis of CS in different populations to identify factors associated with an early diagnosis. DATA SOURCES A systematic literature search via PubMed was performed to identify studies reporting on time to diagnosis in CS. In addition, unpublished data from patients of our tertiary care center and 4 other centers were included. STUDY SELECTION Clinical studies reporting on the time to diagnosis of CS were eligible. Corresponding authors were contacted to obtain additional information relevant to the research question. DATA EXTRACTION Data were extracted from the text of the retrieved articles and from additional information provided by authors contacted successfully. From initially 3326 screened studies 44 were included. DATA SYNTHESIS Mean time to diagnosis for patients with CS was 34 months (ectopic CS: 14 months; adrenal CS: 30 months; and pituitary CS: 38 months; P < .001). No difference was found for gender, age (<18 and ≥18 years), and year of diagnosis (before and after 2000). Patients with pituitary CS had a longer time to diagnosis in Germany than elsewhere. CONCLUSIONS Time to diagnosis differs for subtypes of CS but not for gender and age. Time to diagnosis remains to be long and requires to be improved.
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Affiliation(s)
- German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Eva Hoster
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Marco Losa
- IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | - Atanaska Elenkova
- Department of Endocrinology, Medical University-Sofia, USHATE, "Acad. Ivan Penchev"
| | - Sabina Zacharieva
- Department of Endocrinology, Medical University-Sofia, USHATE, "Acad. Ivan Penchev"
| | - Márcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School; Endocrinology Service, AC Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Felicia Alexandra Hanzu
- Department of Endocrinology, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Theresa Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Prachi Bansal
- Department of Endocrinology, Seth Gordhandas Sunderdas Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - María-José Barahona
- Department of Endocrinology, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Elisa Cosaro
- Section of Endocrinology Department of Medicine, University of Verona, Verona, Italy
| | - Sema Ciftci Dogansen
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - Philip C Johnston
- Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, North Ireland
| | - Ricardo Santos de Oliveira
- Division of Pediatric Neurosurgery of the Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Christian Raftopoulos
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Elena Valassi
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
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Müller LM, Kienitz T, Deutschbein T, Riester A, Hahner S, Burger-Stritt S, Berr CM, Oßwald A, Braun L, Rubinstein G, Reincke M, Quinkler M. Glucocorticoid Receptor Polymorphisms Influence Muscle Strength in Cushing's Syndrome. J Clin Endocrinol Metab 2020; 105:5587858. [PMID: 31613324 DOI: 10.1210/clinem/dgz052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/24/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT An important clinical feature of Cushing's syndrome (CS) is proximal muscle myopathy caused by glucocorticoid induced protein metabolism. However, interindividual differences cannot be explained solely by the pure extent of hypercortisolemia. OBJECTIVE To evaluate the effects of glucocorticoid receptor (GR) polymorphisms (BclI, N363S, ER22/23EK and A3669G), which influence peripheral glucocorticoid sensitivity on muscular function in endogenous CS. METHODS 205 patients with proven endogenous CS (128 central, 77 adrenal) from 3 centers of the German Cushing's Registry and 125 subjects, in whom CS was ruled out, were included. All subjects were assessed for grip strength (via hand grip dynamometer) and performed a chair-rising test (CRT). DNA samples were obtained from peripheral blood leukocytes for GR genotyping. RESULTS In patients with active CS, normalized handgrip strength of the dominant and nondominant hand was higher in A3669G minor allele than in wildtype carriers (P = .006 and P = .021, respectively). CS patients in remission and ruled-out CS showed no differences in handgrip strength regarding A3669G minor allele and wildtype carriers. Male CS patients harboring the ER22/23EK wildtype presented lower hand grip strength than minor allele carriers (P = .049 dominant hand; P = .027 nondominant hand). The other polymorphisms did not influence handgrip strength. CRT showed no differences regarding GR polymorphisms carrier status. CONCLUSION Handgrip strength seems to be more susceptible to hypercortisolism in A3669G wildtype than in A3669G minor allele carriers. This might partially explain the inter-individual differences of glucocorticoid-induced myopathy in patients with endogenous CS. ER22/23EK polymorphism seems to exert sex-specific differences.
