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Zhou H, Zhang P, Yin Y, Liu L, Li J, Xu H, Fan Y, Su X, Lyu Z, Gu W, Mu Y. Long-term cardiometabolic outcomes of primary bilateral macronodular adrenal hyperplasia. J Endocrinol Invest 2025:10.1007/s40618-025-02561-0. [PMID: 40252189 DOI: 10.1007/s40618-025-02561-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Accepted: 02/28/2025] [Indexed: 04/21/2025]
Abstract
PURPOSE This study investigated long-term alterations in cardiometabolic comorbidities among patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) who received surgical or conservative treatments. METHODS A single-center, retrospective study analyzed 132 patients with PBMAH, divided into a surgery group (n = 68) and a control group (n = 64) based on treatment modalities. The main outcomes included changes in blood pressure (BP), blood glucose, lipids, and body weight. RESULTS Among the 132 patients, hypertension, abnormal glucose metabolism, dyslipidemia, and overweight/obesity were prevalent in over 50% of cases. The surgery group demonstrated significantly greater improvements in BP, blood glucose, and weight control compared with the control group. Adrenalectomy was associated with enhanced BP control, blood glucose control, and at least one cardiometabolic risk factor control. In a group of 95 patients with mild autonomous cortisol secretion, the surgery group also exhibited higher rates of improvement in BP and blood glucose than the control group. Adrenalectomy was associated with improved BP, blood glucose, and at least one cardiometabolic risk factor. CONCLUSION Our study observed that most patients with PBMAH exhibited at least one cardiometabolic risk factor. Adrenalectomy was associated with improved BP and blood glucose for patients with PBMAH, including those with mild autonomous cortisol secretion.
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Affiliation(s)
- Huixin Zhou
- School of Medicine, Nankai University, 94 Weijin Road, 300071, Tianjin, China
- Department of Endocrinology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, 100853, Beijing, China
| | - Peng Zhang
- Department of Urology, Third Medical Center, Chinese PLA General Hospital, 69 Yongding Road, 100039, Beijing, China
| | - Yaqi Yin
- Department of Endocrinology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, 100853, Beijing, China
| | - Lupeng Liu
- Department of Urology, Third Medical Center, Chinese PLA General Hospital, 69 Yongding Road, 100039, Beijing, China
| | - Jie Li
- Department of Pathology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, 100853, Beijing, China
| | - Huaijin Xu
- School of Medicine, Nankai University, 94 Weijin Road, 300071, Tianjin, China
- Department of Endocrinology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, 100853, Beijing, China
| | - Yu Fan
- Department of Urology, Third Medical Center, Chinese PLA General Hospital, 69 Yongding Road, 100039, Beijing, China
| | - Xiaonan Su
- Department of Urology, Zoucheng People's Hospital, 5677 Chongyi Road, 273500, Jining, China
| | - Zhaohui Lyu
- Department of Endocrinology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, 100853, Beijing, China.
| | - Weijun Gu
- Department of Endocrinology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, 100853, Beijing, China.
| | - Yiming Mu
- School of Medicine, Nankai University, 94 Weijin Road, 300071, Tianjin, China.
- Department of Endocrinology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, 100853, Beijing, China.
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Qu Y, Yang F, Deng Y, Li H, Zhou Y, Zhang X. Advancements in the research of the structure, function, and disease-related roles of ARMC5. Front Med 2025; 19:185-199. [PMID: 39960568 DOI: 10.1007/s11684-024-1108-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 09/18/2024] [Indexed: 05/04/2025]
Abstract
The armadillo repeat containing 5 (ARMC5) gene is part of a family of protein-coding genes that are rich in armadillo repeat sequences, are ubiquitously present in eukaryotes, and mediate interactions between proteins, playing roles in various cellular processes. Current research has demonstrated that reduced expression or absence of the ARMC5 gene in various tumor tissues can lead to uncontrolled cell proliferation, thereby inducing a range of diseases. The ARMC5 gene was initially extensively studied in the context of bilateral macronodular adrenocortical disease (BMAD), with harmful pathogenic variants in ARMC5 identified in approximately 50% of BMAD patients. With advancing research, scientists have discovered that ARMC5 pathogenic variants may also have potential effects on other diseases and could be associated with increased susceptibility to certain cancers. This review aims to present the latest research progress on how the ARMC5 gene plays its role in tumors. It outlines the basic structure of ARMC5 and the regions where it functions, as well as the diseases currently proven to be associated with ARMC5. Moreover, some evidence suggests its relation to embryonic development and the regulation of immune system activity. In conclusion, the ARMC5 gene is a crucial focal point in genetic and medical research. Understanding its function and regulation is of great importance for the development of new therapeutic strategies related to diseases associated with its pathogenic variants.
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Affiliation(s)
- Yang Qu
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Fan Yang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yafang Deng
- State Key Laboratory of Molecular Oncology, Beijing Frontier Research Center for Biological Structure, School of Basic Medical Sciences, Tsinghua University, Beijing, 100084, China
| | - Haitao Li
- State Key Laboratory of Molecular Oncology, Beijing Frontier Research Center for Biological Structure, School of Basic Medical Sciences, Tsinghua University, Beijing, 100084, China.
| | - Yidong Zhou
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Xuebin Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Bouys L, Vaduva P, Jouinot A, Violon F, Vaczlavik A, Barat M, Charchar H, Chasseloup F, Kamilaris C, Espiard S, Haissaguerre M, Raverot G, Kroiss M, Berthon A, Perlemoine K, Tauveron I, Guignat L, Libé R, Groussin L, Assié G, Pasmant E, Reincke M, Borson-Chazot F, Ferrière A, Vantyghem MC, Stratakis CA, Kamenický P, Fragoso MCBV, Chansavang A, Ragazzon B, Bertherat J. KDM1A genetic alterations, a rare cause of primary bilateral macronodular adrenal hyperplasia, strongly associated with food-dependent Cushing's syndrome: results of its systematic germline screening in 301 index cases and genotype/phenotype correlation. Eur J Endocrinol 2025; 192:119-127. [PMID: 39921449 DOI: 10.1093/ejendo/lvaf016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Revised: 11/28/2024] [Accepted: 02/06/2025] [Indexed: 02/10/2025]
Abstract
OBJECTIVE ARMC5 is the most prevalent gene predisposing to primary bilateral macronodular adrenal hyperplasia (PBMAH), but germline KDM1A variants have been identified in the rare PBMAH associated with food-dependent Cushing's syndrome (FDCS). The purpose of this work was to assess the frequency of KDM1A variants in a large series of PBMAH patients. DESIGN A total of 301 consecutive PBMAH index cases from 8 international endocrinology departments were included. Clinical, biological, and imaging data were collected retrospectively. RESULTS Ten (3.3%) patients carried a germline KDM1A pathogenic or likely pathogenic variant, 60 (19.9%) carried a germline ARMC5 alteration, and 231 (76.8%) had no identified genetic predisposition. Food-dependent Cushing's syndrome was present in all patients with KDM1A variants and absent in the 2 other groups. KDM1A patients had a higher 24-h urinary free cortisol (3.0-fold upper limit of normal vs 1.36 for ARMC5 patients and 0.66 for wild-type patients, respectively, P = .0001). In accordance with FDCS pathophysiology, patients with KDM1A variants had a lower morning fasting plasma cortisol (192 nmol/L vs 407 and 428, respectively, P = .0003) and a higher midnight plasma cortisol (487 nmol/L vs 297 and 171.96, respectively, P = .0004). Morning/midnight plasma cortisol ratio below 0.65 holds 100% sensitivity and specificity for the detection of FDCS. All patients with KDM1A variants were women, vs 65% of ARMC5 patients and 67% of wild-type patients (P = .0337). CONCLUSIONS KDM1A germline pathogenic variants are rare in PBMAH and account for <5% of index cases. KDM1A seems constantly associated with FDCS, which can be evoked in front of a morning/midnight plasma cortisol ratio below 0.65.
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Affiliation(s)
- Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Patricia Vaduva
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Anne Jouinot
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Florian Violon
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
- Department of Pathology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
| | - Anna Vaczlavik
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
| | - Maxime Barat
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
- Department of Radiology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
| | - Helaine Charchar
- Department of Endocrinology and Metabolism, University of São Paulo, 05403-010 São Paulo, Brazil
| | - Fanny Chasseloup
- Department of Endocrinology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, 94270 Le Kremlin-Bicêtre, France
- Physiologie et Physiopathologie Endocriniennes, INSERM, Université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France
| | - Crystal Kamilaris
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, MD 20892, United States
| | - Stéphanie Espiard
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, Inserm U1190, 59000 Lille, France
| | - Magalie Haissaguerre
- Department of Endocrinology, Diabetology and Nutrition, Hôpital Haut-Lévêque, CHU Bordeaux, 33600 Pessac, France
| | - Gérald Raverot
- Department of Endocrinology, Groupement Hospitalier Est, Hospices Civils de Lyon, 69500 Bron, France
| | - Matthias Kroiss
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Annabel Berthon
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Karine Perlemoine
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Igor Tauveron
- Department of Endocrinology, CHU Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
| | - Rossella Libé
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
| | - Lionel Groussin
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Guillaume Assié
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Eric Pasmant
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
- Department of Genomic Medicine of Tumors and Cancers, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Françoise Borson-Chazot
- Department of Endocrinology, Groupement Hospitalier Est, Hospices Civils de Lyon, 69500 Bron, France
| | - Amandine Ferrière
- Department of Endocrinology, Diabetology and Nutrition, Hôpital Haut-Lévêque, CHU Bordeaux, 33600 Pessac, France
| | - Marie-Christine Vantyghem
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, Inserm U1190, 59000 Lille, France
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, MD 20892, United States
- Institute of Molecular Biology and Biotechnology, FORTH & ELPEN, SA, 70013 Heraklion, Crete, Greece
| | - Peter Kamenický
- Department of Endocrinology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, 94270 Le Kremlin-Bicêtre, France
- Physiologie et Physiopathologie Endocriniennes, INSERM, Université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France
| | | | - Albain Chansavang
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
- Department of Genomic Medicine of Tumors and Cancers, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
| | - Bruno Ragazzon
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75014 Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, 75014 Paris, France
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Vaduva P, Bertherat J. The molecular genetics of adrenal cushing. Hormones (Athens) 2024; 23:601-610. [PMID: 39388056 DOI: 10.1007/s42000-024-00608-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 09/26/2024] [Indexed: 10/12/2024]
Abstract
Adrenal Cushing represents 20% of cases of endogenous hypercorticism. Unilateral cortisol-producing adenoma (CPA), a benign tumor, and adrenocortical carcinoma (ACC), a malignant tumor, are more frequent than bilateral adrenal nodular diseases (primary bilateral macronodular adrenal hyperplasia (PBMAH) and primary pigmented nodular adrenal disease (PPNAD)).In cortisol-producing adrenal tumors, the signaling pathways mainly altered are the protein kinase A and Wnt/β-catenin pathways. Studying components of these pathways and exploring syndromic and familial cases of these tumors has historically enabled identification of many of the predisposing genes. More recently, pangenomic sequencing revealed alterations in sporadic tumors.In ACC, mainly due to TP53 alterations causing Li-Fraumeni syndrome, germline predisposition is frequent in children, while it is rare in adults. Pathogenic variants in the DNA mismatch repair genes MLH1, MSH2, MSH6, and PMS2, which cause Lynch syndrome or alterations of IGF2 and CDKN1C (11p15 locus) in Beckwith-Wiedemann syndrome, can also cause ACC. Rarely, ACC is described in other hereditary tumor syndromes due to germline pathogenic variants in MEN1 or APC and, in very rare cases, NF1, SDH, PRKAR1A, or BRCA2. Concerning ACC somatic alterations, TP53 and genetic or epigenetic alterations at the 11p15 locus are also frequently described, as well as CTNNB1 and ZNRF3 pathogenic variants.CPAs mainly harbor somatic pathogenic variants in PRKACA and CTNNB1 and, less frequently, PRKAR1A, PRKACB, or GNAS1 pathogenic variants. Isolated PBMAH is due to ARMC5 inactivating pathogenic variants in 20 to 25% of cases and to KDM1A pathogenic variants in food-dependent Cushing. Syndromic PBMAH may be due to germline pathogenic variants in MEN1, APC, or FH, causing type 1 multiple endocrine neoplasia, familial adenomatous polyposis, or hereditary leiomyomatosis-kidney cancer syndrome, respectively. PRKAR1A germline pathogenic variants are the main alteration causing PPNAD (isolated or part of Carney complex).
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Affiliation(s)
- Patricia Vaduva
- Genomic and Signaling of Endocrine Tumors team, INSERM U1016, CNRS UMR8104, Cochin Institute, Paris Cité University, Paris, 75005, France
- Department of Endocrinology, Diabetes and Nutrition, Rennes University Hospital, Rennes, 35000, France
| | - Jerome Bertherat
- Genomic and Signaling of Endocrine Tumors team, INSERM U1016, CNRS UMR8104, Cochin Institute, Paris Cité University, Paris, 75005, France.
- Department of Endocrinology, Reference center for rare adrenal diseases, Cochin Hospital, APHP, Paris, 75014, France.
