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Sakuma I, Higuchi S, Fujimoto M, Takiguchi T, Nakayama A, Tamura A, Kohno T, Komai E, Shiga A, Nagano H, Hashimoto N, Suzuki S, Mayama T, Koide H, Ono K, Sasano H, Tatsuno I, Yokote K, Tanaka T. Cushing Syndrome Due to ACTH-Secreting Pheochromocytoma, Aggravated by Glucocorticoid-Driven Positive-Feedback Loop. J Clin Endocrinol Metab 2016; 101:841-6. [PMID: 26700559 PMCID: PMC4803163 DOI: 10.1210/jc.2015-2855] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Pheochromocytoma is a catecholamine-producing tumor that originates from adrenal chromaffin cells and is capable of secreting various hormones, including ACTH. CASE DESCRIPTION A 56-year-old female presented with Cushingoid appearance and diabetic ketoacidosis. Endocrinological examinations demonstrated ectopic ACTH production with hypercortisolemia and excess urinary cortisol accompanied by elevated plasma and urine catecholamines. Computed tomography revealed a large left adrenal tumor with bilateral adrenal enlargement. Metaiodobenzylguanidine scintigraphy revealed abnormal accumulation in the tumor, which was eventually diagnosed as pheochromocytoma with ectopic ACTH secretion with subsequent manifestation of Cushing's syndrome. Ectopic ACTH secretion and catecholamine production were blocked by metyrapone treatment, whereas dexamethasone paradoxically increased ACTH secretion. Left adrenalectomy resulted in complete remission of Cushing's syndrome and pheochromocytoma. IN VITRO STUDIES Immunohistological analysis revealed that the tumor contained two functionally distinct chromaffin-like cell types. The majority of tumor cells stained positive for tyrosine hydroxylase (TH), whereas a minor population of ACTH-positive tumor cells was negative for TH. Furthermore, gene expression and in vitro functional analyses using primary tumor tissue cultures demonstrated that dexamethasone facilitated ACTH as well as catecholamine secretion with parallel induction of proopiomelanocortin (POMC), TH, and phenylethanolamine N-methyltransferase mRNA, supporting a glucocorticoid-dependent positive-feedback loop of ACTH secretion in vivo. DNA methylation analysis revealed that the POMC promoter of this tumor, particularly the E2F binding site, was hypomethylated. CONCLUSION We present a case of ectopic ACTH syndrome associated with pheochromocytoma. ACTH up-regulation with paradoxical response to glucocorticoid, possibly through the hypomethylation of the POMC promoter, exacerbated the patient's condition.
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Affiliation(s)
- Ikki Sakuma
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Seiichiro Higuchi
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Masanori Fujimoto
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Tomoko Takiguchi
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Akitoshi Nakayama
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Ai Tamura
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Takashi Kohno
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Eri Komai
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Akina Shiga
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Hidekazu Nagano
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Naoko Hashimoto
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Sawako Suzuki
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Takafumi Mayama
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Hisashi Koide
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Katsuhiko Ono
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Hironobu Sasano
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Ichiro Tatsuno
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Koutaro Yokote
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
| | - Tomoaki Tanaka
- Department of Clinical Cell Biology and Medicine (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; Division of Diabetes, Endocrinology, and Metabolism (I.S., S.H., M.F., T.Tak., A.T., T.K., E.K., A.S., H.N., N.H., S.S., T.M., H.K., K.Y., T.Tan.), Chiba University Hospital, Chiba 260-8670, Japan; Department of Pathology (K.O., H.S.), Tohoku University Graduate School of Medicine, Sendai City, Miyagi 980-8575, Japan; and Center for Diabetes, Metabolism, and Endocrinology (I.T.), Toho University Sakura Medical Center, Sakura, Chiba 285-0841, Japan
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