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Affiliation(s)
- Lisa Marie Müller
- Endocrinology in Charlottenburg, Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Stephanie Burger-Stritt
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Christina M Berr
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Oßwald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
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Fankhauser M, Bechmann N, Lauseker M, Goncalves J, Favier J, Klink B, William D, Gieldon L, Maurer J, Spöttl G, Rank P, Knösel T, Orth M, Ziegler CG, Aristizabal Prada ET, Rubinstein G, Fassnacht M, Spitzweg C, Grossman AB, Pacak K, Beuschlein F, Bornstein SR, Eisenhofer G, Auernhammer CJ, Reincke M, Nölting S. Synergistic Highly Potent Targeted Drug Combinations in Different Pheochromocytoma Models Including Human Tumor Cultures. Endocrinology 2019; 160:2600-2617. [PMID: 31322702 PMCID: PMC6795182 DOI: 10.1210/en.2019-00410] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 05/30/2019] [Accepted: 07/14/2019] [Indexed: 01/09/2023]
Abstract
There are no officially approved therapies for metastatic pheochromocytomas apart from ultratrace 131I-metaiodbenzylguanidine therapy, which is approved only in the United States. We have, therefore, investigated the antitumor potential of molecular-targeted approaches in murine pheochromocytoma cell lines [monocyte chemoattractant protein (MPC)/monocyte chemoattractant protein/3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT)], immortalized mouse chromaffin Sdhb-/- cells, three-dimensional pheochromocytoma tumor models (MPC/MTT spheroids), and human pheochromocytoma primary cultures. We identified the specific phosphatidylinositol-3-kinase α inhibitor BYL719 and the mammalian target of rapamycin inhibitor everolimus as the most effective combination in all models. Single treatment with clinically relevant doses of BYL719 and everolimus significantly decreased MPC/MTT and Sdhb-/- cell viability. A targeted combination of both inhibitors synergistically reduced MPC and Sdhb-/- cell viability and showed an additive effect on MTT cells. In MPC/MTT spheroids, treatment with clinically relevant doses of BYL719 alone or in combination with everolimus was highly effective, leading to a significant shrinkage or even a complete collapse of the spheroids. We confirmed the synergism of clinically relevant doses of BYL719 plus everolimus in human pheochromocytoma primary cultures of individual patient tumors with BYL719 attenuating everolimus-induced AKT activation. We have thus established a method to assess molecular-targeted therapies in human pheochromocytoma cultures and identified a highly effective combination therapy. Our data pave the way to customized combination therapy to target individual patient tumors.
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Affiliation(s)
- Maria Fankhauser
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Nicole Bechmann
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - Michael Lauseker
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Campus Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Judith Goncalves
- Institut National de la Santé et de la Recherche Médicale, UMR970, Paris-Cardiovascular Research Center, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Judith Favier
- Institut National de la Santé et de la Recherche Médicale, UMR970, Paris-Cardiovascular Research Center, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Barbara Klink
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- National Center of Genetics, Laboratoire National de Santé, Dudelange, Luxembourg
- German Cancer Consortium, Dresden, Germany
| | | | - Laura Gieldon
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- German Cancer Consortium, Dresden, Germany
- German Cancer Research Center, Heidelberg, Germany
- Core Unit for Molecular Tumor Diagnostics, National Center for Tumor Diseases, Heidelberg, Germany
| | - Julian Maurer
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Gerald Spöttl
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Petra Rank
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Thomas Knösel
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Michael Orth
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Christian G Ziegler
- Department of Medicine III, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | | | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Martin Fassnacht
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital, University of Würzburg, Würzburg, Germany
| | - Christine Spitzweg
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
- Royal Free Hospital ENETS Centre of Excellence, London, United Kingdom
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Stefan R Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Graeme Eisenhofer
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Christoph J Auernhammer
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
| | - Svenja Nölting
