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Rizk RC, Yasrab M, Chu LC, Weisberg EM, Fishman EK. An incidental large adrenal schwannoma: A case report. Radiol Case Rep 2024; 19:3008-3012. [PMID: 38741689 PMCID: PMC11089284 DOI: 10.1016/j.radcr.2024.04.036] [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: 02/28/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/16/2024] Open
Abstract
Adrenal schwannoma is a rare tumor of Schwann cell origin that represents less than 0.2% of all adrenal tumors. These typically benign tumors are most often found in the head, neck, and limbs. However, schwannomas can also rarely occur rarely in the adrenal gland within the retroperitoneal cavity. In the adrenal gland, these tumors arise from the medulla and are difficult to diagnose, often misdiagnosed as other benign or malignant entities. In this article, we report the case of a 43-year-old female with a large left adrenal mass revealed by biopsy to be a schwannoma. We focus on the use of radiological imaging modalities and immunohistochemical analysis to optimize diagnosis and treatment intervention of this rare tumor.
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Affiliation(s)
- Ryan C. Rizk
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Mohammad Yasrab
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Linda C. Chu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Edmund M. Weisberg
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Elliot K. Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
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2
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Fuß CT, Megerle F, Fassnacht M. [Adrenal tumors: current standards in clinical management]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024:10.1007/s00108-024-01727-x. [PMID: 38864873 DOI: 10.1007/s00108-024-01727-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/13/2024]
Abstract
Adrenal tumors are among the most common tumors in humans. They are most frequently discovered incidentally during abdominal imaging for other reasons or due to clinical symptoms (e.g. Conn's or Cushing's syndrome, pheochromocytoma or androgen excess). Although over 80% of adrenal tumors are benign, in cases of hormone excess, they are associated with significantly increased morbidity. In highly malignant adrenocortical carcinoma (ACC), early diagnosis is of particular prognostic relevance. Therefore, this review presents the diagnostic procedure for what are referred to as adrenal incidentalomas and provide recommendations for the management of ACC and pheochromocytomas/paragangliomas (PPGL). In primary diagnosis, sufficient hormone diagnostics is required for all adrenal tumors, as this is the only way to identify all patients with relevant hormone excess. Imaging has increasingly improved in recent years and allows a reliable assessment of the tumor's malignancy in most cases. Imaging of first choice is unenhanced computed tomography (CT), while magnetic resonance imaging (MRI) and fluorodeoxyglucose-18 positron emission tomography (FDG-PET/CT) are reserved for special situations, as published evidence on these procedures is more limited. The treatment of ACC and PPGL is complex and is carried out on an interdisciplinary basis at specialized centers. In the case of localized disease, surgery is the only curative treatment option. There are now clear recommendations for individualized adjuvant therapy for ACC. In metastatic disease, mitotane with or without platinum-containing chemotherapy is the standard. Other lines of therapy should be discussed with a reference center. Over 35% of PPGL have a germline mutation; therefore, genetic testing should be offered. In metastatic PPGL, an individual decision is required between active surveillance, radionuclide therapy, sunitinib or chemotherapy.
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Affiliation(s)
- Carmina Teresa Fuß
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Felix Megerle
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Martin Fassnacht
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
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3
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Mansour N, Heinrich K, Zhang D, Winkelmann M, Ingenerf M, Gold L, Klambauer K, Rudelius M, Klauschen F, von Bergwelt-Baildon M, Ricke J, Heinemann V, Westphalen CB, Kunz WG. Patient eligibility for trials with imaging response assessment at the time of molecular tumor board presentation. Cancer Imaging 2024; 24:70. [PMID: 38849902 PMCID: PMC11157753 DOI: 10.1186/s40644-024-00708-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/11/2024] [Indexed: 06/09/2024] Open
Abstract
PURPOSE To assess the eligibility of patients with advanced or recurrent solid malignancies presented to a molecular tumor board (MTB) at a large precision oncology center for inclusion in trials with the endpoints objective response rate (ORR) or duration of response (DOR) based on Response Evaluation Criteria in Solid Tumors (RECIST version 1.1). METHODS Prospective patients with available imaging at the time of presentation in the MTB were included. Imaging data was reviewed for objectifiable measurable disease (MD) according to RECIST v1.1. Additionally, we evaluated the patients with MD for representativeness of the identified measurable lesion(s) in relation to the overall tumor burden. RESULTS 262 patients with different solid malignancies were included. 177 patients (68%) had MD and 85 (32%) had non-measurable disease (NMD) at the time point of MTB presentation in accordance with RECIST v1.1. MD was not representative of the overall tumor burden in eleven patients (6%). The main reasons for NMD were lesions with longest diameter shorter than 10 mm (22%) and non-measurable peritoneal carcinomatosis (18%). Colorectal cancer and malignant melanoma displayed the highest rates of MD (> 75%). In contrast, gastric cancer, head and neck malignancies, and ovarian carcinoma had the lowest rates of MD (< 55%). In case of MD, the measurable lesions were representative of the overall tumor burden in the vast majority of cases (94%). CONCLUSION Approximately one third of cancer patients with advanced solid malignancies are not eligible for treatment response assessment in trials with endpoints ORR or DOR at the time of MTB presentation. The rate of patients eligible for trials with imaging endpoints differs significantly based on the underlying malignancy and should be taken under consideration during the planning of new precision oncology trials.
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Affiliation(s)
- Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Kathrin Heinrich
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Danmei Zhang
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK partner site Munich), Heidelberg, Germany
| | - Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Lukas Gold
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Konstantin Klambauer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Martina Rudelius
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Frederick Klauschen
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK partner site Munich), Heidelberg, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Volker Heinemann
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany.
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Araujo-Castro M. Pheochromocytoma. Preoperative approach. Med Clin (Barc) 2024:S0025-7753(24)00286-0. [PMID: 38849272 DOI: 10.1016/j.medcli.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 06/09/2024]
Abstract
Pheochromocytomas are rare neuroendocrine tumors that derive from the chromaffin cells of the adrenal medulla and secrete catecholamines. The measurement of plasma or fractionated urine metanephrines is the hormonal determination of choice for the biochemical diagnosis. Once the biochemical diagnosis is confirmed, the next step is the localization study. It is recommended to request a genetic study in all patients with pheochromocytomas since 40% of cases are hereditary. Once the diagnostic study is completed, preoperative treatment with alpha blockers should be instituted at least 7-14 days before adrenalectomy. However, in low-risk patients, the omission of presurgical treatment could be considered if the surgery is performed in centers with experience and a strict monitoring of the patient is carried out during the perioperative period. This document offers a practical guide on the diagnosis and perioperative approach in patients with pheochromocytomas.