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Ghanbari Boroujeni MR, Meftah E, Zarimeidani F, Rahmati R, Esfahanian F. Primary bilateral macronodular adrenal hyperplasia: A rare case report of Cushing syndrome and review of literature. Medicine (Baltimore) 2024; 103:e40050. [PMID: 39465833 PMCID: PMC11479408 DOI: 10.1097/md.0000000000040050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 09/24/2024] [Indexed: 10/29/2024] Open
Abstract
RATIONALE Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a rare cause of ACTH-independent Cushing syndrome (CS), accounting for <2% of CS cases. Diagnosing PBMAH can be difficult and challenging for clinicians. PATIENT CONCERNS We report a 52-year-old female, a patient with a history of intermittent fever for 3 years. She presented with nausea, headache, and dizziness for several days, along with fatigue, myalgia, muscle weakness, exertional dyspnea, hoarseness, spontaneous bruising over the past several months, and long-term psychological complaints. Additionally, we observed periorbital and facial edema, right lower quadrant tenderness, and abdominal striae during the examination. DIAGNOSES Her laboratory results showed increased cortisol and suppressed ACTH, and an abdominal CT scan revealed 2 heterogeneous masses in the adrenal glands. These findings led us to the diagnosis of PBMAH in this patient. The existence of aberrant receptors was evaluated, and the tests were negative. INTERVENTIONS The patient underwent left adrenalectomy and corticosteroid therapy after the surgery. Her clinical complaints improved after the surgery. OUTCOMES However, her dependency on corticosteroids was not transient after unilateral adrenalectomy, and she still needs glucocorticoid supplementation 1 year after surgery. LESSONS This patient is a case of PBMAH who presented with fever and CS symptoms and underwent unilateral adrenalectomy. Interestingly, she had suppressed cortisol levels for at least 1 year after the unilateral adrenalectomy. Therefore, we suggest further research on the most effective treatment strategies for PBMAH.
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Affiliation(s)
| | - Elahe Meftah
- Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Zarimeidani
- Students Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Rahem Rahmati
- Students Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Fatemeh Esfahanian
- Department of Endocrinology, Vali-Asr Hospital, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Bouys L, Violon F, Louiset E, Sibony M, Lefebvre H, Bertherat J. Bilateral Adrenocortical Nodular Disease and Cushing's Syndrome. J Clin Endocrinol Metab 2024; 109:2422-2432. [PMID: 38888184 DOI: 10.1210/clinem/dgae419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/05/2024] [Accepted: 06/13/2024] [Indexed: 06/20/2024]
Abstract
Primary pigmented nodular adrenocortical disease (PPNAD) and bilateral macronodular adrenocortical disease (BMAD) are 2 forms of adrenocortical nodular diseases causing Cushing's syndrome but are 2 very distinct conditions. PPNAD, affecting mostly young patients with an almost constant severe Cushing's syndrome, is characterized by pigmented micronodules, usually less than 1 cm, not always visible on imaging. On the contrary, BMAD is predominantly diagnosed in the fifth and sixth decades, with highly variable degrees of cortisol excess, from mild autonomous cortisol secretion to overt Cushing's syndrome. BMAD presents as large bilateral adrenal macronodules, easily observed on imaging. Both diseases are often genetically determined: frequently PPNAD is observed in a multiple neoplasia syndrome, Carney complex, and a germline genetic defect is identified in around 80% of index cases, always affecting key actors of the cAMP/protein kinase A (PKA) pathway: mostly PRKAR1A, encoding the PKA 1-alpha regulatory subunit. On the other hand, BMAD appears mostly isolated, and 2 predisposing genes are known at present: ARMC5, accounting for around 20% of index cases, and the recently identified KDM1A, causing the rare presentation with food-dependent Cushing's syndrome, mediated by the ectopic expression of the glucose-dependent insulinotropic polypeptide receptor (GIPR) in adrenal nodules. GIPR was the first demonstrated receptor to illegitimately regulate cortisol secretion in nodular adrenocortical diseases, and a myriad of other receptors and paracrine signals were discovered afterward. The last 30 years were pivotal in the understanding of the genetics and pathophysiology of bilateral adrenocortical nodular diseases, leading to a personalized approach of these fascinating conditions.
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Affiliation(s)
- Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, F-75014 Paris, France
- Genomics and Signaling of Endocrine Tumors, Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, F-75014 Paris, France
| | - Florian Violon
- Genomics and Signaling of Endocrine Tumors, Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, F-75014 Paris, France
- Department of Pathology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, F-75014 Paris, France
| | - Estelle Louiset
- Adrenal and Gonadal Pathophysiology, Université Rouen Normandie, INSERM, NorDiC UMR 1239, F-76000 Rouen, France
| | - Mathilde Sibony
- Genomics and Signaling of Endocrine Tumors, Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, F-75014 Paris, France
- Department of Pathology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, F-75014 Paris, France
| | - Hervé Lefebvre
- Adrenal and Gonadal Pathophysiology, Université Rouen Normandie, INSERM, NorDiC UMR 1239, F-76000 Rouen, France
- Department of Endocrinology, Diabetes and Metabolic Diseases, CHU Rouen, F-76000 Rouen, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, F-75014 Paris, France
- Genomics and Signaling of Endocrine Tumors, Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris-Cité, F-75014 Paris, France
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Barlas T, Gultekin II, Altintop SE, Cindil E, Yalcin MM, Cerit ET, Sozen TS, Poyraz A, Altinova AE, Toruner FB, Karakoc MA, Akturk M. Beyond symptomatology: A comparative analysis of unilateral and bilateral macronodular mild autonomous cortisol secretion. Clin Endocrinol (Oxf) 2024; 101:99-107. [PMID: 38935859 DOI: 10.1111/cen.15109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE To investigate the clinical, laboratory findings and signal intensity index (SII) on magnetic resonance imaging (MRI) of patients with bilateral and unilateral macronodular mild autonomous cortisol secretion (MACS). PATIENTS AND MEASUREMENTS Clinical and laboratory findings of 81 patients with MACS were examined from retrospective records. SII of adenomas and internodular areas were evaluated by MRI. The unilateral group included patients with an adrenal macronodule (≥1 cm) in a single adrenal gland, while the bilateral group included patients with at least one macronodule in both adrenal glands. RESULTS In total, 46 patients were in the unilateral (57%), while 35 (43%) patients were in the bilateral groups. The dehydroepiandrosterone sulphate (DHEA-S) level was lower in the unilateral than in the bilateral group (p < .001). The presence of type 2 diabetes mellitus (T2DM), glycosylated haemoglobin (HbA1c) and low-density lipoprotein (LDL) concentrations were higher in the bilateral group (p < .05). However, no significant difference was detected in terms of adrenocorticotropic hormone (ACTH) and overnight 1 mg dexamethasone suppression test (DST) between the two groups (p > .05). There was no difference in SII between adenomas within the same patient, as well as between the unilateral and bilateral groups (p > .05). Logistic regression analysis based on the differentiation between unilateral and bilateral macronodular MACS demonstrated that DHEA-S, HbA1c and LDL concentrations were associated factors. CONCLUSION DHEA-S levels may not be as suppressed in patients with bilateral macronodular MACS as compared to those with unilateral adenoma. T2DM and hypercholesterolaemia have a higher frequency in bilateral patients. However, ACTH, overnight 1 mg DST and SII may not provide additional information for differentiation of bilaterality and unilaterality.
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Affiliation(s)
- Tugba Barlas
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Isil Imge Gultekin
- Department of Radiology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Sabri Engin Altintop
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Emetullah Cindil
- Department of Radiology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Mehmet Muhittin Yalcin
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Ethem Turgay Cerit
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Tevfik Sinan Sozen
- Department of Urology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Aylar Poyraz
- Department of Pathology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Alev Eroglu Altinova
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Fusun Balos Toruner
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Mehmet Ayhan Karakoc
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Mujde Akturk
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Ankara, Turkey
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Salame AAM, Charchar HLS, de Oliveira Dourado JP, Mendonca B, Alencar GA, de Araújo LJT, Arantes PR, Rabelo NN, Figueiredo EG, Fragoso MCBV. Neuroradiological features of patients with bilateral macronodular adrenocortical disease and meningiomas associated or not with genetic variants of ARMC5- a case series. J Neurooncol 2024; 168:405-413. [PMID: 38630387 DOI: 10.1007/s11060-024-04680-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/10/2024] [Indexed: 06/20/2024]
Abstract
INTRODUCTION Meningiomas are the most common primary brain and central nervous system tumors, accounting for approximately 40% of these tumors. The most important exams for the radiological study of meningiomas are computed tomography (CT) and magnetic resonance imaging (MRI). We aimed to analyze the radiological features of patients with meningioma related to the simultaneous presence of bilateral macronodular adrenocortical disease (BMAD), with or without pathogenic variants of ARMC5. METHODS This study included 10 patients who were diagnosed with BMAD. All of them had a radiological diagnosis of expansive brain lesions suggestive of meningioma. All patients underwent brain MRI and a neuroradiolgist analyzed the following parameters: number, site and size of lesions; presence of calcification, edema and bone involvement. RESULTS AND DISCUSSION Eight patients presented with germline variants of ARMC5; the other 2, did not. The most significant result was the incidence of multiple meningiomas, which was 50% in BMAD patients, whereas the average incidence described thus far is lower than 10%. Considering location, the 22 tumors in the BMAD patients were 5 convexity tumors (22.7%), and 17 skull base tumors (77.2%), the opposite proportion of patients without BMAD. A total of 40.9% of the tumors had calcification, 9% had cerebral edema and 40.9% had bone invasion due to hyperostosis. The literature describes meningioma calcification in 25% of patients, bone invasion by tumor hyperostosis in 20%, and cerebral edema in approximately 60%. CONCLUSION Relevant results were found considering the rate of multiple meningiomas and tumor location. This finding reinforces the need for further research into the neurological effects caused by genetic variants of ARMC5 in patients with BMAD.
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Affiliation(s)
- Arthur Araújo Massoud Salame
- Adrenal Unit, Laboratory of Hormones and Molecular Genetics LIM/42, Division of Endocrinology and Metabolism, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Helaine Laiz Silva Charchar
- Adrenal Unit, Laboratory of Hormones and Molecular Genetics LIM/42, Division of Endocrinology and Metabolism, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - José Paulo de Oliveira Dourado
- Neurosurgery Department, Instituto Tocantinense Presidente Antônio Carlos Porto S/A- ITPAC Porto, Porto Nacional, Brazil.
| | - Berenice Mendonca
- Adrenal Unit, Laboratory of Hormones and Molecular Genetics LIM/42, Division of Endocrinology and Metabolism, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Guilherme Asmar Alencar
- Adrenal Unit, Endocrinology Service of the University Hospital of the Federal University of Santa Catarina, Florianópolis, Brazil
| | | | - Paula Ricci Arantes
- Departamento de Radiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, LIM 44, Sao Paulo, SP, Brazil
| | - Nicollas Nunes Rabelo
- Division of Neurosurgery, Clinics Hospital, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Maria Candida Barisson Villares Fragoso
- Adrenal Unit, Laboratory of Hormones and Molecular Genetics LIM/42, Division of Endocrinology and Metabolism, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
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Gillis T, Low G, Wilson MP. Cushing's syndrome diagnosed incidentally on CT imaging. BMJ Case Rep 2024; 17:e258830. [PMID: 38453225 PMCID: PMC10921431 DOI: 10.1136/bcr-2023-258830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
In this case report, we describe an uncommon presentation of Cushing's syndrome in a patient in their 60s who presented to the emergency department with left-sided chest pain. The initial workup for the patient was unremarkable except for an elevated blood pressure and elevated fasting plasma glucose. A CT scan of the chest, abdomen and pelvis was performed, demonstrating a splenic artery thrombus with multiple splenic infarcts, in addition to a combination of macronodular adrenal hyperplasia, bilateral gynecomastia, centripetal fat distribution and suspected mild bone demineralisation. Adrenocorticotropic hormone-independent macronodular adrenal hyperplasia, a rare aetiology responsible for Cushing's syndrome, was raised as a potential unifying diagnosis for the patient's hypercoagulable status, which was subsequently confirmed on an endocrinological investigation. The case report underscores the importance of communicating clinically relevant details to the imaging specialist in combination with considering a broad differential, including endocrine disorders, when evaluating an undifferentiated patient with atypical imaging findings.