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Munich, Germany
- Correspondence: Svenja Nölting, MD, Med. Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstraße 1, 80336 Munich, Germany. E-mail:
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Lechner B, Heinrich D, Nölting S, Osswald-Kopp A, Rubinstein G, Sauerbeck J, Beuschlein F, Reincke M. [Update on endocrine hypertension]. Internist (Berl) 2019; 59:1163-1179. [PMID: 30280206 DOI: 10.1007/s00108-018-0505-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Endocrine disorders are the most common causes of secondary hypertension. Early diagnosis and specific treatment are crucial for improvement of the prognosis. This article provides an overview on which clinical constellations point to an increased risk of secondary causes of hypertension. These include spontaneous hypokalemia, young age at onset of hypertension, adrenal incidentaloma and therapy refractive arterial hypertension. The basic diagnostics include determination of the aldosterone to renin ratio, measurement of free plasma metanephrines and a 1 mg dexamethasone suppression test. Borderline results require repeated control testing and/or confirmatory testing under standardized test conditions. In cases of repeatedly conspicuous results referral to a specialized clinic should be considered for further clarification and confirmation of the diagnosis. Imaging diagnostics may constitute an adjunct to laboratory testing after the diagnosis has been confirmed. Therapeutic algorithms vary depending on the underlying endocrine disease.
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Affiliation(s)
- B Lechner
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Campus Innenstadt, Ziemssenstr. 1, 80336, München, Deutschland.
| | - D Heinrich
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Campus Innenstadt, Ziemssenstr. 1, 80336, München, Deutschland
| | - S Nölting
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Campus Innenstadt, Ziemssenstr. 1, 80336, München, Deutschland
| | - A Osswald-Kopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Campus Innenstadt, Ziemssenstr. 1, 80336, München, Deutschland
| | - G Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Campus Innenstadt, Ziemssenstr. 1, 80336, München, Deutschland
| | - J Sauerbeck
- Klinik und Poliklinik für Nuklearmedizin, Klinikum der Universität München, München, Deutschland
| | - F Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Campus Innenstadt, Ziemssenstr. 1, 80336, München, Deutschland
| | - M Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Campus Innenstadt, Ziemssenstr. 1, 80336, München, Deutschland
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Osswald A, Quinkler M, Di Dalmazi G, Deutschbein T, Rubinstein G, Ritzel K, Zopp S, Bertherat J, Beuschlein F, Reincke M. Long-Term Outcome of Primary Bilateral Macronodular Adrenocortical Hyperplasia After Unilateral Adrenalectomy. J Clin Endocrinol Metab 2019; 104:2985-2993. [PMID: 30844071 DOI: 10.1210/jc.2018-02204] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/01/2019] [Indexed: 02/03/2023]
Abstract
CONTEXT Unilateral adrenalectomy has been proposed in selected patients with primary bilateral macronodular adrenocortical hyperplasia (PBMAH), but its long-term outcome is unclear. OBJECTIVE The aim of this study was to analyze long-term clinical and biochemical outcomes of unilateral adrenalectomy vs bilateral adrenalectomy in patients with PBMAH in comparison with the outcome of cortisol-producing adenoma (CPA) treated with unilateral adrenalectomy. DESIGN Retrospective observational study in three German and one Italian academic tertiary care center. PATIENTS AND METHODS Twenty-five patients with PBMAH after unilateral adrenalectomy (unilat-ADX-PBMAH), nine patients with PBMAH and bilateral adrenalectomy (bilat-ADX-PBMAH), and 39 patients with CPA and unilateral adrenalectomy (unilat-ADX-CPA) were included. RESULTS Baseline clinical and biochemical parameters were comparable in patients with unilat-ADX-PBMAH, bilat-ADX-PBMAH, and unilat-ADX-CPA. Directly after surgery, 84% of the patients with unilat-ADX-PBMAH experienced initial remission of Cushing syndrome (CS). In contrast, at last follow-up (median, 50 months), 32% of the patients with unilat-ADX-PBMAH were biochemically controlled compared with nearly all patients in the other two groups (P = 0.000). Adrenalectomy of the contralateral side had to be performed in 12% of the initial patients with unilat-ADX-PBMAH. Three of 20 patients with unilat-ADX-PBMAH (15%) died during follow-up, presumably of CS-related causes; no deaths occurred in the other two groups (P = 0.008). Deaths occurred exclusively in patients who were not biochemically controlled after unilateral ADX. CONCLUSIONS Our data suggest that unilateral adrenalectomy of patients with PBMAH leads to clinical remission and a lower incidence of adrenal crisis but in less sufficient biochemical control of hypercortisolism, potentially leading to higher mortality.