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Affiliation(s)
- Marta Araujo-Castro
- Departamento de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal e Instituto de Investigación Ramón y Cajal (IRYCIS), Madrid, España.
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Tizianel I, Barbot M, Ceccato F. Subtyping of Cushing's Syndrome: A Step Ahead. Exp Clin Endocrinol Diabetes 2024. [PMID: 38574761 DOI: 10.1055/a-2299-5065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Cushing's Syndrome (CS) is a rare disease due to chronic endogenous cortisol secretion. In recent years, new developments have broadened the spectrum of differential diagnosis, traditionally categorized as adrenocorticotropic hormone (ACTH)-dependent and ACTH-independent forms. Moreover, increased awareness of the detrimental effects of cortisol on cardiometabolic health and the risk of cardiovascular events lead to increased diagnosis of mild forms, especially in the context of adrenal incidentalomas.This review provides an up-to-date narrative of the most recent literature regarding the challenges of CS diagnosis. After the description of the diagnostic tools available, the functional non-neoplastic hypercortisolism (formerly known as pseudo-Cushing state) is characterized, followed by the subtyping of the different conditions of hypercortisolism, including the differential diagnosis of ACTH-dependent forms and the management of adrenal hypercortisolism, with peculiar attention to the new genetic classification of adrenal CS, mild autonomous cortisol secretion, and bilateral adrenal adenomas.
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Affiliation(s)
- Irene Tizianel
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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Koh JM, Song K, Kwak MK, Suh S, Kim BJ, Sung TY, Hong JH, Jeong BC, Kim JH, Lee SH. Adrenalectomy Improves Body Weight, Glucose, and Blood Pressure Control in Patients With Mild Autonomous Cortisol Secretion: Results of an Randomized Controlled Trial by the Co-work of Adrenal Research (COAR) Study. Ann Surg 2024; 279:945-952. [PMID: 38126763 DOI: 10.1097/sla.0000000000006183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To assess the metabolic effects of adrenalectomy in patients with mild autonomous cortisol secretion (MACS). BACKGROUND Despite retrospective studies showing the association of adrenalectomy for MACS with beneficial metabolic effects, there have been only 2 randomized prospective studies with some limitations to date. METHODS A prospective, multicenter study randomized 132 patients with adrenal incidentaloma without any features of Cushing syndrome but with serum cortisol >50 nmol/L after a 1 mg overnight dexamethasone suppression test into an adrenalectomy group (n = 66) or control group (n = 66). The primary outcomes were changes in body weight, glucose, and blood pressure (BP). RESULTS Among the 118 participants who completed the study with a median follow-up duration of 48 months (range: 3-66), the adrenalectomy group (n = 46) exhibited a significantly higher frequency of improved weight control, glucose control, and BP control (32.6%, 45.7%, and 45.7%, respectively) compared with the control group (n = 46; 6.5%, P = 0.002; 15.2%, P = 0.002; and 23.9%, P = 0.029, respectively) after matching for age and sex. Adrenalectomy [odds ratio (OR) = 10.38, 95% CI = 2.09-51.52, P = 0.004], body mass index (OR = 1.39, 95% CI = 1.08-1.79, P = 0.010), and cortisol after a 1 mg overnight dexamethasone suppression test levels (OR = 92.21, 95% CI = 5.30-1604.07, P = 0.002) were identified as independent factors associated with improved weight control. Adrenalectomy (OR = 5.30, 95% CI = 1.63-17.25, P = 0.006) and diabetes (OR = 8.05, 95% CI = 2.34-27.65, P = 0.001) were independently associated with improved glucose control. Adrenalectomy (OR = 2.27, 95% CI = 0.87-5.94, P = 0.095) and hypertension (OR = 10.77, 95% CI = 3.65-31.81, P < 0.001) demonstrated associations with improved BP control. CONCLUSIONS adrenalectomy improved weight, glucose, and BP control in patients with MACS.
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Affiliation(s)
- Jung-Min Koh
- Department of Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Keeho Song
- Department of Medicine, Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Mi Kyung Kwak
- Department of Medicine, Division of Endocrinology and Metabolism, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Korea
| | - Sunghwan Suh
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Beom-Jun Kim
- Department of Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Department of Medicine, Division of Endocrinology and Metabolism, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Department of Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Dery L, Stern J, Shimon I, Rudman Y, Kushnir S, Shochat T, Fleseriu M, Akirov A. Impact of etiology, sex, diabetes mellitus and remission status on erythrocytic profile in patients with cushing's syndrome: a large population database study. Pituitary 2024:10.1007/s11102-024-01399-8. [PMID: 38769229 DOI: 10.1007/s11102-024-01399-8] [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] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE The study aimed to characterize the erythrocytic profile in patients with cushing's syndrome (CS) versus controls from the normal population according to etiology, sex, presence of diabetes mellitus (DM) and hypercortisolemia remission status. METHODS This retrospective cohort analysis compared erythrocytic parameters between patients with CS of pituitary (CD) and adrenal (aCS) etiology and age, sex, body mass index (BMI) and socioeconomic status-matched controls in a 1:5 ratio. Laboratory values at baseline were calculated as mean values during the year preceding CS diagnosis, and over one year thereafter. RESULTS The cohort included 397 CS patients (68.26% female; mean age 51.11 ± 16.85 years) and 1970 controls. Patients with CS had significantly higher baseline median levels of hemoglobin (Hgb) (13.70 g/dL vs. 13.12 g/dL [p < 0.0001]) and hematocrit (Hct) (41.64% vs. 39.80% [p < 0.0001]) compared to controls. These differences were observed for both CD and aCS and for both sexes. Patients who attained remission had Hgb and Hct levels comparable to controls (13.20 g/dL and 40.08% in patients with CD and aCS vs. 13.20 g/dL and 39.98% in controls). Meanwhile, those with persistent/recurrent disease maintained elevated levels. Patients with comorbid DM had similar Hgb but higher Hct (p = 0.0419), while patients without DM showed elevated erythrocytic values compared to controls (p < 0.0001). CONCLUSION Our data illustrates that erythrocytic parameters are directly influenced by glucocorticoid excess as Hgb and Hct are higher in patients with CS, and normalize after remission. We have identified the influence of DM on erythrocytic parameters in patients with CS for the first time.
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Affiliation(s)
- Laura Dery
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Julia Stern
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Shimon
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Yaron Rudman
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Shiri Kushnir
- Research Authority, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Tzipora Shochat
- Biostatistics Unit, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Maria Fleseriu
- Departments of Medicine and Neurological Surgery, Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Amit Akirov
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.