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Affiliation(s)
- Timber Gillis
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Gavin Low
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Mitchell P Wilson
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
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10
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Tizianel I, Detomas M, Deutschbein T, Fassnacht M, Albiger N, Iacobone M, Scaroni C, Ceccato F. Corticotropin-releasing hormone test predicts the outcome of unilateral adrenalectomy in primary bilateral macronodular adrenal hyperplasia. J Endocrinol Invest 2024; 47:749-756. [PMID: 37796369 PMCID: PMC10904413 DOI: 10.1007/s40618-023-02204-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/17/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Primary bilateral adrenal hyperplasia (PBMAH) is associated with hypercortisolism and a heterogeneous clinical expression in terms of cortisol secretion and related comorbidities. Historically, treatment of choice was bilateral adrenalectomy (B-Adx); however, recent data suggest that unilateral adrenalectomy (U-Adx) may be an effective alternative. For the latter, factors predicting the postsurgical outcome (e.g., biochemical control) have not been identified yet. METHODS PBMAH patients undergoing U-Adx for overt Cushing's syndrome (CS) in two tertiary care centers were retrospectively analysed. Remission was defined as a normalization of urinary free cortisol (UFC) without the need for medical treatment. The potential of hCRH test as a predictor of U-Adx outcome was evaluated in a subgroup. RESULTS 23 patients were evaluated (69% females, mean age 55 years). Remission rate after U-Adx was 74% at last follow up (median 115 months from UAdx). Before U-Adx, a positive ACTH response to hCRH (Δ%ACTH increase > 50% from baseline) was associated with higher remission rates. CONCLUSIONS Three of four patients with PBMAH are surgically cured with U-Adx. Pre-operative hCRH testing can be useful to predict long-term remission rates.
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Affiliation(s)
- I Tizianel
- Endocrine Unit, Department of Medicine DIMED, Padua, Italy
- Endocrine Unit, University-Hospital of Padova, Padua, Italy
| | - M Detomas
- University Hospital, University of Würzburg, Würzburg, Germany, Department of Internal Medicine I, Division of Endocrinology and Diabetes, Würzburg, Germany
| | - T Deutschbein
- University Hospital, University of Würzburg, Würzburg, Germany, Department of Internal Medicine I, Division of Endocrinology and Diabetes, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - M Fassnacht
- University Hospital, University of Würzburg, Würzburg, Germany, Department of Internal Medicine I, Division of Endocrinology and Diabetes, Würzburg, Germany
| | - N Albiger
- Radiotherapy Unit, Istituto Oncologico Veneto, Endocrinology, ULSS6, Padua, Euganea, Italy
| | - M Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - C Scaroni
- Endocrine Unit, Department of Medicine DIMED, Padua, Italy
- Endocrine Unit, University-Hospital of Padova, Padua, Italy
| | - F Ceccato
- Endocrine Unit, Department of Medicine DIMED, Padua, Italy.
- Endocrine Unit, University-Hospital of Padova, Padua, Italy.
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11
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Kidawara Y, Kakutani-Hatayama M, Fukuoka H, Koyama H. Prolonged Hypokalemia Following Metyrapone Treatment for Primary Bilateral Macronodular Adrenal Cortical Disease. JCEM CASE REPORTS 2024; 2:luae015. [PMID: 38304012 PMCID: PMC10833143 DOI: 10.1210/jcemcr/luae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Indexed: 02/03/2024]
Abstract
Surgical treatment is generally the standard therapeutic regimen used for primary bilateral macronodular adrenal cortical disease (PBMACD). However, in cases for which surgery is difficult or in which there is mild cortisol hypersecretion, metyrapone treatment can be selected. Although hypokalemia has been occasionally noted following metyrapone administration for Cushing syndrome associated with an adrenal adenoma, all such cases have been reported to be transient. Hypokalemia induced by metyrapone treatment is thought to occur due to excessive suppression of cortisol secretion, resulting in overproduction of adrenocorticotropic hormone from the pituitary gland, ultimately leading to excessive production of 11-deoxycorticosterone (DOC) in the adrenal cortex. A 52-year-old man diagnosed with PBMACD and started on metyrapone treatment subsequently presented with persistent hypokalemia. Interestingly, following initiation of metyrapone, blood test findings indicated marginal changes in serum cortisol, adrenocorticotropic hormone, and dehydroepiandrosterone sulfate levels, even when DOC levels were already markedly elevated. In addition to the effects of metyrapone, the present findings suggest a unique DOC synthesis regulatory mechanism involved in the pathogenesis of PBMACD.
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Affiliation(s)
- Yonekazu Kidawara
- Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Hyogo 663-8501, Japan
| | - Miki Kakutani-Hatayama
- Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Hyogo 663-8501, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Hidenori Koyama
- Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Hyogo 663-8501, Japan
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Kloock S, Ziegler CG, Dischinger U. Obesity and its comorbidities, current treatment options and future perspectives: Challenging bariatric surgery? Pharmacol Ther 2023; 251:108549. [PMID: 37879540 DOI: 10.1016/j.pharmthera.2023.108549] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/08/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023]
Abstract
Obesity and its comorbidities, including type 2 diabetes mellitus, cardiovascular disease, heart failure and non-alcoholic liver disease are a major health and economic burden with steadily increasing numbers worldwide. The need for effective pharmacological treatment options is strong, but, until recently, only few drugs have proven sufficient efficacy and safety. This article provides a comprehensive overview of obesity and its comorbidities, with a special focus on organ-specific pathomechanisms. Bariatric surgery as the so far most-effective therapeutic strategy, current pharmacological treatment options and future treatment strategies will be discussed. An increasing knowledge about the gut-brain axis and especially the identification and physiology of incretins unfolds a high number of potential drug candidates with impressive weight-reducing potential. Future multi-modal therapeutic concepts in obesity treatment may surpass the effectivity of bariatric surgery not only with regard to weight loss, but also to associated comorbidities.
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Affiliation(s)
- Simon Kloock
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Christian G Ziegler
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany; Department of Internal Medicine III, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Ulrich Dischinger
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany; Comprehensive Heart Failure Center, Würzburg, Germany.
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13
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Morelli V, Elli FM, Frigerio S, Vena W, Palmieri S, Lucca C, Maffini MA, Contarino A, Bagnaresi F, Mantovani G, Arosio M. Prevalence and clinical features of armadillo repeat-containing 5 mutations carriers in a single center cohort of patients with bilateral adrenal incidentalomas. Eur J Endocrinol 2023; 189:242-251. [PMID: 37625448 DOI: 10.1093/ejendo/lvad088] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/18/2023] [Accepted: 06/27/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE We aimed to evaluate the prevalence of armadillo repeat-containing 5 (ARMC5) genetic defects in our cohort of bilateral adrenal incidentaloma (BAI) patients and to evaluate the possible existence of genotype-phenotype correlations. DESIGN Cross-sectional study. SETTING Tertiary care center. PARTICIPANTS 72 BAI patients. MAIN OUTCOME MEASURE(S) The following data have been collected: morning adrenocorticotropic hormone (ACTH) concentrations; cortisol levels after 1 mg overnight dexamethasone suppression test (F-1mgDST); urinary free cortisol (UFC) levels; diameter of the adrenal masses; and the association with overweight/obesity, arterial hypertension, diabetes mellitus, dyslipidemia, cardiovascular events, unrelated neoplasia, osteoporosis, thyroid nodular disease, and primary hyperparathyroidism. A search for ARMC5 germline and somatic pathogenic variants was performed in all patients and in the adrenal tissue of patients operated on, respectively. RESULTS The prevalence of germline ARMC5 pathogenic variants among patients with mild autonomous cortisol secretion (MACS+, defined as F-1mgDST > 1.8 µg/dL) was 18.8%. No germline pathogenic variants were detected in patients without MACS. Moreover, somatic ARMC5 pathogenic variants were also found in the adrenal tissue of six patients without germline ARMC5 variants. The F-1mgDST levels >5 µg/dL predicted with a poor sensitivity but a 90.5% specificity in identifying the presence of ARMC5 germline pathogenic variants. We did not find any clinical parameter predictive of the ARMC5 mutation presence. CONCLUSIONS In MACS+ BAI patients, germline ARMC5 gene pathogenic variants are frequent. Further studies are needed to elucidate the pathophysiological role of somatic ARMC5 pathogenic variants on adrenal tumor development in otherwise wild-type (WT) patients.
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Affiliation(s)
- Valentina Morelli
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy
| | - Francesca Marta Elli
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Sofia Frigerio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Walter Vena
- Diabetes Center, Humanitas Gavazzeni Institute, 24125 Bergamo, Italy
| | - Serena Palmieri
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Camilla Lucca
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Antonia Maffini
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Andrea Contarino
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Francesca Bagnaresi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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14
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Шевэ А, Елфимова АР, Бельцевич ДГ. [Primary bilateral macronodular adrenal hyperplasia: clinical and laboratory features]. PROBLEMY ENDOKRINOLOGII 2023; 69:58-67. [PMID: 37448248 PMCID: PMC10350612 DOI: 10.14341/probl13301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 04/30/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Primary bilateral macronodular adrenal hyperplasia (PBMAH) is characterized by bilateral benign adrenocortical lesions, which in some cases lead to Cushing syndrome (CS). Due to the low detection, non-specific, erased clinical picture and slow, long-term progression, it is difficult to assess the true prevalence of PBMAH. This also leads to fairly limited literature data. A detailed analysis of biochemical, imaging parameters, the clinical presentations, in particular, an assessment of the course of comorbidities (arterial hypertension (AH), diabetes (DM), osteoporosis), is necessary to develop an algorithm for managing patients with PBMAH. AIM Analysis of clinical and laboratory characteristics of patients with various forms of PBMAH. MATERIALS AND METHODS A single-center, retrospective, observational, cross-sectional study was carried out. This study included 110 patients with PBMAH who got referred to the National Research Center for Endocrinology in the period from 2013-2023. We carried out comparative and correlation analysis of hormonal (plasma cortisol concentrations after 1 mg dexamethasone (1-mg DST), urinary free cortisol (СКМ), ACTH), biochemical (glycated hemoglobin), radiological data (nodular tissue volume), course of comorbidities (metabolic syndrome, DM, AH, osteoporosis) in three groups of patients: with overt CS, mild autonomous cortisol excess (MACE) and comorbid diseases, and patients with PBMAH without hormonal activity. RESULTS Among 110 patients 79.1% were women, median age - 60 [51; 68]. The proportion of hormonally inactive forms of PBMAH was 37.3%, the overt CS and MACE was detected in 25.4 and 37.3% consequently. According to the hormonal -examination data: the cortisol level during 1-mg DST was 173.8 nmol/l [86.0; 441.0], ACTH - 3.35 pg/ml [1.00; 8.00], СКМ - 445.5 [249.0; 900.0]. Statistically significant positive moderate correlations were found between the volume of nodular tissue and the level of cortisol after PDT1 (r=0.40, p<0.001), СКМ (r=0.29, p<0.004), as well as a negative moderate correlation between the volume and the level of ACTH (r=-0.40, p<0.001). When analyzing the prevalence and clinical severity of comorbid conditions, DM was diagnosed in 22 (53.7%), AH in 36 (87.8%), obesity and osteoporosis - 23 (56%) and 3 (7.3%) patients. There was no statistically significant difference in the prevalence of CS-associated diseases among the above groups (p=0.56). CONCLUSION PBMAH is a heterogeneous pathology with different clinical, hormonal, and imaging characteristics. A correlation was found between the volume of nodular tissue and the degree of hormonal activity of PBMAH. The obtained results emphasize the difficulty in determining clear indications for surgical treatment in the group of patients with MACE. The radicality of proposed surgical procedure should be weighed against its potential complications.
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Affiliation(s)
- А. Шевэ
- Национальный медицинский исследовательский центр эндокринологии
| | - А. Р. Елфимова
- Национальный медицинский исследовательский центр эндокринологии
| | - Д. Г. Бельцевич
- Национальный медицинский исследовательский центр эндокринологии
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Araujo-Castro M, Reincke M. Primary bilateral macronodular adrenal hyperplasia: A series of 32 cases and literature review. ENDOCRINOL DIAB NUTR 2023; 70:229-239. [PMID: 37116968 DOI: 10.1016/j.endien.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/17/2022] [Indexed: 04/30/2023]
Abstract
Primary bilateral macronodular adrenal hyperplasia (PBMAH) accounts for <2% of cases of Cushing's syndrome. The majority of patients present with no obvious steroid excess it means with autonomous cortisol secretion (ACS). The classic treatment for patients with overt Cushing's syndrome is bilateral adrenalectomy, but unilateral resection of the larger adrenal gland can result in clinical and/or biochemical remission in >90% of cases, especially in cases of ACS. In this article, a series of 32 cases with PBMAH is described. Most of the cases of PBMAH had ACS, except for one case with overt Cushing's syndrome. A study of aberrant receptors was performed in six patients, being negative in three cases, positive in the metoclopramide test in two cases and positive in the metoclopramide test and in the mixed meal test in another patient. The patient with overt Cushing's syndrome was treated with adrenostatic therapy achieving biochemical control, while two patients with ACS underwent unilateral adrenalectomy with resection of the largest adrenal gland, demonstrating hypercortisolism remission and improvement of cardiovascular risk factors after surgery. This article describes a series of 32 cases of PBMAH and offers a comprehensive review of PBMAH.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal [Ramon y Cajal University Hospital], Instituto de Investigación Ramón y Cajal (IRYCIS) [Ramon y Cajal Research Institute], Spain; Universidad de Alcalá [University of Alcalá], Madrid, Spain.
| | - Martín Reincke
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
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Violon F, Bouys L, Berthon A, Ragazzon B, Barat M, Perlemoine K, Guignat L, Terris B, Bertherat J, Sibony M. Impact of Morphology in the Genotype and Phenotype Correlation of Bilateral Macronodular Adrenocortical Disease (BMAD): A Series of Clinicopathologically Well-Characterized 35 Cases. Endocr Pathol 2023. [PMID: 36864263 DOI: 10.1007/s12022-023-09751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Bilateral macronodular adrenocortical disease (BMAD) is characterized by the development of adrenal macronodules resulting in a pituitary-ACTH independent Cushing's syndrome. Although there are important similarities observed between the rare microscopic descriptions of this disease, the small series published are not representative of the molecular and genetic heterogenicity recently described in BMAD. We analyzed the pathological features in a series of BMAD and determined if there is correlation between these criteria and the characteristics of the patients. Two pathologists reviewed the slides of 35 patients who underwent surgery for suspicion of BMAD in our center between 1998 and 2021. An unsupervised multiple factor analysis based on microscopic characteristics divided the cases into 4 subtypes according to the architecture of the macronodules (containing or not round fibrous septa) and the proportion of the different cell types: clear, eosinophilic compact, and oncocytic cells. The correlation study with genetic revealed subtype 1 and subtype 2 are associated with the presence of ARMC5 and KDM1A pathogenic variants, respectively. By immunohistochemistry, all cell types expressed CYP11B1 and HSD3B1. HSD3B2 staining was predominantly expressed by clear cells whereas CYP17A1 staining was predominant on compact eosinophilic cells. This partial expression of steroidogenic enzymes may explain the low efficiency of cortisol production in BMAD. In subtype 1, trabeculae of eosinophilic cylindrical cells expressed DAB2 but not CYP11B2. In subtype 2, KDM1A expression was weaker in nodule cells than in normal adrenal cells; alpha inhibin expression was strong in compact cells. This first microscopic description of a series of 35 BMAD reveals the existence of 4 histopathological subtypes, 2 of which are strongly correlated with the presence of known germline genetic alterations. This classification emphasizes that BMAD has heterogeneous pathological characteristics that correlate with some genetic alterations identified in patients.