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Affiliation(s)
- Andrea Osswald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
| | | | - Guido Di Dalmazi
- Endocrinology Unit and Center for Applied Biomedical Research, Department of Medical and Surgical Sciences, Alma Mater University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
| | - Jerome Bertherat
- Université Paris Descartes, hôpital Cochin, centre de référence des maladies rares de la surrénale, service d'endocrinologie, Paris, France
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
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Rubinstein G, Osswald A, Zopp S, Ritzel K, Theodoropoulou M, Beuschlein F, Reincke M. Therapeutic options after surgical failure in Cushing's disease: A critical review. Best Pract Res Clin Endocrinol Metab 2019; 33:101270. [PMID: 31036383 DOI: 10.1016/j.beem.2019.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Indexed: 12/17/2022]
Abstract
Cushing's disease (CD) is the most common etiology of Cushing's syndrome (CD) due to corticotroph pituitary adenoma, which are in most cases small (80-90% microadenomas) and in about 40% cannot be visualized on imaging of the sella. First-line treatment for CD is transsphenoidal surgery (TSS) with the aim of complete adenoma removal and preservation of pituitary gland function. As complete adenoma resection is not always possible, surgical failure is a common problem. This can be the case either due to persistent hypercortisolism after first TSS or recurrence of hypercortisolism after initially achieving remission. For these scenarios exist several therapeutic options with their inherent characteristics, which will be covered by this review.
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Affiliation(s)
- German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, University Hospital, Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany.
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Savas M, Wester VL, de Rijke YB, Rubinstein G, Zopp S, Dorst K, van den Berg SAA, Beuschlein F, Feelders RA, Reincke M, van Rossum EFC. Hair Glucocorticoids as a Biomarker for Endogenous Cushing's Syndrome: Validation in Two Independent Cohorts. Neuroendocrinology 2019; 109:171-178. [PMID: 30759443 DOI: 10.1159/000498886] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 10/31/2018] [Accepted: 02/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The current diagnostic workup of Cushing's syndrome (CS) requires various tests which only capture short-term cortisol exposure, whereas patients with endogenous CS generally have elevated cortisol levels over longer periods of time. Scalp hair assessment has emerged as a convenient test in capturing glucocorticoid concentrations over long periods of time. The aim of this multicenter, multinational, prospective, case-control study was to evaluate the diagnostic efficacy of scalp hair glucocorticoids in screening of endogenous CS. METHODS We assessed the diagnostic performances of hair cortisol (HairF), hair cortisone (HairE), and the sum of both (sumHairF+E), as measured by a state-of-the-art LC-MS/MS technique, in untreated patients with confirmed endogenous CS (n = 89) as well as in community controls (n = 295) from the population-based Lifelines cohort study. RESULTS Both glucocorticoids were significantly elevated in CS patients when compared to controls. A high diagnostic efficacy was found for HairF (area under the curve 0.87 [95% CI: 0.83-0.92]), HairE (0.93 [0.89-0.96]), and sumHairF+E (0.92 [0.88-0.96]) (all p < 0.001). The participants were accurately classified at the optimal cutoff threshold in 86% of the cases (81% sensitivity, 88% specificity, and 94% negative predictive value [NPV]) by HairF, in 90% of the cases (87% sensitivity, 90% specificity, and 96% NPV) by HairE, and in 87% of the cases (86% sensitivity, 88% specificity, and 95% NPV) by the sumHairF+E. HairE was shown to be the most accurate in differentiating CS patients from controls. CONCLUSION Scalp hair glucocorticoids, especially hair cortisone, can be seen as a promising biomarker in screening for CS. Its convenience in collection and workup additionally makes it feasible for first-line screening.