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Puglisi S, Barač Nekić A, Morelli V, Alessi Y, Fosci M, Pani A, Zibar Tomsic K, Palmieri S, Ferraù F, Pia A, Chiodini I, Kastelan D, Reimondo G, Terzolo M. Are comorbidities of patients with adrenal incidentaloma tied to sex? Front Endocrinol (Lausanne) 2024; 15:1385808. [PMID: 38808113 PMCID: PMC11130385 DOI: 10.3389/fendo.2024.1385808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024] Open
Abstract
Background A recent cross-sectional study showed that both comorbidities and mortality in patients with adrenal incidentaloma (AI) are tied to sex. However, few longitudinal studies evaluated the development of arterial hypertension, hyperglycemia, dyslipidemia and bone impairment in patients with AI. The aim of this study is to analyze the impact of sex in the development of these comorbidities during long-term follow-up. Methods We retrospectively evaluated 189 patients (120 females, 69 males) with AI, from four referral centers in Italy and Croatia. Clinical characteristics, comorbidities and cortisol after 1-mg dexamethasone suppression test (1-mg DST) were assessed at baseline and at last follow-up visit (LFUV). Median follow-up was 52 (Interquartile Range 25-86) months. Results The rates of arterial hypertension and hyperglycemia increased over time both in females (65.8% at baseline versus 77.8% at LFUV, p=0.002; 23.7% at baseline versus 39.6% at LFUV, p<0.001; respectively) and males (58.0% at baseline versus 69.1% at LFUV, p=0.035; 33.8% at baseline versus 54.0% at LFUV, p<0.001; respectively). Patients were stratified in two groups using 1.8 µg/dl as cut-off of cortisol following 1-mg DST: non-functional adrenal tumors (NFAT) and tumors with mild autonomous cortisol secretion (MACS). In the NFAT group (99 patients, females 62.6%), at baseline, we did not observe any difference in clinical characteristics and comorbidities between males and females. At LFUV, males showed a higher frequency of hyperglycemia than females (57.6% versus 33.9%, p=0.03). In the MACS group (89 patients, females 64.0%), at baseline, the prevalence of hypertension, hyperglycemia and dyslipidemia was similar between sexes, despite females were younger (60, IQR 55-69 versus 67.5, IQR 61-73, years; p=0.01). Moreover, females presented higher rates of bone impairment (89.3% versus 54.5%, p=0.02) than males. At LFUV, a similar sex-related pattern was observed. Conclusion Patients with AI frequently develop arterial hypertension and hyperglycemia and should be periodically checked for these comorbidities, regardless of sex. In patients with MACS, the lack of difference between sexes in the frequency of cardiometabolic comorbidities despite that females are younger, and the higher frequency of bone impairment in females, suggest a sex-specific effect of cortisol.
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Affiliation(s)
- Soraya Puglisi
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Anja Barač Nekić
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Valentina Morelli
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Ylenia Alessi
- Department of Human Pathology G. Barresi, Endocrine Unit, University Hospital G. Martino, University of Messina, Messina, Italy
| | - Michele Fosci
- Department of Medical Sciences and Public Health, Endocrinology and Obesity Unit, University of Cagliari, Cagliari, Italy
| | - Angelo Pani
- Department of Medical Sciences and Public Health, Endocrinology and Obesity Unit, University of Cagliari, Cagliari, Italy
| | - Karin Zibar Tomsic
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Serena Palmieri
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Ferraù
- Department of Human Pathology G. Barresi, Endocrine Unit, University Hospital G. Martino, University of Messina, Messina, Italy
| | - Anna Pia
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Iacopo Chiodini
- Department of Biotechnology and Translational Medicine, Unit of Endocrinology, Ospedale Niguarda Cà Granda, University of Milan, Milan, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
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Carsote M, Ciobica ML, Sima OC, Ciuche A, Popa-Velea O, Stanciu M, Popa FL, Nistor C. Personalized Management of Malignant and Non-Malignant Ectopic Mediastinal Thyroid: A Proposed 10-Item Algorithm Approach. Cancers (Basel) 2024; 16:1868. [PMID: 38791947 PMCID: PMC11120123 DOI: 10.3390/cancers16101868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
We aimed to analyze the management of the ectopic mediastinal thyroid (EMT) with respect to EMT-related cancer and non-malignant findings related to the pathological report, clinical presentation, imaging traits, endocrine profile, connective tissue to the cervical (eutopic) thyroid gland, biopsy or fine needle aspiration (FNA) results, surgical techniques and post-operatory outcome. This was a comprehensive review based on revising any type of freely PubMed-accessible English, full-length original papers including the keywords "ectopic thyroid" and "mediastinum" from inception until March 2024. We included 89 original articles that specified EMTs data. We classified them into four main groups: (I) studies/case series (n = 10; N = 36 EMT patients); (II) malignant EMTs (N = 22 subjects; except for one newborn with immature teratoma in the EMT, only adults were reported; mean age of 62.94 years; ranges: 34 to 90 years; female to male ratio of 0.9). Histological analysis in adults showed the following: papillary (N = 11/21); follicular variant of the papillary type (N = 2/21); Hürthle cell thyroid follicular malignancy (N = 1/21); poorly differentiated (N = 1/21); anaplastic (N = 2/21); medullary (N = 1/21); lymphoma (N = 2/21); and MALT (mucosa-associated lymphoid tissue) (N = 1/21); (III) benign EMTs with no thyroid anomalies (N = 37 subjects; mean age of 56.32 years; ranges: 30 to 80 years; female to male ratio of 1.8); (IV) benign EMTs with thyroid anomalies (N = 23; female to male ratio of 5.6; average age of 52.1 years). This panel involved clinical/subclinical hypothyroidism (iatrogenic, congenital, thyroiditis-induced, and transitory type upon EMT removal); thyrotoxicosis (including autonomous activity in EMTs that suppressed eutopic gland); autoimmune thyroiditis/Graves's disease; nodules/multinodular goiter and cancer in eutopic thyroid or prior thyroidectomy (before EMT detection). We propose a 10-item algorithm that might help navigate through the EMT domain. To conclude, across this focused-sample analysis (to our knowledge, the largest of its kind) of EMTs, the EMT clinical index of suspicion remains low; a higher rate of cancer is reported than prior data (18.8%), incident imagery-based detection was found in 10-14% of the EMTs; surgery offered an overall good outcome. A wide range of imagery, biopsy/FNA and surgical procedures is part of an otherwise complex personalized management.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Clinical Endocrinology V, “C.I. Parhon” National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Mihai-Lucian Ciobica
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine I and Rheumatology, “Dr. Carol Davila” Central Military University Emergency Hospital, 010825 Bucharest, Romania
| | - Oana-Claudia Sima
- PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Adrian Ciuche
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military University Emergency Hospital, 010242 Bucharest, Romania
| | - Ovidiu Popa-Velea
- Department of Medical Psychology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, Lucian Blaga University of Sibiu, 550024 Sibiu, Romania;
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania;
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military University Emergency Hospital, 010242 Bucharest, Romania
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10