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Affiliation(s)
- Florian Violon
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France
- Department of Pathology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Lucas Bouys
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Annabel Berthon
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France
| | - Bruno Ragazzon
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France
| | - Maxime Barat
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France
| | - Karine Perlemoine
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France
| | - Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Benoit Terris
- Department of Pathology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France.
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France.
| | - Mathilde Sibony
- Université Paris-Cité, Institut Cochin, CNRS UMR8104, Inserm U1016, Paris, France.
- Department of Pathology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France.
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Yu Z, Gao J, Sun F. The effect of unilateral adrenalectomy on patients with primary bilateral macronodular adrenal hyperplasia. Hormones (Athens) 2023; 22:235-242. [PMID: 36800160 DOI: 10.1007/s42000-023-00428-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 01/09/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE To evaluate the long-term effect of unilateral adrenalectomy (uADX) on patients with primary bilateral macronodular adrenal hyperplasia (PBMAH). METHODS We retrospectively reviewed 29 patients (including 11 men and 18 women) with PBMAH and Cushing's syndrome (CS) between 2005 and 2019 who underwent uADX in our center. Clinical symptoms, serum cortisol (8:00 a.m., 4:00 p.m., and 0:00 a.m.), 24 h urinary free cortisol (UFC), computed tomography (CT) scan of the adrenal gland, and pituitary nuclear magnetic resonance (MR) scan performed before and after operation were analyzed. RESULTS The median follow-up time was 39 (13-134) months. uADX decreased significantly at 24 h UFC (median: 357.14 vs. 89.50 ug/24 h, P < 0.001) and serum cortisol (8:00 a.m.) (median: 22.88 vs. 12.50 ug/uL, P < 0.001) 1 year after surgery. In total, 17 of 29 patients had normal UFC again 1 year after surgery, while one of them suffered a relapse after 61 months. However, uADX failed to decrease UFC to the normal range in the other patients. Ten of the remaining 12 uncured patients and the relapsed patient finally underwent contralateral adrenalectomy (cADX). The 24 h UFC of the patients who were cured (n = 17) after uADX was significantly lower than that of the uncured patients (n = 12) (222.30 vs. 579.10 ug/24 h, P = 0.011). CONCLUSION uADX may be an appropriate treatment for patients with mildly elevated cortisol, while contralateral adrenalectomy (cADX) may be required for patients with highly elevated cortisol. The level of 24 h UFC is helpful to predict patients' prognosis.
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Affiliation(s)
- Zhongwei Yu
- Department of Urology, RuiJin Hospital Lu Wan Branch, Shanghai Jiaotong University School of Medicine, Shanghai, 200020, China
| | - Jie Gao
- Department of Endocrinology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Fukang Sun
- Department of Urology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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18
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Bertherat J, Bourdeau I, Bouys L, Chasseloup F, Kamenicky P, Lacroix A. Clinical, pathophysiologic, genetic and therapeutic progress in Primary Bilateral Macronodular Adrenal Hyperplasia. Endocr Rev 2022:6957368. [PMID: 36548967 DOI: 10.1210/endrev/bnac034] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) usually present bilateral benign adrenocortical macronodules at imaging and variable levels of cortisol excess. PBMAH is a rare cause of primary overt Cushing's syndrome, but may represent up to one third of bilateral adrenal incidentalomas with evidence of cortisol excess. The increased steroidogenesis in PBMAH is often regulated by various G-protein coupled receptors aberrantly expressed in PBMAH tissues; some receptor ligands are ectopically produced in PBMAH tissues creating aberrant autocrine/paracrine regulation of steroidogenesis. The bilateral nature of PBMAH and familial aggregation, led to the identification of germline heterozygous inactivating mutations of the ARMC5 gene, in 20-25% of the apparent sporadic cases and more frequently in familial cases; ARMC5 mutations/pathogenic variants can be associated with meningiomas. More recently, combined germline mutations/pathogenic variants and somatic events inactivating the KDM1A gene were specifically identified in patients affected by GIP-dependent PBMAH. Functional studies demonstrated that inactivation of KDM1A leads to GIP-receptor (GIPR) overexpression and over or down-regulation of other GPCRs. Genetic analysis is now available for early detection of family members of index cases with PBMAH carrying identified germline pathogenic variants. Detailed biochemical, imaging, and co-morbidities assessment of the nature and severity of PBMAH is essential for its management. Treatment is reserved for patients with overt or mild cortisol/aldosterone or other steroid excesses taking in account co-morbidities. It previously relied on bilateral adrenalectomy; however recent studies tend to favor unilateral adrenalectomy, or less frequently, medical treatment with cortisol synthesis inhibitors or specific blockers of aberrant GPCR.
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Affiliation(s)
- Jerôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Fanny Chasseloup
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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A Novel ARMC5 Germline Variant in Primary Macronodular Adrenal Hyperplasia Using Whole-Exome Sequencing. Diagnostics (Basel) 2022; 12:diagnostics12123028. [PMID: 36553033 PMCID: PMC9777150 DOI: 10.3390/diagnostics12123028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Primary macronodular adrenocortical hyperplasia (PMAH) is a rare form of adrenal Cushing’s syndrome with incomplete penetrance which may be sporadic or autosomal dominant. The inactivation of the ARMC5 gene, a potential tumor suppressor gene, is one of the associated causes of PMAH. This study aimed to identify the variant responsible for Iranian familial PMAH. Methods: The proband, a 44-year-old woman, was directed to whole-exome sequencing (WES) of the blood sample to discover a germline variant. In addition, the identified causative variant was confirmed and segregated in other and available unaffected family members. Results: The novel germline heterozygous missense variant, c.2105C>A in the ARMC5 gene, was found, and the same germline variant as the proband was confirmed in two affected sisters. This variant was detected in the brother of the proband with an asymptomatic condition and this considered because of incomplete penetrance and age-dependent appearance. The function of the ARMC5 protein would be damaged by the identified variant, according to in silico and computer analyses that followed. Conclusion: The new germline ARMC5 variation (c.2105C>A, (p. Ala702Glu)) was interpreted as a likely pathogenic variant based on ACMG and Sherloc standards. PMAH may be diagnosed early using genetic testing that shows inherited autosomal dominant mutations in the ARMC5 gene.
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20
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Cavalcante IP, Berthon A, Fragoso MC, Reincke M, Stratakis CA, Ragazzon B, Bertherat J. Primary bilateral macronodular adrenal hyperplasia: definitely a genetic disease. Nat Rev Endocrinol 2022; 18:699-711. [PMID: 35922573 DOI: 10.1038/s41574-022-00718-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/08/2022]
Abstract
Primary bilateral macronodular adrenal hyperplasia (PBMAH) is an adrenal cause of Cushing syndrome. Nowadays, a PBMAH diagnosis is more frequent than previously, as a result of progress in the diagnostic methods for adrenal incidentalomas, which are widely available. Although some rare syndromic forms of PBMAH are known to be of genetic origin, non-syndromic forms of PBMAH have only been recognized as a genetic disease in the past 10 years. Genomics studies have highlighted the molecular heterogeneity of PBMAH and identified molecular subgroups, allowing improved understanding of the clinical heterogeneity of this disease. Furthermore, the generation of these subgroups permitted the identification of new genes responsible for PBMAH. Constitutive inactivating variants in ARMC5 and KDM1A are responsible for the development of distinct forms of PBMAH. To date, pathogenic variants of ARMC5 are responsible for 20-25% of PBMAH, whereas germline KDM1A alterations have been identified in >90% of PBMAH causing food-dependent Cushing syndrome. The identification of pathogenic variants in ARMC5 and KDM1A demonstrated that PBMAH, despite mostly being diagnosed in adults aged 45-60 years, is a genetic disorder. This Review summarizes the important progress made in the past 10 years in understanding the genetics of PBMAH, which have led to a better understanding of the pathophysiology, opening new clinical perspectives.
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Affiliation(s)
- Isadora P Cavalcante
- Université Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
| | - Annabel Berthon
- Université Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
| | - Maria C Fragoso
- Department of Endocrinology, Adrenal Unit, University of Sao Paulo, Sao Paulo, Brazil
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, München, Germany
| | | | - Bruno Ragazzon
- Université Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France.
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21
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Rosenfeld BH, Vedere T, Hamilton P, Nam GH, Malchoff CD, Ristau BT. Resolution of manic symptoms following unilateral adrenalectomy in patient with primary bilateral macronodular adrenal hyperplasia. Urol Case Rep 2022; 45:102277. [PMID: 36406008 PMCID: PMC9668685 DOI: 10.1016/j.eucr.2022.102277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/02/2022] [Indexed: 11/12/2022] Open
Abstract
Primary bilateral macronodular adrenal hyperplasia (PBMAH) is often associated with symptoms of cortisol excess, which may include neuropsychological symptoms. We report a patient with PBMAH who presented with manic symptoms that resolved following unilateral adrenalectomy.
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22
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Bengoa-Rojano N, Fernández-Argüeso M, Botella-Carretero J, Pascual-Corrales E, Araujo-Castro M. Prevalencia y fenotipo de la hiperplasia suprarrenal macronodular bilateral primaria con secreción autónoma de cortisol: un estudio de 98 pacientes. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Wang W, Wei F. A novel pathogenic variant of ARMC5 in a patient with primary bilateral macronodular adrenal hyperplasia: a case report. BMC Endocr Disord 2022; 22:211. [PMID: 35996143 PMCID: PMC9396781 DOI: 10.1186/s12902-022-01128-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Primary bilateral macronodular adrenal hyperplasia (PBMAH), also known as adrenocorticotropic hormone (ACTH)-independent macronodular adrenal hyperplasia, is a rare cause of endogenous Cushing's syndrome. In many familial cases of PBMAH, the variants in armadillo repeat containing 5 (ARMC5) gene are found to be associated with the disease. Here, we report a case of PBMAH harboring a novel frameshift variant in ARMC5 gene, which has not been previously reported in the literature. CASE PRESENTATION A 67-year-old woman was referred due to the clinical features of Cushing's syndrome. Radiological imaging and hormonal testing were carried out. The serum levels of cortisol were remarkably increased at late night and did not suppress even after 1 mg of dexamethasone administration, while the plasma levels of ACTH hormone were decreased significantly. The patient underwent unilateral left-sided laparoscopic adrenalectomy, and the diagnosis of PBMAH was substantiated by histopathological analysis. Moreover, the partial envelope was incomplete and the cell proliferation index was low. Specifically, inhibin α-subunit ( +), syn focal ( +), Ki-67 ~ 3% ( +), CgA (-) and CEA (-) were observed. DNA sequencing data revealed that a novel frameshift variant (c.363_373delGCCAGTGCGCC, p.Pro122Alafs*61) was identified in ARMC5 gene. However, this variant was not detected in the daughter of the patient. The rest of the family members, including her sister, son and two brothers, were not consented for genetic testing. CONCLUSIONS Early detection of ARMC5 variant status and familial screening might have important clinical implications for the diagnosis and prognosis of PBMAH patients. A novel ARMC5 frameshift variant (c.363_373delGCCAGTGCGCC, p.Pro122Alafs*61) was identified to be associated with the pathogenesis of PBMAH. ARMC5 sequencing may improve the identification of a causative gene variant for PBMAH and allow earlier diagnosis of this disease.