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Affiliation(s)
- Mesut Savas
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Obesity Center CGG (Centrum Gezond Gewicht), Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Vincent L Wester
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Obesity Center CGG (Centrum Gezond Gewicht), Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Yolanda B de Rijke
- Obesity Center CGG (Centrum Gezond Gewicht), Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kristien Dorst
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitäts-Spital Zürich, Zurich, Switzerland
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,
- Obesity Center CGG (Centrum Gezond Gewicht), Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,
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Braun LT, Riester A, Oßwald-Kopp A, Fazel J, Rubinstein G, Bidlingmaier M, Beuschlein F, Reincke M. Toward a Diagnostic Score in Cushing's Syndrome. Front Endocrinol (Lausanne) 2019; 10:766. [PMID: 31787931 PMCID: PMC6856055 DOI: 10.3389/fendo.2019.00766] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 12/26/2022] Open
Abstract
Cushing's syndrome (CS) is a classical rare disease: it is often suspected in patients who do not have the disease; at the same time, it takes a mean of 3 years to diagnose CS in affected individuals. The main reason is the extreme rarity (1-3/million/year) in combination with the lack of a single lead symptom. CS has to be suspected when a combination of signs and symptoms is present, which together make up the characteristic phenotype of cortisol excess. Unusual fat distribution affecting the face, neck, and trunk; skin changes including plethora, acne, hirsutism, livid striae, and easy bruising; and signs of protein catabolism such as thinned and vulnerable skin, osteoporotic fractures, and proximal myopathy indicate the need for biochemical screening for CS. In contrast, common symptoms like hypertension, weight gain, or diabetes also occur quite frequently in the general population and per se do not justify biochemical testing. First-line screening tests include urinary free cortisol excretion, dexamethasone suppression testing, and late-night salivary cortisol measurements. All three tests have overall reasonable sensitivity and specificity, and first-line testing should be selected on the basis of the physiologic conditions of the patient, drug intake, and available laboratory quality control measures. Two normal test results usually exclude the presence of CS. Other tests and laboratory parameters like the high-dose dexamethasone suppression test, plasma ACTH, the CRH test, and the bilateral inferior petrosal sinus sampling are not part of the initial biochemical screening. As a general rule, biochemical screening should only be performed if the pre-test probability for CS is reasonably high. This article provides an overview about the current standard in the diagnosis of CS starting with clinical scores and screenings, the clinical signs, relevant differential diagnoses, the first-line biochemical screening, and ending with a few exceptional cases.
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Affiliation(s)
- Leah T. Braun
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Anna Riester
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Andrea Oßwald-Kopp
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Julia Fazel
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - German Rubinstein
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Martin Bidlingmaier
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Felix Beuschlein
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Martin Reincke
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
- *Correspondence: Martin Reincke
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Rubinstein G, Bavdaz B, De Bunder S, Blázquez N. [Incidence of Streptococcus pyogenes pharyngitis in Bariloche, Argentina]. Rev Argent Microbiol 2005; 37:84-6. [PMID: 16178462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
The incidence and seasonality of pharyngitis by S. pyogenes in Bariloche, a city where long periods of low temperatures result in extended indoor activities were studied. A total of 5276 throat swab specimens collected during 2000-2003 in the clinical microbiology laboratories of the three main medical institutions of the city, were analyzed. Samples were cultured on blood-agar media containing 5% defibrinated sheep blood, and incubated for 24-48 h at 35 degrees C. Strains were identified using standard procedures. Monthly means for throat swabs, S. pyogenes isolates, and percent of S. pyogenes pharyngitis, were estimated. The incidence of pharyngitis by this microorganism was greater than 24% for every month within the April-December period, reaching a maximum in November (33%). February was the month with the lowest incidence (13%). It was observed an increasing trend since March through November with a through in July, and a marked decrease that began in December, reaching its lowest rate in January and February, the warmest months. This seasonal pattern differs from those observed for temperate climates. The incidence of S. pyogenes pharyngitis in Bariloche was high through the greater part of the year, since about the middle of autumn to the beginning of summer.