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Khadembashiri MM, Mohseni S, Harandi H, Pejman Sani M, Khadembashiri MA, Atlasi R, SeyedAlinaghi S, Mohajeri- Tehrani M, Larijani B. Comparison of adrenalectomy with conservative treatment on mild autonomous cortisol secretion: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1374711. [PMID: 38808111 PMCID: PMC11131104 DOI: 10.3389/fendo.2024.1374711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
Objective This systematic review and meta-analysis was conducted to compare the benefits of adrenalectomy and conservative treatment for comorbidities associated with mild autonomous cortisol secretion (MACS) in patients diagnosed with MACS. Background MACS is the most common benign hormone-secreting functional adrenal incidentaloma. Overproduction of cortisol is observed in MACS patients, resulting in a variety of long-term health issues, including arterial hypertension (HTN), diabetes mellitus (DM), dyslipidemia, obesity, and osteoporosis; however, the classic clinical manifestations of Cushing's syndrome (CS) are not present. Methods A systematic search was conducted using MEDLINE, Embase, Web of Sciences, and Scopus databases on December, 2023. Two reviewers independently extracted data and assessed the quality of the included articles. A meta-analysis was performed to compare the beneficial effects of adrenalectomy versus conservative management for MACS-related comorbidities. Results Fifteen articles were included in this study, which evaluated 933 MACS patients (384 Adrenalectomy and 501 Conservative treatment, and 48 excluded due to incomplete follow-up duration). MACS diagnosis criteria were different among the included articles. All studies, however, stated that there must be no overt CS symptoms. Meta-analysis demonstrates the overall advantage of adrenalectomy over conservative treatment for MACS-related comorbidities (Cohen's d = -0.49, 95% CI [-0.64, -0.34], p = 0.00). Subgroup analysis indicated that the systolic blood pressure (pooled effect size = -0.81, 95% CI [-1.19, -0.42], p = 0.03), diastolic blood pressure (pooled effect size = -0.63, 95% CI [-1.05, -0.21], p = 0.01), and BMD (pooled effect size = -0.40, 95% CI [-0.73, -0.07], p = 0.02) were significantly in favor of adrenalectomy group rather than conservative treatment but no significant differences between the two treatment groups in other MACS-related comorbidities were reported. Conclusion Despite the limited and diverse data, this study demonstrates the advantage of adrenalectomy over conservative treatment for MACS-related comorbidities.
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Affiliation(s)
- Mohamad Mehdi Khadembashiri
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Mohseni
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Harandi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Pejman Sani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Amin Khadembashiri
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Rasha Atlasi
- Non-Communicable Diseases Research Center, Endocrine Population Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Mohajeri- Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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11
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Güneş M, Güneş E, Kaya Mİ, Küçükelyas HD, Barut H, Öner S. Relationship Between Dexamethasone Suppression Test Cortisol Level >0.9 μg/dL and Depression and Quality of Life in Adrenal Incidentalomas: A Single Center Observational Case-Control Study. Endocr Pract 2024:S1530-891X(24)00510-X. [PMID: 38729569 DOI: 10.1016/j.eprac.2024.05.002] [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: 02/05/2024] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE There has been increasing evidence that patients with adrenal incidentalomas (AIs) who have 1-mg dexamethasone suppression test (DST) cortisol levels >0.9 μg/dL may be exposed to the adverse consequences of hypercortisolaemia. We aim to evaluate whether there is a difference in Beck Depression Inventory-II (BDI-II) and quality of life (QoL) score in patients with AI based on the threshold of a DST cortisol level >0.9 μg/dL. METHODS This case-control study included 42 nonfunctional adrenal incidentaloma (NFAI), 53 mild autonomic cortisol secretion (MACS) and 42 healthy controls (HCs). In addition, patients were categorized as ≤0.9 and >0.9 μg/dL according to their DST cortisol results. RESULTS There was no difference in the QoL and BDI-II scores of MACS compared to NFAI. The BDI-II score was higher and QoL was lower in MACS and NFAI compared to HCs. The difference in QoL and BDI-II scores between MACS and NFAI remained insignificant when the DST cortisol levels threshold was graded upward (5.0 μg/dL). The prevalence of depression was higher in the AI >0.9 μg/dL group than the AI ≤0.9 μg/dL group (respectively, 16.7% and 55.8%, P = .003), BDI-II scores were higher in the AI >0.9 μg/dL group than in the AI ≤0.9 μg/dL group and HCs. The DST was an independent factor affecting the frequency of depression (odds ratio: 1.39, P = .037). CONCLUSION MACS and patients with NFAI had similar QoL and depression scores according to the 1.8 μg/dL and above, whereas, had lower QoL and higher depression scores according to the 0.9 μg/dL.
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Affiliation(s)
- Mutlu Güneş
- Department of Endocrinology, Metabolism and Diabetes, Bursa Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey.
| | - Elif Güneş
- Department of Endocrinology, Metabolism and Diabetes, Bursa State Hospital, Health Sciences University, Bursa, Turkey
| | - Muhammet İlker Kaya
- Department of Internal Medicine, Bursa State Hospital, Health Sciences University, Bursa, Turkey
| | | | - Hatice Barut
- Department of Neurology, Bursa State Hospital, Health Sciences University, Bursa, Turkey
| | - Sedat Öner
- Department of Urology, Bursa State Hospital, Health Sciences University, Bursa, Turkey
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12
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Kwak MH, Yun JS, Kim JN, Lee YR, Kim CK, Kang KA. Validation of the modified CT criteria for identifying non-adenomas. Abdom Radiol (NY) 2024; 49:1603-1614. [PMID: 38411694 DOI: 10.1007/s00261-024-04206-x] [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: 08/14/2023] [Revised: 12/30/2023] [Accepted: 01/12/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Although adrenal computed tomography (CT) percentage washout is a potentially powerful imaging technique for differentiating adrenal adenomas from non-adenomas, its application to non-adenomas can be problematic. Recently, modified criteria for diagnosing pheochromocytomas using adrenal CT were developed based on data from 199 patients with surgically proven pheochromocytomas and adenomas. However, these criteria have not been thoroughly validated. The purpose of this study was to validate the performance of the modified criteria for diagnosing non-adenomas including pheochromocytomas. METHODS The conventional and modified criteria were applied to 266 patients from two cohorts who had surgically proven lipid-poor adenomas (155/266, 58.3%) and non-adenomas (111/266, 41.7%) and underwent adrenal CT. Two radiologists calculated the attenuation on each dynamic phase and percentage washout of adrenal masses. The final assessments based on the conventional and modified criteria were categorized into adenomas or non-adenomas. The diagnostic performance of each criterion for diagnosing non-adenomas was evaluated using the area under the receiver operating characteristic curve (AUC). False negatives and positives were also compared. RESULTS The AUC for the diagnosis of non-adenomas was 0.806 for conventional criteria and 0.858 for modified criteria (p = 0.047). The false-negative rate of conventional criteria for the diagnosis of non-adenomas was 29.7%. Use of modified criteria could have reduced the false-negative rate by to 7.2%. The false-positive rate increased from 9% to 21.3% when using the modified criteria. CONCLUSION The utilization of modified criteria has the potential to identify additional non-adenomas that would otherwise be misdiagnosed as adenomas using conventional criteria alone.