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Affiliation(s)
- Wei Wang
- Department of Endocrinology, First Affiliated Hospital of Baotou Medical Collage, Inner Mongolia University of Science and Technology, Baotou, 014010, Inner Mongolia, China
| | - Feng Wei
- Department of Endocrinology, First Affiliated Hospital of Baotou Medical Collage, Inner Mongolia University of Science and Technology, Baotou, 014010, Inner Mongolia, China.
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24
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Gao J, Yu Z, Sun F, Xu B, Zhang C, Wang H, Lu J, Lei T. The Relationship Between Baseline Cortisol Levels and Surgery Method of Primary Bilateral Macronodular Adrenal Hyperplasia. Horm Metab Res 2022; 54:354-360. [PMID: 35697044 DOI: 10.1055/a-1850-2169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aim was to explore the associations between baseline cortisol levels and surgery method of primary bilateral macronodular adrenal hyperplasia (PBMAH). We retrospectively reviewed the clinical features and management of 30 patients (18 females and 12 males) who were diagnosed with PBMAH in our center between 2005 and 2019. Based on surgery method, we divided the patients into two groups: unilateral adrenalectomy (UA) group; and bilateral adrenalectomy (BA) group. Serum cortisol rhythm and 24-hour urinary free cortisol (UFC/24 h) levels were assayed using chemiluminescence method. Associations between baseline cortisol levels and BA were assessed using logistic regression. The predictive value of baseline cortisol levels for BA was calculated using receiver operating characteristic (ROC) curves. Twenty patients (66.7%) underwent UAs and ten patients (33.3%) underwent BAs. After adjusting for age, sex, BMI, SBP, and adrenal volume, the concentrations of baseline serum cortisol (8 AM, 4 PM, and 0 AM) and UFC/24 h were associated with bilateral adrenalectomy (all p<0.05). The area under the ROC curve based on 8 AM serum cortisol level model was larger than that in models based on 4 PM, 0 AM serum cortisol levels and UFC/24 h, but the differences were non-significant (all p>0.05). According to maximum Youden index criteria, the optimal cutoffs of 8 AM serum cortisol level and UFC were 26.89 μg/dl and 406.65 μg/24 h, respectively, for BA. The baseline cortisol levels are positively associated with BA. Increased levels of baseline cortisol levels may predict higher possibility of BA, which should be confirmed by prospective studies.
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Affiliation(s)
- Jie Gao
- Department of Endocrinology, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhongwei Yu
- Department of Urology, Ruijin Hospital Lu Wan Branch, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fukang Sun
- Department of Urology, Shanghai Jiao Tong University Medical School Affiliated Ruijin Hospital, Shanghai, China
| | - Bilin Xu
- Department of Endocrinology, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Cuiping Zhang
- Department of Endocrinology, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongping Wang
- Department of Endocrinology, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jun Lu
- Department of Endocrinology, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Tao Lei
- Department of Endocrinology, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
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25
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Bengoa-Rojano N, Fernández-Argüeso M, Botella-Carretero JI, Pascual-Corrales E, Araujo-Castro M. Prevalence and phenotype of primary bilateral macronodular adrenal hyperplasia with autonomous cortisol secretion: a study of 98 patients. Rev Clin Esp 2022; 222:458-467. [PMID: 35597729 DOI: 10.1016/j.rceng.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/22/2022] [Indexed: 01/06/2023]
Abstract
AIM This study evaluated prevalence of primary bilateral macronodular adrenal hyperplasia (PBMAH). It also analyzed the differential phenotype of patients with PBMAH compared to other bilateral adrenal lesions that do not meet the definition of PBMAH. METHODS We reviewed the medical records of 732 patients diagnosed with an adrenal incidentaloma at our center. Ninety-eight patients with subclinical hypercortisolism were included in the analysis. We defined PBMAH as the presence of plasma cortisol > 1.8 μg/dL after an over-night 1-mg dexamethasone test, bilateral adrenal hyperplasia, and bilateral adrenal nodules > 1 cm. RESULTS A total of 31 patients had PBMAH. Patients with PBMAH showed greater prevalence of autonomous cortisol secretion (plasma cortisol > 5.0 μg/dL after an overnight 1-mg dexamethasone test) than patients without PBMAH (OR 4.1, 95%CI 1.38-12.09, p = 0.010). Tumor size and total adenomatous mass were significantly greater in patients with PBMAH compared to patients without PBMAH (30.2 ± 12.16 vs. 24.3 ± 8.47 mm, p = 0.010 and 53.9 ± 20.8 vs. 43.3 ± 14.62 mm, p = 0.023), respectively. A greater proportion of patients with PBMAH had diabetes compared to patients without PBMAH (45.2% vs. 25.4%, p = 0.05). CONCLUSION PBMAH is present in one-third of patients with adrenal incidentaloma and subclinical hypercortisolism. Patients with PBMAH showed greater autonomous cortisol secretion, bigger tumor size, and higher rates of diabetes than those without PBMAH.
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Affiliation(s)
- N Bengoa-Rojano
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Fernández-Argüeso
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J I Botella-Carretero
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biosanitaria en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Madrid. Spain
| | - E Pascual-Corrales
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Araujo-Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Facultad de Medicina, Universidad de Alcalá, Alcalá de Henares (Madrid). Spain.
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26
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Fernandez C, Bhatia S, Rucker A, Celio L. Intermittent Blurry Vision: An Unexpected Presentation of Cushing’s Syndrome Due to Primary Bilateral Macronodular Adrenal Hyperplasia (PBMAH). Cureus 2022; 14:e25017. [PMID: 35712330 PMCID: PMC9197089 DOI: 10.7759/cureus.25017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/28/2022] Open
Abstract
Cushing’s syndrome (CS) is an uncommon endocrine disorder resulting from prolonged exposure to elevated glucocorticoids, with 10-15 million annual cases per the American Association of Neurological Surgeons. Exogenous and endogenous causes can further be divided into adrenocorticotropic hormone (ACTH) dependent (i.e Cushing’s Disease) or ACTH independent. ACTH-independent CS can be caused by primary bilateral macronodular adrenal hyperplasia (PBMAH) representing less than 1% cases of CS. We report a case of a woman presenting with chronic resistant hypertension, episodic blurry vision, weight gain and wasting of extremities. She was diagnosed with Cushing’s syndrome due to PBMAH. Our patient’s presentation was unusual as she presented at 40 years old, 10 years earlier than expected for PBMAH; and primarily with complaints of episodic blurry vision. Her symptoms also progressed rapidly as signs and symptoms largely presented over the course of 12 months, however responded well to surgical resection.
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27
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Silva Charchar HL, Fragoso MCBV. An Overview of the Heterogeneous Causes of Cushing’s Syndrome due to Primary Macronodular Adrenal Hyperplasia (PMAH). J Endocr Soc 2022; 6:bvac041. [PMID: 35402764 PMCID: PMC8989153 DOI: 10.1210/jendso/bvac041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Primary macronodular adrenal hyperplasia (PMAH) is considered a rare cause of adrenal Cushing syndrome, is pituitary ACTH-independent, generally results from bilateral adrenal macronodules (>1 cm), and is often associated with variable cortisol secretion, resulting in a heterogeneous clinical presentation. Recent advances in the molecular pathogenesis of PMAH have offered new insights into the comprehension of this heterogeneous and complex adrenal disorder. Different molecular mechanisms involving the actors of the cAMP/protein kinase A pathway have been implicated in the development of PMAH, including germline and/or somatic molecular defects such as hyperexpression of the G-protein aberrant receptors and pathogenic variants of MC2R, GNAS, PRKAR1A, and PDE11A. Nevertheless, since 2013, the ARMC5 gene is believed to be a major genetic cause of PMAH, accounting for more than 80% of the familial forms of PMAH and 30% of apparently sporadic cases, except in food-dependent Cushing syndrome in which ARMC5 is not involved. Recently, 2 independent groups have identified that the tumor suppressor gene KDM1A is responsible for PMAH associated specifically with food-dependent Cushing syndrome. Consequently, PMAH has been more frequently genetically associated than previously assumed. This review summarizes the most important aspects, including hormone secretion, clinical presentation, radiological imaging, and molecular mechanisms, involved in familial Cushing syndrome associated with PMAH.
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Affiliation(s)
- Helaine Laiz Silva Charchar
- Unidade de Suprarrenal, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Maria Candida Barisson Villares Fragoso
- Unidade de Suprarrenal, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
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28
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Tan XG, Zhu J, Cui L. MicroRNA expression signature and target prediction in familial and sporadic primary macronodular adrenal hyperplasia (PMAH). BMC Endocr Disord 2022; 22:11. [PMID: 34986816 PMCID: PMC8729020 DOI: 10.1186/s12902-021-00910-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 12/05/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Primary macronodular adrenal hyperplasia (PMAH), previously termed ACTH-independent macronodular adrenal hyperplasia (AIMAH), is a rare cause of Cushing's syndrome usually characterized by functioning adrenal macronodules and increased cortisol production. METHODS To screen and analyse the microRNA (miRNA) profile of PMAH in order to elucidate its possible pathogenesis, a miRNA microarray was used to test tissue samples from patients with familial PMAH, patients with sporadic PMAH and normal control samples of other nontumour adrenocortical tissues and identify characteristic microRNA expression signatures. Randomly selected miRNAs were validated by quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). Furthermore, the key signalling pathways and miRNAs involved in PMAH pathogenesis were determined by gene ontology and pathway analysis. RESULTS Characteristic microRNA expression signatures were identified for patients with familial PMAH (16 differentially expressed microRNAs) and patients with sporadic PMAH (8 differentially expressed microRNAs). The expression of the selected miRNAs was confirmed by qRT-PCR, suggesting the high reliability of the miRNA array analysis results. Pathway analysis showed that the most enriched pathway was the renal cell carcinoma pathway. Overexpression of miR-17, miR-20a and miR-130b may inhibit glucocorticoid-induced apoptosis in PMAH pathogenesis. CONCLUSION We identified the miRNA signatures in patients with familial and sporadic PMAH. The differentially expressed miRNAs may be involved in the mechanisms of PMAH pathogenesis. Specific miRNAs, such as miR-17, miR-20a and miR-130b, may be new targets for further functional studies of PMAH.
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Affiliation(s)
- Xiao-Gang Tan
- Department of Thoracic Surgery, Xuan Wu Hospital of Capital Medical University, Beijing, 100053, China
| | - Jie Zhu
- Department of Urology Surgery, Chinese PLA General Hospital, Beijing, 100082, China
| | - Liang Cui
- Department of Urology Surgery, Civil Aviation General Hospital, Beijing, 100123, China.
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29
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Araujo-Castro M, Marazuela M. Cushing´s syndrome due to bilateral adrenal cortical disease: Bilateral macronodular adrenal cortical disease and bilateral micronodular adrenal cortical disease. Front Endocrinol (Lausanne) 2022; 13:913253. [PMID: 35992106 PMCID: PMC9389040 DOI: 10.3389/fendo.2022.913253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Cushing´s syndrome (CS) secondary to bilateral adrenal cortical disease may be caused by bilateral macronodular adrenal cortical disease (BMACD) or by bilateral micronodular adrenal cortical disease (miBACD). The size of adrenal nodules is a key factor for the differentiation between these two entities (>1cm, BMACD and <1cm; miBACD). BMACD can be associated with overt CS, but more commonly it presents with autonomous cortisol secretion (ACS). Surgical treatment of BMACD presenting with CS or with ACS and associated cardiometabolic comorbidities should be the resection of the largest adrenal gland, since it leads to hypercortisolism remission in up to 95% of the cases. Medical treatment focused on the blockade of aberrant receptors may lead to hypercortisolism control, although cortisol response is frequently transient. miBACD is mainly divided in primary pigmented nodular adrenocortical disease (PPNAD) and isolated micronodular adrenocortical disease (i-MAD). miBACD can present at an early age, representing one of the main causes of CS at a young age. The high-dose dexamethasone suppression test can be useful in identifying a paradoxical increase in 24h-urinary free cortisol, that is a quite specific in PPNAD. Bilateral adrenalectomy is generally the treatment of choice in patients with overt CS in miBACD, but unilateral adrenalectomy could be considered in cases with asymmetric disease and mild hypercortisolism. This article will discuss the clinical presentation, genetic background, hormonal and imaging features and treatment of the main causes of primary bilateral adrenal hyperplasia associated with hypercortisolism.
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Ramón y Cajal University Hospital, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
- Departament of Medicine, Alcalá University, Madrid, Spain
- *Correspondence: Marta Araujo-Castro,
| | - Mónica Marazuela
- Endocrinology & Nutrition Department, La Princesa University Hospital, Madrid, Spain
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30
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Pitsava G, Maria AG, Faucz FR. Disorders of the adrenal cortex: Genetic and molecular aspects. Front Endocrinol (Lausanne) 2022; 13:931389. [PMID: 36105398 PMCID: PMC9465606 DOI: 10.3389/fendo.2022.931389] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Adrenal cortex produces glucocorticoids, mineralocorticoids and adrenal androgens which are essential for life, supporting balance, immune response and sexual maturation. Adrenocortical tumors and hyperplasias are a heterogenous group of adrenal disorders and they can be either sporadic or familial. Adrenocortical cancer is a rare and aggressive malignancy, and it is associated with poor prognosis. With the advance of next-generation sequencing technologies and improvement of genomic data analysis over the past decade, various genetic defects, either from germline or somatic origin, have been unraveled, improving diagnosis and treatment of numerous genetic disorders, including adrenocortical diseases. This review gives an overview of disorders associated with the adrenal cortex, the genetic factors of these disorders and their molecular implications.