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Affiliation(s)
- G Rubinstein
- Laboratorio de Bacteriología, Hospital Ramón Carrillo, F.P. Moreno 651 (8400), Bariloche, Argentina.
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Affiliation(s)
- H Czosnek
- Department of Field Crops and Genetics, Otto Warburg Center for Biotechnology in Agriculture, Faculty of Agricultural, Food and Environmental Quality Sciences, Hebrew University of Jerusalem, Rehovot 76100, Israel
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Rubinstein G. Sex-role reversal and clinical judgment of mental health. J Sex Marital Ther 2001; 27:9-19. [PMID: 11224955 DOI: 10.1080/00926230152035813] [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] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The separation between nonconformist lifestyles and mental disorders plays a central role in behavioral therapeutic orientations, where emphasis is put on the client's definition of the problem, and in existential and humanistic orientations, which encourage the development of the client's individuality. In the present study, 621 psychotherapists and students intending to practice psychotherapy ranked the mental state of a male client suffering from social phobia related to examination situations. Half of the subjects received a case history of a law intern (married to a teacher), suffering from social phobia related to the oral bar. The other half received a case history of a student in a teachers' college (married to a lawyer) suffering from social phobia related to being tested in teaching a class. The mental state of the latter has been perceived as significantly more severe than that of the former. This difference in perception was not related to the subject's sex, professional experience, and the frequency of a similar client in their practice. Results are discussed in the context of the liberal political attitudes and the secular orientation of the subjects.
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Affiliation(s)
- G Rubinstein
- School of Behavioral Sciences, Netanya Academic College, Netanya, Israel.
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González S, Rajadhyaksha M, Rubinstein G, Anderson RR. Characterization of psoriasis in vivo by reflectance confocal microscopy. J Med 2000; 30:337-56. [PMID: 10851567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Among available non-invasive imaging tools, confocal reflectance microscopy (CM) provides the highest-resolution optical sectioning of skin in vivo, to a controlled depth of 200-350 microns, the level of the upper reticular dermis. In this study, CM was used to view the histological features of psoriasis in vivo in lesional and non-lesional skin of five patients with stable psoriasis vulgaris. Stereohistological analysis of non-invasive confocal sections, and the correlation with transverse (en face) hematoxylin- and eosin-stained sections from biopsies, was also performed. In psoriatic lesions, nucleated corneocytes and collections of infiltrating inflammatory cells were clearly seen. Morphometric parameters such as epidermal height, length of papillary dermis, and the count of dermal papillae were also easily quantified. In the upper dermis, dilated capillary loops were always present. Since CM sections are en face, the presence or absence of the granular layer could not be visualized in single frames, but could be monitored in a sequence of real-time videotaped images. In summary, CM provides a new technique for histologically evaluating psoriasis in vivo.