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Affiliation(s)
- Min Hwan Kwak
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Ji-Sup Yun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Na Kim
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Rae Lee
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Kyo Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
| | - Kyung A Kang
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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13
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Tan T, Diab J, Chia P, Singh A, Campbell P, Guevara R. An imaging and diagnostic conundrum-the adrenal haemangioma. J Surg Case Rep 2024; 2024:rjae286. [PMID: 38706490 PMCID: PMC11068444 DOI: 10.1093/jscr/rjae286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 05/07/2024] Open
Abstract
The adrenal haemangioma, a rare benign vascular tumour, is increasingly detected through abdominal imaging. Just over 70 surgical cases have been reported since 1955. Their potential large size and overlapping imaging features with adrenocortical carcinoma poses a diagnostic challenge. Adrenalectomy is often needed for a definitive diagnosis due to inconclusive imaging. We report the case of a 61-year-old female presenting with an incidental finding of a right-sided 9.5-cm adrenal mass on imaging. Due to the risk of adrenocortical carcinoma with inconclusive imaging findings, an open right adrenalectomy was performed. The patient was discharged after 6 days with no complications. Post-surgical histopathology confirmed a diagnosis of adrenal haemangioma with a secondary adrenal pseudocyst. The presence of an adrenal incidentaloma with discordant radiological features proves to be a diagnostic conundrum. Therefore, in the setting of contradictory radiology and concerning mass size, we recommend adrenalectomy for definitive diagnosis of an adrenal haemangioma.
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Affiliation(s)
- Tiffany Tan
- Department of Endocrine Surgery, Liverpool Hospital, Liverpool, NSW 2170, Australia
| | - Jason Diab
- Department of Endocrine Surgery, Liverpool Hospital, Liverpool, NSW 2170, Australia
- School of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
- School of Medicine, University of Notre Dame, Darlinghurst, NSW 2010, Australia
| | - Philip Chia
- Department of Endocrine Surgery, Liverpool Hospital, Liverpool, NSW 2170, Australia
- School of Medicine, University of Sydney, NSW 2052, Australia
| | - Amandeep Singh
- Department of Endocrine Surgery, Liverpool Hospital, Liverpool, NSW 2170, Australia
- School of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, NSW 2170, Australia
| | - Peter Campbell
- Department of Endocrine Surgery, Liverpool Hospital, Liverpool, NSW 2170, Australia
- School of Medicine, University of Sydney, NSW 2052, Australia
| | - Ronald Guevara
- Department of Endocrine Surgery, Liverpool Hospital, Liverpool, NSW 2170, Australia
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14
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Glazer DI. Editorial Comment: CT With Adrenal-Washout Protocol Is Not Useful for Heterogeneous Nodules. AJR Am J Roentgenol 2024; 222:e2431086. [PMID: 38447028 DOI: 10.2214/ajr.24.31086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Affiliation(s)
- Daniel I Glazer
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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15
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Willems JIA, Tummers-de Lind van Wijngaarden RFA, Dubelaar IJM, De Kruif MD, Leers MPG, Luu IHY, Peeters RP, van Twist DJL. Thyroid and adrenal incidentalomas on chest CT: Prevalence, diagnostic work-up and outcomes in a cohort of COVID-19 suspected patients. Eur J Intern Med 2024; 123:114-119. [PMID: 38123419 DOI: 10.1016/j.ejim.2023.12.008] [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: 10/19/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Due to increased use of computed tomography (CT), prevalence of thyroid and adrenal incidentalomas is rising. Yet, previous studies on the outcomes of diagnostic work-up of incidentalomas are subjected to inclusion bias. Therefore, we aimed to investigate prevalence and outcomes of diagnostic work-up of thyroid and adrenal incidentalomas detected on chest CT in a less selected population of COVID-19 suspected patients. DESIGN A retrospective, observational cohort study. METHODS We included all COVID-19 suspected patients who underwent chest CT between March 2020 and March 2021. Radiology reports and medical records were reviewed for the presence and subsequent diagnostic work-up of thyroid and adrenal incidentalomas. RESULTS A total of 1,992 consecutive COVID-19 patients were included (59.4% male, median age 71 years [IQR: 71-80]). Thyroid and adrenal incidentalomas were identified in 95 (4.8%) and 133 (6.7%) patients, respectively. Higher prevalence was observed with increasing age, among female patients and in patients with malignancy. Forty-four incidentalomas were further analyzed, but no malignancies were found. Only three lesions were hormonally active (1 thyrotoxicosis and 2 mild autonomous cortisol secretion). Diagnostic work-up did not lead to any change in clinical management in 97.7% of the analyzed patients. CONCLUSION Prevalence rates of thyroid and adrenal incidentalomas on chest CT in a less selected COVID-19 cohort were 4.8% and 6.7%, respectively. Yet, as all incidentalomas turned out to be benign and only three lesions were (mildly) hormonally active, this raises the question whether intensive diagnostic work-up of incidentalomas is necessary in all patients.
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Affiliation(s)
- Jeresa I A Willems
- Department of Internal Medicine, Zuyd Thyroid Center, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | | | - Ivo J M Dubelaar
- Department of Radiology, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Martijn D De Kruif
- Department of Pulmonology, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Math P G Leers
- Department of Clinical Chemistry and Hematology, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Inge H Y Luu
- Department of Internal Medicine, Zuyd Thyroid Center, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands
| | - Robin P Peeters
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Daan J L van Twist
- Department of Internal Medicine, Zuyd Thyroid Center, Zuyderland Medical Center, Sittard, Heerlen, the Netherlands.