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Affiliation(s)
- Georgia Pitsava
- Division of Intramural Research, Division of Population Health Research, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
| | - Andrea G. Maria
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
| | - Fabio R. Faucz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
- Molecular Genomics Core (MGC), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
- *Correspondence: Fabio R. Faucz,
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KDM1A inactivation causes hereditary food-dependent Cushing syndrome. Genet Med 2021; 24:374-383. [PMID: 34906447 DOI: 10.1016/j.gim.2021.09.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/10/2021] [Accepted: 09/14/2021] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study aimed to investigate the genetic cause of food-dependent Cushing syndrome (FDCS) observed in patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) and adrenal ectopic expression of the glucose-dependent insulinotropic polypeptide receptor. Germline ARMC5 alterations have been reported in about 25% of PBMAH index cases but are absent in patients with FDCS. METHODS A multiomics analysis of PBMAH tissues from 36 patients treated by adrenalectomy was performed (RNA sequencing, single-nucleotide variant array, methylome, miRNome, exome sequencing). RESULTS The integrative analysis revealed 3 molecular groups with different clinical features, namely G1, comprising 16 patients with ARMC5 inactivating variants; G2, comprising 6 patients with FDCS with glucose-dependent insulinotropic polypeptide receptor ectopic expression; and G3, comprising 14 patients with a less severe phenotype. Exome sequencing revealed germline truncating variants of KDM1A in 5 G2 patients, constantly associated with a somatic loss of the KDM1A wild-type allele on 1p, leading to a loss of KDM1A expression both at messenger RNA and protein levels (P = 1.2 × 10-12 and P < .01, respectively). Subsequently, KDM1A pathogenic variants were identified in 4 of 4 additional index cases with FDCS. CONCLUSION KDM1A inactivation explains about 90% of FDCS PBMAH. Genetic screening for ARMC5 and KDM1A can now be offered for most PBMAH operated patients and their families, opening the way to earlier diagnosis and improved management.
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Aouinati Y, Mjabber A, Haraj NE, Aziz SE, Chadli A. Adrenocorticotropic hormone (ACTH) independent Cushing's syndrome due to unilateral adrenocortical hyperplasia: two case reports. Pan Afr Med J 2021; 38:367. [PMID: 34367446 PMCID: PMC8308852 DOI: 10.11604/pamj.2021.38.367.26040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/20/2021] [Indexed: 11/23/2022] Open
Abstract
Adrenal unilateral macronodular hyperplasia is a rare cause of Cushing's syndrome. We discuss the case of two patients who present Cushing syndrome due to unilateral adrenal hyperplasia. They presented the signs of clinical hypercorticism as well as metabolic, cardiovascular and osteoporotic complications. Both patients presented clinical and laboratory signs of adrenocorticotropic hormone (ACTH)-independent Cushing syndrome with elevated urinary free cortisol (UFC) levels, adrenal computed tomography (CT) scan revealed the appearance of unilateral adrenal adenoma and normal contralateral adrenal gland. Adrenalectomy was performed under laparoscopic surgery; the resected mass was pathologically diagnosed as unilateral nodular adrenal hyperplasia. Unilateral adrenal hyperplasia is a very rare etiology of ACTH-independent Cushing syndrome, often mistaken for adenoma on CT and only pathological examination can confirm the diagnosis.
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Affiliation(s)
- Yousra Aouinati
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Amal Mjabber
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Nassim Essabah Haraj
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Siham El Aziz
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Asmaa Chadli
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
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Meloche-Dumas L, Mercier F, Lacroix A. Role of unilateral adrenalectomy in bilateral adrenal hyperplasias with Cushing's syndrome. Best Pract Res Clin Endocrinol Metab 2021; 35:101486. [PMID: 33637447 DOI: 10.1016/j.beem.2021.101486] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Primary bilateral adrenocortical hyperplasias are rare forms of pituitary ACTH-independent Cushing's syndrome (CS). They are divided between primary bilateral macronodular adrenal hyperplasia (PBMAH) and micronodular adrenal hyperplasia (MiBAH), which is subdivided in primary pigmented nodular adrenocortical disease (PPNAD) and isolated micronodular adrenocortical disease (i-MAD). One of the most debated aspects surrounding these entities is their most appropriate therapy. Although bilateral adrenalectomy (BA) has previously been the most utilized therapy for patients with overt CS, recent studies have indicated that unilateral adrenalectomy (UA) can be effective in patients with PBMAH and some with MiBAH with fewer long-term side effects. Medical therapies can also be used for bridging to surgery or rarely in the long-term for these patients. We review the various degrees of CS resulting from PBMAH and MiBAH, with a special focus on their respective therapies including UA, taking into account the recent pathophysiological and genetics findings.
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Affiliation(s)
- Léamarie Meloche-Dumas
- Surgical Oncology Service, Department of Surgery, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
| | - Frédéric Mercier
- Surgical Oncology Service, Department of Surgery, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
| | - André Lacroix
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
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Abstract
CONTEXT Endogenous Cushing syndrome (CS) is characterized by excess cortisol secretion, which is driven by tumorous secretion of corticotropin in the majority of patients. Untreated, CS results in substantial morbidity and mortality. Tumor-directed surgery is generally the first-line therapy for CS. However, hypercortisolism may persist or recur postoperatively; in other cases, the underlying tumor may not be resectable or its location may not be known. Yet other patients may be acutely ill and require stabilization before definitive surgery. In all these cases, additional interventions are needed, including adrenally directed medical therapies. EVIDENCE ACQUISITION Electronic literature searches were performed to identify studies pertaining to adrenally acting agents used for CS. Data were abstracted and used to compile this review article. EVIDENCE SYNTHESIS Adrenally directed medical therapies inhibit one or several enzymes involved in adrenal steroidogenesis. Several adrenally acting medical therapies for CS are currently available, including ketoconazole, metyrapone, osilodrostat, mitotane, and etomidate. Additional agents are under investigation. Drugs differ with regards to details of their mechanism of action, time course of pharmacologic effect, safety and tolerability, potential for drug-drug interactions, and route of administration. All agents require careful dose titration and patient monitoring to ensure safety and effectiveness, while avoiding hypoadrenalism. CONCLUSIONS These medications have an important role in the management of CS, particularly among patients with persistent or recurrent hypercortisolism postoperatively or those who cannot undergo tumor-directed surgery. Use of these drugs mandates adequate patient instruction and close monitoring to ensure treatment goals are being met while untoward adverse effects are minimized.
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Affiliation(s)
- Nicholas A Tritos
- Neuroendocrine Unit and Neuroendocrine and Pituitary Tumor Clinical Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Ozgen Saydam B, Adiyaman SC, Demir L, Yener S. ADRENOCORTICOTROPIC HORMONE IMMUNOASSAY INTERFERENCE IN A PATIENT WITH SUBCLINICAL HYPERCORTISOLISM. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:379-382. [PMID: 33363666 DOI: 10.4183/aeb.2020.379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Context Immunoassays are vulnerable to occasional analytical errors despite their sensitivity and specificity. Adrenocorticotropic hormone (ACTH) is among hormones which are vulnerable to assay interference. Objective In this case report, we aimed to present a case of ACTH interference in a patient with subclinical hypercortisolism. Case report We present a case of subclinical hypercortisolism with unexpectedly elevated levels of ACTH in whom interference was shown by different biochemical methods.It is important for the clinician to keep in mind the possibility of interference when clinical and laboratory results are discordant. The communication between the clinician and laboratory staff is important while interpreting results. This case report shows that ACTH interference should be considered in patients with subclinical hypercortisolism who have unexpectedly high levels of adrenocorticotropic hormone.
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Affiliation(s)
- B Ozgen Saydam
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
| | - S C Adiyaman
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
| | - L Demir
- Izmir Katip Celebi University, Ataturk Training and Research Hospital, Department of Biochemistry, Izmir, Turkey
| | - S Yener
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
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Zhang F, Lin X, Yu X. Primary macronodular adrenal hyperplasia (PMAH) can be generated by a new ARMC5 germline variant (c.52C>T (p.Gln18X)). Endocr J 2020; 67:1179-1186. [PMID: 32713866 DOI: 10.1507/endocrj.ej20-0163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Primary macronodular adrenal hyperplasia (PMAH) is a rare cause of Cushing syndrome (CS). In many cases of the PMAH family, variant in ARMC5, a putative tumor suppressor gene, are thought to induce the disease. The purpose of this study was to report a large Chinese family, in which a new germline heterozygous variant of ARMC5 (c.52C>T (p.Gln18X)) was found. A 64-year-old female patient (proband) was admitted to the hospital due to bilateral adrenal masses. In order to clarify the nature and function of adrenal masses, the proband completed several relevant screening tests of the adrenal function. After an ectopic receptor screening test and genetic testing, a new ARMC5 gene variant was found that might had led to the occurrence of PMAH. Because of its characteristic of autosomal dominant inheritance, the proband's relatives were recommended to conduct the genetic test. We collected the family members' genetic information, in which have 27 individuals, the proband tested the whole exon sequence, and 12 participants tested the Sanger sequence. Finally, 7 individuals were found have the same germline variant of ARMC5 as the proband. Subsequent computer analysis predicted that the variant significantly impaired protein function and resulted in inactivation of ARMC5. We found a new germline ARMC5 variant (c.52C>T (p.Gln18X)), which may induced PMAH. ARMC5 sequencing can improve the identification of clinical forms of PMAH and allow early diagnosis of the disease.
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Affiliation(s)
- Fan Zhang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, Liaoning 110001, China
| | - Xinyue Lin
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, Liaoning 110001, China
| | - Xiaohui Yu
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, Liaoning 110001, China
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Zhang Q, Xiao H, Zhao L, Li Y, Chen K, Zang L, Du J, Wang X, Guo Q, Yang G, Ba J, Gu W, Lyu Z, Dou J, Mu Y, Lu J. Analysis of clinical and pathological features of primary bilateral macronodular adrenocortical hyperplasia compared with unilateral cortisol-secreting adrenal adenoma. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1173. [PMID: 33241022 PMCID: PMC7576081 DOI: 10.21037/atm-20-5963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Primary bilateral macronodular adrenocortical hyperplasia (PBMAH) is a rare condition with untypical subclinical symptoms of Cushing’s syndrome (CS). This study aimed to compare the clinical and pathological features of PBMAH with unilateral cortisol-secreting adrenal adenoma (UAA). Methods We prospectively included 46 PBMAH patients and 205 UAA patients from January 2000 to February 2014. Cortisol levels and 24 hours urine free cortisol (UFC) were determined at baseline and during dexamethasone suppression test (DST) using the chemiluminescence method. Computed tomography (CT) examination of the adrenal glands was performed in all patients. For patients treated with adrenalectomy, hematoxylin, and eosin, staining was performed for pathological examination. Results The proportion of patients with autonomous cortisol secretion was significantly higher in PBMAH patients (39.1%) than UAA patients (6.8%). The PBMAH patients showed significantly lower levels of basal cortisol, low dose dexamethasone suppressed cortisol, and high dose dexamethasone suppressed cortisol than the UAA patients (452.6±183.3 vs. 578.7±166.4 nmol/L, P=0.003; 394.5±298.9 vs. 549.2±217.7 nmol/L, P=0.002; 397.3±282.3 vs. 544.3±187.6 nmol/L, P=0.003). Similarly, the PBMAH patients had significantly lower levels of basal 24 hours UFC, low dose dexamethasone suppressed 24 hours UFC, and high dose dexamethasone suppressed 24 hours UFC than the UAA patients (1,144.4±1,048.1 vs. 1,674.9±1,520.4 nmol/24 h, P=0.032; 1,157.3±1,483.5 vs. 1,940.1±1,360.9 nmol/24 h, P=0.003; 1,256.4±1,767.0 vs. 1,969.9±1,361.7 nmol/24 h, P=0.011). Conclusions PBMAH is often associated with atypical CS symptoms. The clinical and imaging features of PBMAH are useful for the differential diagnosis of this disease.
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Affiliation(s)
- Qian Zhang
- Department of Endocrinology, the Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Haiying Xiao
- Department of Endocrinology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Ling Zhao
- Department of Endocrinology, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
| | - Yijun Li
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Kang Chen
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Li Zang
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jin Du
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xianling Wang
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qinghua Guo
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guoqing Yang
- Department of Endocrinology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Jianming Ba
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weijun Gu
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhaohui Lyu
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Juming Lu
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
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38
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Pan B, Wang S, Chen Z, Zou G. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography findings in a patient with bilateral macronodular adrenal hyperplasia. BJR Case Rep 2020; 6:20200034. [PMID: 32922849 PMCID: PMC7465743 DOI: 10.1259/bjrcr.20200034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 11/05/2022] Open
Abstract
Adrenocorticotropic hormone-independent macronodular adrenal hyperplasia (AIMAH) is a rare bilateral adrenocorticotropic hormone (ACTH)-independent nodular adrenal hyperplastic disease. Most patients with AIMAH are usually asymptomatic and only a small percentage present with subclinical or apparent Cushing's syndrome caused by excessive corticosteroid secretion. Herein, we reported the case of a 51-year-old female with bilateral macronodular adrenal hyperplasia with mild fluorodeoxyglucose uptake based on PET/CT imaging findings. Her symptoms resolved after surgical resection of the right adrenal gland.