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Affiliation(s)
- S González
- Wellman Laboratories of Photomedicine, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
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Rubinstein G. Is the neuropeptide urocortin, a member of the corticotropin-releasing factor family, involved in schizophrenia? Schizophr Res 2000; 42:165-6. [PMID: 10742654 DOI: 10.1016/s0920-9964(99)00126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rubinstein G. Attitudes of Israeli gay students toward other minorities: an exploratory study. Isr J Psychiatry Relat Sci 2000; 36:272-81. [PMID: 10687303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Notwithstanding significant changes in the legal and psychiatric status of homosexuals, they are still very much victims of public prejudice. It may be asked, however, how they view other minority groups. The present study compared the political attitudes of members of a gay political party at the Hebrew University with a control group of heterosexual university students matched for demographic characteristics. Homosexual subjects showed significantly more support for left-wing parties (particularly Meretz). A significant difference was also found in the party nominated by subjects as most opposed to their own views. Homosexual subjects showed a much higher rate of opposition to Moledet (a right-wing extremist party) and Shas (a religious party), whereas heterosexual subjects were more often opposed to left-wing extremist parties. Notwithstanding this finding, levels of political tolerance for the party most opposed to their own views was higher among homosexual subjects than among the control group. Whether these results are related to the minority status of homosexuals, or to the ideology of the political left is not clear, and is recommended as a topic for further research.
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Affiliation(s)
- G Rubinstein
- School of Behavioral Sciences, Netanya Academic College, Tel Aviv, Israel.
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González S, Rubinstein G, Mordovtseva V, Rajadhyaksha M, Anderson RR. In vivo abnormal keratinazation in Darier-White's disease as viewed by real-time confocal imaging. J Cutan Pathol 1999; 26:504-8. [PMID: 10599941 DOI: 10.1111/j.1600-0560.1999.tb01797.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Darier-White's disease is a rare autosomal-dominant disorder of keratinization. The underlying pathology for the clinical presentation is acantholysis, and various types of dyskeratosis and acanthosis. In this study, we utilized a non-invasive optical imaging modality, confocal reflectance microscopy, to identify specific histologic features of Darier-White's disease in vivo. Micrographic findings in the confocal images were corps ronds, suprabasal clefts, acantholytic suprabasal keratinocytes, and villi. Real-time confocal images are illustrative and can be well correlated with known light microscopic phenomena, particularly in the case of keratinization abnormalities in Darier-White's disease.
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Affiliation(s)
- S González
- Dermatology Department, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
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Rubinstein G, Lekishvili N, Khananashvili L, Kandelaki S. Refractometric Investigation of Polymer Gradient Optical Media Based on Some Organic and Elementorganic Monomers. INT J POLYM MATER PO 1998. [DOI: 10.1080/00914039808034856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rubinstein G, Czosnek H. Long-term association of tomato yellow leaf curl virus with its whitefly vector Bemisia tabaci: effect on the insect transmission capacity, longevity and fecundity. J Gen Virol 1997; 78 ( Pt 10):2683-9. [PMID: 9349491 DOI: 10.1099/0022-1317-78-10-2683] [Citation(s) in RCA: 185] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The association between tomato yellow leaf curl geminivirus (TYLCV, Israeli isolate) and its insect vector, the whitefly Bemisia tabaci, was investigated. Insects that emerged during a 24 h period were caged with TYLCV-infected plants for a 48 h acquisition access period, then with egg-plants--a TYLCV non-host--for the rest of their lives. While TYLCV DNA was associated with the whiteflies during their entire adult life, the amount of capsid protein rapidly decreased and was not detectable in the insect after approximately 12 days of age. The ability of the infected whiteflies to transmit TYLCV to tomato test plants steadily decreased with age but did not disappear completely. Transmission by viruliferous insects decreased from 100% to 10-20% during their adult lifetime, compared with a decrease from 100% to 50% for non-viruliferous insects. The association of TYLCV with adult B. tabaci led to a reduction of 17-23% in their life expectancy compared with insects that had not acquired the virus, and to a 40-50% decrease in the mean number of eggs laid. These results suggest that TYLCV has some features reminiscent of an insect pathogen.
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Affiliation(s)
- G Rubinstein
- Department of Field Crops and Genetics, and the Otto Warburg Centre for Biotechnology in Agriculture, Faculty of Agriculture, The Hebrew University of Jerusalem, Rehovot, Israel
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