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16
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Nistor C, Carsote M, Cucu AP, Stanciu M, Popa FL, Ciuche A, Ciobica ML. Primary Cardiac Intimal Sarcoma: Multi-Layered Strategy and Core Role of MDM2 Amplification/Co-Amplification and MDM2 Immunostaining. Diagnostics (Basel) 2024; 14:919. [PMID: 38732333 PMCID: PMC11083306 DOI: 10.3390/diagnostics14090919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Primary cardiac tumours are relatively uncommon (75% are benign). Across the other 25%, representing malignant neoplasia, sarcomas account for 75-95%, and primary cardiac intimal sarcoma (PCIS) is one of the rarest findings. We aimed to present a comprehensive review and practical considerations from a multidisciplinary perspective with regard to the most recent published data in the specific domain of PCIS. We covered the issues of awareness amid daily practice clinical presentation to ultra-qualified management in order to achieve an adequate diagnosis and prompt intervention, also emphasizing the core role of MDM2 immunostaining and MDM2 genetic analysis. An additional base for practical points was provided by a novel on-point clinical vignette with MDM2-positive status. According to our methods (PubMed database search of full-length, English publications from January 2021 to March 2023), we identified three studies and 23 single case reports represented by 22 adults (male-to-female ratio of 1.2; male population with an average age of 53.75 years, range: 35-81; woman mean age of 55.5 years, range: 34-70) and a 4-year-old child. The tumour-related clinical picture was recognized in a matter of one day to ten months on first admission. These non-specific data (with a very low index of suspicion) included heart failure at least NYHA class II, mitral regurgitation and pulmonary hypertension, acute myocardial infarction, ischemic stroke, obstructive shock, and paroxysmal atrial fibrillation. Awareness might come from other complaints such as (most common) dyspnoea, palpitation, chest pressure, cough, asthenia, sudden fatigue, weakness, malaise, anorexia, weight loss, headache, hyperhidrosis, night sweats, and epigastric pain. Two individuals were initially misdiagnosed as having endocarditis. A history of prior treated non-cardiac malignancy was registered in 3/23 subjects. Distant metastasis as the first step of detection (n = 2/23; specifically, brain and intestinal) or during follow-up (n = 6/23; namely, intestinal, brain and bone, in two cases for each, and adrenal) required additional imagery tools (26% of the patients had distant metastasis). Transoesophageal echocardiography, computed tomography (CT), magnetic resonance imagery, and even 18F-FDG positronic emission tomography-CT (which shows hypermetabolic lesions in PCIS) represent the basis of multimodal tools of investigation. Tumour size varied from 3 cm to ≥9 cm (average largest diameter of 5.5 cm). The most frequent sites were the left atrium followed by the right ventricle and the right atrium. Post-operatory histological confirmation was provided in 20/23 cases and, upon tumour biopsy, in 3/23 of them. The post-surgery maximum free-disease interval was 8 years, the fatal outcome was at the earliest two weeks since initial admission. MDM2 analysis was provided in 7/23 subjects in terms of MDM2-positive status (two out of three subjects) at immunohistochemistry and MDM2 amplification (four out of five subjects) at genetic analysis. Additionally, another three studies addressed PCISs, and two of them offered specific MDM2/MDM2 assays (n = 35 patients with PCISs); among the provided data, we mention that one cohort (n = 20) identified a rate of 55% with regard to MDM2 amplification in intimal sarcomas, and this correlated with a myxoid pattern; another cohort (n = 15) showed that MDM2-positive had a better prognostic than MDM2-negative immunostaining. To summarize, MDM2 amplification and co-amplification, for example, with MDM4, CDK4, HMGA3, CCND3, PDGFRA, TERT, KIT, CCND3, and HDAC9, might improve the diagnosis of PCIS in addition to MDM2 immunostaining since 10-20% of these tumours are MDM2-negative. Further studies are necessary to highlight MDM2 applicability as a prognostic factor and as an element to be taken into account amid multi-layered management in an otherwise very aggressive malignancy.
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Affiliation(s)
- Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.N.); (A.C.)
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania;
| | - Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Clinical Endocrinology V, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania
| | - Anca-Pati Cucu
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania;
- PhD Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania;
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania;
| | - Adrian Ciuche
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.N.); (A.C.)
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania;
| | - Mihai-Lucian Ciobica
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Internal Medicine I and Rheumatology, “Dr. Carol Davila” Central Military University Emergency Hospital, 010825 Bucharest, Romania
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17
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Mu D, Qian X, Ma Y, Wang X, Gao Y, Ma X, Xie S, Hou L, Zhang Q, Zhao F, Xia L, Lin L, Qiu L, Wu J, Yu S, Cheng X. Plasma steroid profiling combined with machine learning for the differential diagnosis in mild autonomous cortisol secretion from nonfunctioning adenoma in patients with adrenal incidentalomas. Endocr Pract 2024:S1530-891X(24)00498-1. [PMID: 38657794 DOI: 10.1016/j.eprac.2024.04.008] [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: 03/02/2024] [Revised: 04/12/2024] [Accepted: 04/17/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND To assess the diagnostic value of combining plasma steroid profiling with machine learning (ML) in differentiating between mild autonomous cortisol secretion (MACS) and nonfunctioning adenoma (NFA) in patients with adrenal incidentalomas. METHODS The plasma steroid profiles data in the laboratory information system were screened from January 2021 to December 2023. EXtreme Gradient Boosting (XGBoost) was applied to establish diagnostic models using plasma 24-steroid panels and/or clinical characteristics of the subjects. The SHapley Additive exPlanation (SHAP) method was used for explaining the model. RESULTS 76 patients with MACS and 86 patients with NFA were included in the development and internal validation cohort while the external validation cohort consisted of 27 MACS and 21 NFA cases. Among five ML models evaluated, XGBoost demonstrated superior performance with an AUC of 0.77 using 24 steroid hormones. The SHAP method identified five steroids that exhibited optimal performance in distinguishing MACS from NFA, namely dehydroepiandrosterone (DHEA), 11-deoxycortisol, 11β-hydroxytestosterone, testosterone, and dehydroepiandrosteronesulfate (DHEAS). Upon incorporating clinical features into the model, the AUC increased to 0.88, with a sensitivity of 0.77 and specificity of 0.82. Furthermore, the results obtained through SHAP revealed that lower levels of testosterone, DHEA, LDL-c, BMI, and ACTH along with higher level of 11-deoxycortisol significantly contributed to the identification of MACS in the model. CONCLUSIONS We have elucidated the utilization of ML-based steroid profiling to discriminate between MACS and NFA in patients with adrenal incidentalomas. This approach holds promise for distinguishing these two entities through a single blood collection.