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Affiliation(s)
- Bo Pan
- PET/CT Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei 23001, China
| | - Shicun Wang
- PET/CT Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei 23001, China
| | - Zongke Chen
- PET/CT Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei 23001, China
| | - Guichang Zou
- Institute on Aging and Brain Disorders, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230026, China
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39
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Berthon A, Bertherat J. Update of Genetic and Molecular Causes of Adrenocortical Hyperplasias Causing Cushing Syndrome. Horm Metab Res 2020; 52:598-606. [PMID: 32097969 DOI: 10.1055/a-1061-7349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Bilateral hyperplasias of the adrenal cortex are rare causes of chronic endogenous hypercortisolemia also called Cushing syndrome. These hyperplasias have been classified in two categories based on the adrenal nodule size: the micronodular types include Primary Pigmented Nodular Adrenocortical Disease (PPNAD) and isolated Micronodular Adrenal Disease (iMAD) and the macronodular also named Primary Bilateral Macronodular Adrenal Hyperplasia (PBMAH). This review discusses the genetic and molecular causes of these different forms of hyperplasia that involve mutations and dysregulation of various regulators of the cAMP/protein kinase A (PKA) pathway. PKA signaling is the main pathway controlling cortisol secretion in adrenocortical cells under ACTH stimulation. Although mutations of the regulatory subunit R1α of PKA (PRKAR1A) is the main cause of familial and sporadic PPNAD, inactivation of two cAMP-binding phosphodiesterases (PDE11A and PDE8B) are associated with iMAD even if they are also found in PPNAD and PBMAH cases. Interestingly, PBMAH that is observed in multiple familial syndrome such as APC, menin, fumarate hydratase genes, has initially been associated with the aberrant expression of G-protein coupled receptors (GPCR) leading to an activation of cAMP/PKA pathway. However, more recently, the discovery of germline mutations in Armadillo repeat containing protein 5 (ARMC5) gene in 25-50% of PBMAH patients highlights its importance in the development of PBMAH. The potential relationship between ARMC5 mutations and aberrant GPCR expression is discussed as well as the potential other causes of PBMAH.
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40
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Yoshiaki Tanno F, Srougi V, Almeida MQ, Ide Yamauchi F, Morbeck Almeida Coelho F, Nishi MY, Claudia Nogueira Zerbini M, Silvia Correa Soares I, Adelaide Albergaria Pereira M, Laiz Silva Charchar H, Meneses Ferreira Lacombe A, Balderrama Brondani V, Srougi M, Carlos Nahas W, Mendonca BB, Luis Chambô J, Candida Barisson Villares Fragoso M. A New Insight into the Surgical Treatment of Primary Macronodular Adrenal Hyperplasia. J Endocr Soc 2020; 4:bvaa083. [PMID: 32724871 PMCID: PMC7375340 DOI: 10.1210/jendso/bvaa083] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022] Open
Abstract
Purpose This prospective study presents the results of a new approach in the treatment of primary macronodular adrenal hyperplasia (PMAH), with simultaneous total adrenalectomy of the larger adrenal gland and partial adrenalectomy of the contralateral adrenal gland (adrenal-sparing surgery). Materials and Methods We performed a prospective study including 17 patients with PMAH treated surgically with adrenal-sparing surgery in a tertiary referral hospital, with a median follow-up of 41 months. Clinical, hormonal, and genetic parameters were evaluated before surgery and during follow-up. All patients had at least 1 radiological examination before and after the procedure. Results Among the 17 patients, all but 1 patient had complete hypercortisolism control, and 12 recovered normal adrenal function after surgery. Significant improvement in clinical parameters was observed: weight loss (P = .004); reduction of both systolic (P = .001) and diastolic (P = .001) blood pressure; and reduction in the number of antihypertensive drugs (P < .001). Intra-, peri-, and postoperative complications were not observed. Conclusion Adrenal-sparing surgery is a safe and feasible procedure to treat patients with PMAH, providing a substantial chance of hypercortisolism control without the disadvantages of lifetime corticosteroid replacement.
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Affiliation(s)
- Fabio Yoshiaki Tanno
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Victor Srougi
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Madson Q Almeida
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Ide Yamauchi
- Instituto de Radiologia- INRAD, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Morbeck Almeida Coelho
- Instituto de Radiologia- INRAD, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mirian Yumie Nishi
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Iracy Silvia Correa Soares
- Serviço de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Adelaide Albergaria Pereira
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Helaine Laiz Silva Charchar
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Amanda Meneses Ferreira Lacombe
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vania Balderrama Brondani
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Miguel Srougi
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Willian Carlos Nahas
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Luis Chambô
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Candida Barisson Villares Fragoso
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Sarda Y, Shenoy D, Shetty S, Ullal S, Katyal S. Lean Cushing's. J Family Med Prim Care 2020; 9:3759-3761. [PMID: 33102366 PMCID: PMC7567194 DOI: 10.4103/jfmpc.jfmpc_230_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 11/17/2022] Open
Abstract
This is a case report of 59 years old male with adrenocorticotropic hormone ACTH-independent macronodular adrenal hyperplasia (AIMAH), which is a rare cause of Cushing's syndrome. He was detected to have adrenal lesions incidentally on imaging. The biochemical evaluation was suggestive of endogenous ACTH-independent Cushing's syndrome. Contrast Enhanced CT of the abdomen done to characterize the lesion was suggestive of bilateral macro-nodular adrenal hyperplasia. There was no evidence of cushingoid features except for type 2 diabetes mellitus suggestive of subclinical Cushing's. He was not planned for any immediate medical/surgical management since metabolic control was achieved with oral anti-diabetics (OADs) and anti-hypertensive medications. He is on regular follow up with well-controlled sugars and blood pressure.
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42
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Mariani BMDP, Nishi MY, Wanichi IQ, Brondani VB, Lacombe AMF, Charchar H, Pereira MAA, Srougi V, Tanno FY, Ceccato F, Regazzo D, Barbot M, Occhi G, Albiger NME, Vieira-Corrêa M, Kater CE, Scaroni C, Chambô JL, Zerbini MCN, Mendonca BB, Almeida MQ, Fragoso MCBV. Allelic Variants of ARMC5 in Patients With Adrenal Incidentalomas and in Patients With Cushing's Syndrome Associated With Bilateral Adrenal Nodules. Front Endocrinol (Lausanne) 2020; 11:36. [PMID: 32117062 PMCID: PMC7019100 DOI: 10.3389/fendo.2020.00036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/17/2020] [Indexed: 12/13/2022] Open
Abstract
Objective: Germline ARMC5 mutations are considered to be the main genetic cause of primary macronodular adrenal hyperplasia (PMAH). PMAH is associated with high variability of cortisol secretion caused from subclinical hypercortisolism to overt Cushing's syndrome (CS), in general due to bilateral adrenal nodules and rarely could also be due to non-synchronic unilateral adrenal nodules. The frequency of adrenal incidentalomas (AI) associated with PMAH is unknown. This study evaluated germline allelic variants of ARMC5 in patients with bilateral and unilateral AI and in patients with overt CS associated with bilateral adrenal nodules. Methods: We performed a retrospective multicenter study involving 123 patients with AI (64 bilateral; 59 unilateral). We also analyzed 20 patients with ACTH pituitary independent overt CS associated with bilateral adrenal nodules. All patients underwent germline genotyping analysis of ARMC5; abdominal CT and were classified as normal, possible or autonomous cortisol secretion, according to the low doses of dexamethasone suppression test. Results: We identified only one pathogenic allelic variant among the patients with bilateral AI. We did not identify any pathogenic allelic variants of ARMC5 in patients with unilateral AI. Thirteen out of 20 patients (65%) with overt CS and bilateral adrenal nodules were carriers of pathogenic germline ARMC5 allelic variants, all previously described. The germline ARMC5 mutation was observed in only one patient with bilateral AI; it was associated with autonomous cortisol secretion and showed to be a familial form. Conclusion: The rarity of germline ARMC5 mutations in AI points to other molecular mechanisms involved in this common adrenal disorder and should be investigated. In contrast, patients with overt Cushing's syndrome and bilateral adrenal nodules had the presence of ARMC5 mutations that were with high prevalence and similar to the literature. Therefore, we recommend the genetic analysis of ARMC5 for patients with established Cushing's syndrome and bilateral adrenal nodules rather than patients with unilateral AI.
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Affiliation(s)
- Beatriz Marinho de Paula Mariani
- Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, São Paulo, Brazil
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mirian Yumie Nishi
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ingrid Quevedo Wanichi
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vania Balderrama Brondani
- Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, São Paulo, Brazil
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Amanda Meneses Ferreira Lacombe
- Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, São Paulo, Brazil
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Helaine Charchar
- Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, São Paulo, Brazil
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Victor Srougi
- Divisao de Urologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Yoshiaki Tanno
- Divisao de Urologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine, Padova University/Hospital, Padova, Italy
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine, Padova University/Hospital, Padova, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine, Padova University/Hospital, Padova, Italy
| | - Gianluca Occhi
- Department of Biology, University of Padova, Padova, Italy
| | - Nora Maria Elvira Albiger
- Department of Biology, University of Padova, Padova, Italy
- Endocrinology Division, Department of Medical and Surgical Sciences, University of Padua, Padua, Italy
| | - Marcelo Vieira-Corrêa
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, The Federal University of São Paulo Medical School, São Paulo, Brazil
| | - Claudio Elias Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, The Federal University of São Paulo Medical School, São Paulo, Brazil
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine, Padova University/Hospital, Padova, Italy
| | - José Luis Chambô
- Divisao de Urologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Claudia Nogueira Zerbini
- Departmento de Patologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice B. Mendonca
- Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, São Paulo, Brazil
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Madson Q. Almeida
- Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, São Paulo, Brazil
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Instituto Do Câncer Do Estado de São Paulo, São Paulo, Brazil
| | - Maria Candida Barisson Villares Fragoso
- Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, São Paulo, Brazil
- Laboratorio de Hormônios e Genética Molecular LIM/42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Instituto Do Câncer Do Estado de São Paulo, São Paulo, Brazil
- *Correspondence: Maria Candida Barisson Villares Fragoso
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Sai K, Lal A, Lakshmi Maradana J, Velamala PR, Nitin T. Hypokalemia associated with mifepristone use in the treatment of Cushing's syndrome. Endocrinol Diabetes Metab Case Rep 2019; 2019:19-0064. [PMID: 31743097 PMCID: PMC6865352 DOI: 10.1530/edm-19-0064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/20/2019] [Indexed: 11/09/2022] Open
Abstract
SUMMARY Mifepristone is a promising option for the management of hypercortisolism associated with hyperglycemia. However, its use may result in serious electrolyte imbalances, especially during dose escalation. In our patient with adrenocorticotropic hormone-independent macro-nodular adrenal hyperplasia, unilateral adrenalectomy resulted in biochemical and clinical improvement, but subclinical hypercortisolism persisted following adrenalectomy. She was started on mifepristone. Unfortunately, she missed her follow-up appointments following dosage escalation and required hospitalization at an intensive care level for severe refractory hypokalemia. LEARNING POINTS Mifepristone, a potent antagonist of glucocorticoid receptors, has a high risk of adrenal insufficiency, despite high cortisol levels. Mifepristone is associated with hypokalemia due to spill-over effect of cortisol on unopposed mineralocorticoid receptors. Given the lack of a biochemical parameter to assess improvement, the dosing of mifepristone is based on clinical progress. Patients on mifepristone require anticipation of toxicity, especially when the dose is escalated. The half-life of mifepristone is 85 h, requiring prolonged monitoring for toxicity, even after the medication is held.