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Affiliation(s)
- Danni Mu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Xia Qian
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yichen Ma
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Xi Wang
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yumeng Gao
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Xiaoli Ma
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Shaowei Xie
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Lian Hou
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Qi Zhang
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Fang Zhao
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Liangyu Xia
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Liling Lin
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.
| | - Jie Wu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.
| | - Songlin Yu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.
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18
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Prete A, Bancos I. Mild autonomous cortisol secretion: pathophysiology, comorbidities and management approaches. Nat Rev Endocrinol 2024:10.1038/s41574-024-00984-y. [PMID: 38649778 DOI: 10.1038/s41574-024-00984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
The majority of incidentally discovered adrenal tumours are benign adrenocortical adenomas and the prevalence of adrenocortical adenomas is around 1-7% on cross-sectional abdominal imaging. These can be non-functioning adrenal tumours or they can be associated with autonomous cortisol secretion on a spectrum that ranges from rare clinically overt adrenal Cushing syndrome to the much more prevalent mild autonomous cortisol secretion (MACS) without signs of Cushing syndrome. MACS is diagnosed (based on an abnormal overnight dexamethasone suppression test) in 20-50% of patients with adrenal adenomas. MACS is associated with cardiovascular morbidity, frailty, fragility fractures, decreased quality of life and increased mortality. Management of MACS should be individualized based on patient characteristics and includes adrenalectomy or conservative follow-up with treatment of associated comorbidities. Identifying patients with MACS who are most likely to benefit from adrenalectomy is challenging, as adrenalectomy results in improvement of cardiovascular morbidity in some, but not all, patients with MACS. Of note, diagnosis and management of patients with bilateral MACS is especially challenging. Current gaps in MACS clinical practice include a lack of specific biomarkers diagnostic of MACS-related health outcomes and a paucity of clinical trials demonstrating the efficacy of adrenalectomy on comorbidities associated with MACS. In addition, little evidence exists to demonstrate the efficacy and safety of long-term medical therapy in patients with MACS.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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19
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Yildiz BO, Boguszewski CL, da Silva Boguszewski MC, Busetto L, Celik O, Fuleihan GEH, Goulis DG, Hammer GD, Haymart MR, Kaltsas G, Law JR, Lim AYL, Luger A, Macut D, McGowan B, McClung M, Miras AD, Patti ME, Peeters RP, Pignatelli D, Saeed H, Sipos J, Stratakis CA, Tsoli M, van der Lely AJ, Witchel SF, Yazici D. EndoBridge 2023: highlights and pearls. Hormones (Athens) 2024:10.1007/s42000-024-00549-8. [PMID: 38619812 DOI: 10.1007/s42000-024-00549-8] [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: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 04/16/2024]
Abstract
EndoBridge 2023 took place on October 20-22, 2023, in Antalya, Turkey. Accredited by the European Council, the 3-day scientific program of the 11th Annual Meeting of EndoBridge included state-of-the-art lectures and interactive small group discussion sessions incorporating interesting and challenging clinical cases led by globally recognized leaders in the field and was well attended by a highly diverse audience. Following its established format over the years, the program provided a comprehensive update across all aspects of endocrinology and metabolism, including topics in pituitary, thyroid, bone, and adrenal disorders, neuroendocrine tumors, diabetes mellitus, obesity, nutrition, and lipid disorders. As usual, the meeting was held in English with simultaneous translation into Russian, Arabic, and Turkish. The abstracts of clinical cases presented by the delegates during oral and poster sessions have been published in JCEM Case Reports. Herein, we provide a paper on highlights and pearls of the meeting sessions covering a wide range of subjects, from thyroid nodule stratification to secondary osteoporosis and from glycemic challenges in post-bariatric surgery to male hypogonadism. This report emphasizes the latest developments in the field, along with clinical approaches to common endocrine issues. The 12th annual meeting of EndoBridge will be held on October 17-20, 2024 in Antalya, Turkey.
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Affiliation(s)
- Bulent Okan Yildiz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, 06100, Hacettepe, Ankara, Turkey.
| | - Cesar Luiz Boguszewski
- Department of Internal Medicine, Endocrine Division (SEMPR), University Hospital, Federal University of Parana, Curitiba, Brazil
| | | | - Luca Busetto
- Department of Medicine, University of Padova, Padova, Italy
| | - Ozlem Celik
- Department of Endocrinology and Metabolism, School of Medicine, Acibadem University, Istanbul, Turkey
| | - Ghada El-Hajj Fuleihan
- Division of Endocrinology, Deparment of Medicine at the American University of Beirut, Beirut, Lebanon
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Gary D Hammer
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Megan R Haymart
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Gregory Kaltsas
- First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jennifer R Law
- Division of Pediatric Endocrinology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Amanda Yuan Ling Lim
- Imperial College Healthcare NHS Trust, London, UK
- Division of Endocrinology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Anton Luger
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Djuro Macut
- Institute of Endocrinology, University of Belgrade, Belgrade, Serbia
| | - Barbara McGowan
- Guy's and St Thomas Hospital and King's College London, London, UK
| | | | | | | | - Robin P Peeters
- Department of Internal Medicine, Academic Center for Thyroid Disease, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Duarte Pignatelli
- Department of Endocrinology, Centro Hospitalar e Universitário de S. João, Porto, Portugal
| | | | - Jennifer Sipos
- Division Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA
| | | | - Marina Tsoli
- Academic Scholar Fellow at 1st Department of Propaedeutic and Internal Medicine, Laiko Hospital, Athens, Greece
| | - A J van der Lely
- Pituitary Center Rotterdam and Division of Endocrinology, Department of Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Selma F Witchel
- Division of Pediatric Endocrinology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dilek Yazici
- Division of Endocrinology, Department of Internal Medicine, School of Medicine, Koç University, Istanbul, Turkey
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20
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Zhang CD, Ioachimescu AG. Challenges in the postsurgical recovery of cushing syndrome: glucocorticoid withdrawal syndrome. Front Endocrinol (Lausanne) 2024; 15:1353543. [PMID: 38681763 PMCID: PMC11045978 DOI: 10.3389/fendo.2024.1353543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/29/2024] [Indexed: 05/01/2024] Open
Abstract
Glucocorticoid withdrawal syndrome is a challenging clinical phenomenon that can complicate the postsurgical recovery of Cushing syndrome. It is characterized by physical tolerance and dependence to supraphysiologic glucocorticoid exposure during active Cushing syndrome followed by the abrupt decline in cortisol levels after surgical treatment. The symptoms of glucocorticoid withdrawal often overlap with those of postoperative adrenal insufficiency and can be difficult for patients to cope with and for clinicians to treat. This mini review will discuss the clinical characteristics, pathophysiology, and management of glucocorticoid withdrawal syndrome while highlighting recent data in the field.