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Affiliation(s)
- Katta Sai
- Department of Internal Medicine, Saint Vincent Hospital at Worcester Medical Center, Worcester, Massachusetts, USA
| | - Amos Lal
- Department of Internal Medicine, Saint Vincent Hospital at Worcester Medical Center, Worcester, Massachusetts, USA
| | - Jhansi Lakshmi Maradana
- Department of Internal Medicine, Saint Vincent Hospital at Worcester Medical Center, Worcester, Massachusetts, USA
| | - Pruthvi Raj Velamala
- Department of Internal Medicine, Saint Vincent Hospital at Worcester Medical Center, Worcester, Massachusetts, USA
| | - Trivedi Nitin
- Department of Endocrinology, Diabetes, and Metabolism, Saint Vincent Hospital at Worcester Medical Center, Worcester, Massachusetts, USA
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Ferri J, Perelló E, Lorente RI, Argente C, Rossetti P, Pedro T, Martinez-Hervas S, Real JT. Study of abnormal adrenal receptors in subjects with ACTH-independent Cushing's syndrome and nodular adrenal hyperplasia. ACTA ACUST UNITED AC 2019; 67:245-252. [PMID: 31672533 DOI: 10.1016/j.endinu.2019.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/06/2019] [Accepted: 07/10/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION ACTH-independent Cushing's Syndrome (AICS) accounts for 15-20% of cases of Cushing's syndrome, with <1% due to abnormal receptors. Our aim is to study the presence of abnormal receptors in subjects diagnosed with AICS with nodular adrenal hyperplasia in a 14-year period (2002-2016), as well as its clinical-biological and evolutive characteristics. MATERIAL AND METHODS A multicentre descriptive study of a 15-case series of AICS with nodular adrenal hyperplasia (study period: 2002-2016). In these cases, abnormal receptor screening was performed by means of stimulation tests, with a plasma cortisol increase of ≥ 25% from baseline being considered pathologic. RESULTS Of the 15 cases, 13 were female, with a mean age at diagnosis of 56.8 years. In 12 of the 15 cases studied, positivity was detected with stimulation tests, and, of them, 25% were positive for the meal test, 58.3% for posture walking test, 33.3% for desmopressin; 25% for terlipressin; 33.3% for GnRH; 25% for LH and 50% for metoclopramide. Regarding treatment, bilateral adrenalectomy was performed in 16.7% and unilateral adrenalectomy in 41.7%. The rest continue under observation with periodic follow-up (41.7%). CONCLUSIONS In most of the cases studied with AICS and nodular adrenal hyperplasia (80%), an abnormal cortisol response is detected due to the presence of abnormal receptors. The test with the highest percentage of positivity was the postural walking test (58.3%).
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Affiliation(s)
- Jordi Ferri
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España
| | - Eva Perelló
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España
| | - Rosario I Lorente
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España
| | - Carlos Argente
- Endocrinología y Nutrición, Hospital Marina Baixa, Villajoyosa (Alicante), España
| | - Paolo Rossetti
- Endocrinología y Nutrición, Hospital de Gandía, Gandía (Valencia), España
| | - Teresa Pedro
- Endocrinología y Nutrición, Hospital de Dénia, Dénia (Alicante)
| | - Sergio Martinez-Hervas
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM).
| | - José T Real
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM)
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Abstract
Since the initial discovery of mutations in the Armadillo-containing repeat protein 5 gene (ARMC5) in primary bilateral macronodular adrenocortical hyperplasia (PBMAH), efforts have been made to better understand the molecular mechanisms involving ARMC5 in the development of this rare form of Cushing syndrome. It has now been established that germline ARMC5-inactivating mutations, mostly frameshift and nonsense ones, are responsible for roughly 40% of PBMAH cases. ARMC5 is a tumor suppressor gene responsible for a familial form of PBMAH. Furthermore, the presence of inactivating ARMC5 mutations is associated with a more severe CS and hypertension as well as an overall increase in adrenal mass. However, ARMC5 inactivation decreases cortisol secretion both in vitro and in vivo (in mice) suggesting that the way that ARMC5 deficiency leads to Cushing syndrome is complicated and maybe not a direct effect of the ARMC5's loss, requiring additional molecular events to take place. Moreover, in silico predicted damaging ARMC5 variants have been identified in patients of African American descent with primary aldosteronism suggesting a potential role of ARMC5 in predisposing to low renin hypertension. Beyond its role in adrenocortical cells, ARMC5 defects has recently been associated with meningioma and T-cell immune response defects in humans and mice, respectively. Herein, we review recent discoveries in ARMC5's role in adrenal pathophysiology and beyond; clearly, we are only at the beginning of understanding the function of this gene with functions in the adrenal gland, the immune system, and elsewhere.
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Kyo C, Usui T, Kosugi R, Torii M, Yonemoto T, Ogawa T, Kotani M, Tamura N, Yamamoto Y, Katabami T, Kurihara I, Saito K, Kanamoto N, Fukuoka H, Wada N, Murabe H, Inoue T. ARMC5 Alterations in Primary Macronodular Adrenal Hyperplasia (PMAH) and the Clinical State of Variant Carriers. J Endocr Soc 2019; 3:1837-1846. [PMID: 31555754 PMCID: PMC6749843 DOI: 10.1210/js.2019-00210] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
Context Primary macronodular adrenal hyperplasia (PMAH) is a rare type of Cushing or subclinical Cushing syndrome and is associated with bilateral multinodular formation. ARMC5 is one of the responsible genes for PMAH. Objectives This study was performed to identify the genotype-phenotype correlation of ARMC5 in a cohort of Japanese patients. Patients and Methods Fourteen patients with clinically diagnosed PMAH and family members of selected patients were studied for ARMC5 gene alteration and clinical phenotype. The associated nonadrenal tumor tissues were also studied. Results Of fourteen patients with PMAH, 10 had pathogenic or likely pathogenic variants of ARMC5. We found two variants. Five unrelated patients had identical variants (p.R619*). In two patients, the variant was found in offspring with the asymptomatic or presymptomatic state. Six of ten patients who tested positive for the ARMC5 pathogenic or likely pathogenic variant carried nonadrenal tumors; however, no loss of heterozygosity (LOH) or second hit of the ARMC5 gene was evident. The ARMC5 variant–positive group showed a significantly higher basal cortisol level. Furthermore, age-dependent cortisol hypersecretion was seen in the ARMC5 variant–positive group. Conclusions ARMC5 pathogenic variants are common (71%) in Japanese patients with PMAH. p.R619* might be a hot spot in Japanese patients with PMAH. Asymptomatic or presymptomatic pathogenic variant carriers were found among the family members of the patients. Although 50% of ARMC5 variant carriers had nonadrenal neoplastic lesions, no LOH or second hit of ARMC5 in the tumor tissues was evident. The ARMC5 variant–positive mutant group showed a higher basal cortisol level than the negative group.
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Affiliation(s)
- Chika Kyo
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan
| | - Takeshi Usui
- Department of Medical Genetics, Shizuoka General Hospital, Shizuoka, Japan.,Research Support Center, Shizuoka General Hospital, Shizuoka, Japan
| | - Rieko Kosugi
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan.,Department of Medical Genetics, Shizuoka General Hospital, Shizuoka, Japan
| | - Mizuki Torii
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan
| | - Takako Yonemoto
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan.,Department of Medical Genetics, Shizuoka General Hospital, Shizuoka, Japan
| | - Tatsuo Ogawa
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan
| | - Masato Kotani
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan
| | - Naohisa Tamura
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan.,Research Support Center, Shizuoka General Hospital, Shizuoka, Japan
| | - Yutaro Yamamoto
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Isao Kurihara
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kohei Saito
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan.,Department of Medical Genetics, Shizuoka General Hospital, Shizuoka, Japan.,Research Support Center, Shizuoka General Hospital, Shizuoka, Japan.,Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naotetsu Kanamoto
- Department of Endocrinology, Osaka City General Hospital, Osaka, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Hiroyuki Murabe
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tatsuhide Inoue
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan
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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: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [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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48
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Berthon A, Hannah-Shmouni F, Maria AG, Faucz FR, Stratakis CA. High expression of adrenal P450 aromatase (CYP19A1) in association with ARMC5-primary bilateral macronodular adrenocortical hyperplasia. J Steroid Biochem Mol Biol 2019; 191:105316. [PMID: 31014964 PMCID: PMC6615475 DOI: 10.1016/j.jsbmb.2019.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/12/2019] [Accepted: 02/24/2019] [Indexed: 01/12/2023]
Abstract
Primary bilateral macronodular adrenocortical hyperplasia (PBMAH) is a rare cause of ACTH-independent Cushing syndrome (CS), which has been associated with ectopic G-protein coupled receptors (GPCRs) in the adrenal cortex. We recently studied a 51-year-old male with PBMAH who presented with severe CS and hyperestronemia, manifesting clinically with a Cushingoid appearance, gynecomastia, and telangiectasias. Analysis of adrenal tissues following bilateral adrenalectomy showed high expression of P450 aromatase (CYP19A1). The patient carried a germline non-sense pathogenic variant in ARMC5 (p.R173*), with two independent somatic pathogenic variants identified in the right (p.S571*) and left (p.Q235*) adrenal tissues, respectively. The expression of ARMC5 was drastically decreased in the hyperplastic regions when compared to either the adjacent non-hyperplastic regions and samples from PBMAH without pathogenic variants in ARMC5. We found expression of CYP19A1 in other cases of PBMAH, although there were no differences in aromatase expression between ARMC5-mutant and ARMC5-non-mutant cases. We conclude that in select cases, PBMAH can be associated with aromatase expression resulting in elevated estrogens, irrespective of sex. Additionally, CYP19A1 expression does not appear to depend on the ARMC5 variant status.
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Affiliation(s)
- Annabel Berthon
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Fady Hannah-Shmouni
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Andrea Gutierrez Maria
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Fabio R Faucz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA.
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49
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Busceti CL, Ferese R, Bucci D, Ryskalin L, Gambardella S, Madonna M, Nicoletti F, Fornai F. Corticosterone Upregulates Gene and Protein Expression of Catecholamine Markers in Organotypic Brainstem Cultures. Int J Mol Sci 2019; 20:ijms20122901. [PMID: 31197099 PMCID: PMC6627138 DOI: 10.3390/ijms20122901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 12/15/2022] Open
Abstract
Glucocorticoids are produced by the adrenal cortex and regulate cell metabolism in a variety of organs. This occurs either directly, by acting on specific receptors in a variety of cells, or by stimulating catecholamine expression within neighbor cells of the adrenal medulla. In this way, the whole adrenal gland may support specific metabolic requirements to cope with stressful conditions from external environment or internal organs. In addition, glucocorticoid levels may increase significantly in the presence of inappropriate secretion from adrenal cortex or may be administered at high doses to treat inflammatory disorders. In these conditions, metabolic alterations and increased blood pressure may occur, although altered sleep-waking cycle, anxiety, and mood disorders are frequent. These latter symptoms remain unexplained at the molecular level, although they overlap remarkably with disorders affecting catecholamine nuclei of the brainstem reticular formation. In fact, the present study indicates that various doses of glucocorticoids alter the expression of genes and proteins, which are specific for reticular catecholamine neurons. In detail, corticosterone administration to organotypic mouse brainstem cultures significantly increases Tyrosine hydroxylase (TH) and Dopamine transporter (DAT), while Phenylethanolamine N-methyltransferase (PNMT) is not affected. On the other hand, Dopamine Beta-Hydroxylase (DBH) increases only after very high doses of corticosterone.
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Affiliation(s)
| | | | | | - Larisa Ryskalin
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy.
| | | | | | - Ferdinando Nicoletti
- I.R.C.C.S. Neuromed, 86077 Pozzilli, Italy.
- Department of Physiology and Pharmacology, University Sapienza, 00185 Roma, Italy.
| | - Francesco Fornai
- I.R.C.C.S. Neuromed, 86077 Pozzilli, Italy.
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy.
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Tanaka S, Fujishiro M, Nakamura Y, Hatanaka Y, Abe M. Retention of aberrant cortisol secretion in a patient with bilateral macronodular adrenal hyperplasia after unilateral adrenalectomy. Ther Clin Risk Manag 2019; 15:337-342. [PMID: 30880999 PMCID: PMC6398404 DOI: 10.2147/tcrm.s196171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Aberrant cortisol secretion responses after exogenous stimuli such as upright posture, eating a mixed meal or receiving agents influencing aberrant G-protein-coupled receptors in adrenal glands, are often observed in patients with bilateral macronodular adrenal hyperplasia (BMAH). However, little is known about whether this aberrant response is retained after unilateral adrenalectomy. Here, we describe a 61-year-old postmenopausal Japanese woman with unsatisfactorily controlled hypertension who was referred to us for further investigation due to her pre-obesity characteristics (body mass index 28.4 kg/m2). Cushing’s signs and serum cortisol at 16.2 µg/dL with undetectable adrenocorticotropic hormone indicated adrenal Cushing’s syndrome. Adrenal imaging revealed bilaterally enlarged adrenal glands with 131-I adosterol uptake; hence, BMAH was diagnosed. Preoperatively, in vivo screening for aberrant adrenal receptors revealed an aberrant response of cortisol secretion on metoclopramide challenge. The patient underwent unilateral adrenalectomy; thereafter, glucocorticoid replacement therapy was reduced to hydrocortisone 15 mg/day at postoperative day 6. Fasting morning serum cortisol level measured at postoperative day 8 was 2.96 µg/dL, suggesting adrenal insufficiency. However, following metoclopramide administration serum cortisol level rose to 19.7 µg/dL, indicating potential efficient adrenal function. Aberrant cortisol secretory capacity was thus preserved in BMAH, even in a state of adrenal insufficiency after unilateral adrenalectomy. Caution should be exercised when assessing the hypothalamus-pituitary-adrenal axis, because in this patient, a high cortisol level did not guarantee appropriate adrenal function when the patient was challenged by exogenous stimuli.
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Affiliation(s)
- Sho Tanaka
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan,
| | - Midori Fujishiro
- Division of Diabetes and Metabolic Diseases, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshihiro Nakamura
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan,
| | - Yoshinari Hatanaka
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan,
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan,
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