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Affiliation(s)
- Catherine D. Zhang
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Adriana G. Ioachimescu
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
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21
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Oloukoi C, Dohan A, Gaillard M, Hoeffel C, Groussin-Rouiller L, Bertherat J, Jouinot A, Assié G, Fuks D, Sibony M, Soyer P, Jannot AS, Barat M. Differentiation between adrenocortical carcinoma and lipid-poor adrenal adenoma using a multiparametric MRI-based diagnostic algorithm. Diagn Interv Imaging 2024:S2211-5684(24)00081-0. [PMID: 38575426 DOI: 10.1016/j.diii.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the capabilities of multiparametric magnetic resonance imaging (MRI) in differentiating between lipid-poor adrenal adenoma (LPAA) and adrenocortical carcinoma (ACC). MATERIALS AND METHODS Patients of two centers who underwent surgical resection of LPAA or ACC after multiparametric MRI were retrospectively included. A training cohort was used to build a diagnostic algorithm obtained through recursive partitioning based on multiparametric MRI variables, including apparent diffusion coefficient and chemical shift signal ratio (i.e., tumor signal intensity index). The diagnostic performances of the multiparametric MRI-based algorithm were evaluated using a validation cohort, alone first and then in association with adrenal tumor size using a cut-off of 4 cm. Performances of the diagnostic algorithm for the diagnosis of ACC vs. LPAA were calculated using pathology as the reference standard. RESULTS Fifty-four patients (27 with LPAA and 27 with ACC; 37 women; mean age, 48.5 ± 13.3 [standard deviation (SD)] years) were used as the training cohort and 61 patients (24 with LPAA and 37 with ACC; 47 women; mean age, 49 ± 11.7 [SD] years) were used as the validation cohort. In the validation cohort, the diagnostic algorithm yielded best accuracy for the diagnosis of ACC vs. LPAA (75%; 46/61; 95% CI: 55-88) when used without lesion size. Best sensitivity was obtained with the association of the diagnostic algorithm with tumor size (96%; 23/24; 95% CI: 80-99). Best specificity was obtained with the diagnostic algorithm used alone (76%; 28/37; 95% CI: 60-87). CONCLUSION A multiparametric MRI-based diagnostic algorithm that includes apparent diffusion coefficient and tumor signal intensity index helps discriminate between ACC and LPAA with high degrees of specificity and accuracy. The association of the multiparametric MRI-based diagnostic algorithm with adrenal lesion size helps maximize the sensitivity of multiparametric MRI for the diagnosis of ACC.
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Affiliation(s)
- Carmelia Oloukoi
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Anthony Dohan
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France
| | - Martin Gaillard
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Pancreatic and Endocrine Surgery, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Christine Hoeffel
- Department of Radiology, Hôpital Robert Debré, CRESTIC, URCA, 51000 Reims, France
| | - Lionel Groussin-Rouiller
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Jérome Bertherat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Anne Jouinot
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Guillaume Assié
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - David Fuks
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Pancreatic and Endocrine Surgery, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Mathilde Sibony
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Pathology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Philippe Soyer
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Anne-Sophie Jannot
- AP-HP.Centre- Université Paris Cité, Hôpital Européen Georges Pompidou, Medical Informatics, Biostatistics and Public Health Department, 75015, Paris, France; INSERM, UMR_S1138, Cordeliers Research Center, Université Paris Cité, 75006 Paris, France
| | - Maxime Barat
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France.
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22
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Schenker MP, Silverman SG, Mayo-Smith WW, Khorasani R, Glazer DI. Clinical indications, safety, and effectiveness of percutaneous image-guided adrenal mass biopsy: an 8-year retrospective analysis in 160 patients. Abdom Radiol (NY) 2024; 49:1231-1240. [PMID: 38430264 DOI: 10.1007/s00261-024-04211-0] [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: 12/01/2023] [Revised: 01/17/2024] [Accepted: 01/17/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE To assess indications, safety, and effectiveness of percutaneous adrenal mass biopsy in contemporary practice. METHODS This institutional review board-approved, retrospective study included all patients undergoing percutaneous image-guided adrenal mass biopsies at an academic health system from January 6, 2015, to January 6, 2023. Patient demographics, biopsy indications, mass size, laboratory data, pathology results, and complications were recorded. Final diagnoses were based on pathology or ≥ 1 year of imaging follow-up when biopsy specimens did not yield malignant tissue. Test performance calculations excluded repeat biopsies. Continuous variables were compared with Student's t test, dichotomous variables with chi-squared test. RESULTS A total of 160 patients underwent 186 biopsies. Biopsies were indicated to diagnose metastatic disease (139/186; 74.7%), for oncologic research only (27/186; 14.5%), diagnose metastatic disease and oncologic research (15/186; 8%), and diagnose an incidental adrenal mass (5/186; 2.7%). Biopsy specimens were diagnostic in 154 patients (96.3%) and non-diagnostic in 6 (3.8%). Diagnostic biopsies yielded malignant tissue (n = 136), benign adrenal tissue (n = 12), and benign adrenal neoplasms (n = 6) with sensitivity = 98.6% (136/138), specificity = 100% (16/16), positive predictive value = 100% (136/136), and negative predictive value = 88.9% (16/18). Adverse events followed 11/186 procedures (5.9%) and most minor (7/11, 63.6%). The adverse event rate was similar whether tissue was obtained for clinical or research purposes (10/144; 6.9% vs. 1/42; 2.4%, p = 0.27), despite more specimens obtained for research (5.8 vs. 3.7, p < 0.001). CONCLUSION Percutaneous adrenal mass biopsy is safe, accurate, and utilized almost exclusively to diagnose metastatic disease or for oncologic research. The negative predictive value is high when diagnostic tissue samples are obtained. Obtaining specimens for research does not increase adverse event risk.
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Affiliation(s)
- Matthew P Schenker
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Stuart G Silverman
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - William W Mayo-Smith
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ramin Khorasani
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Daniel I Glazer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA.
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23
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Lindh JD, Patrova J, Mannheimer B, Falhammar H. Prevalence and Incidence of Fractures in Patients With Nonfunctional Adrenal Tumors. JAMA Netw Open 2024; 7:e246453. [PMID: 38619841 PMCID: PMC11019395 DOI: 10.1001/jamanetworkopen.2024.6453] [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] [Received: 12/18/2023] [Accepted: 02/15/2024] [Indexed: 04/16/2024] Open
Abstract
Importance It is unclear whether nonfunctional adrenal tumors (NFATs) are associated with fractures. Objective To analyze fracture frequencies in individuals with NFATs. Design, Setting, and Participants A national retrospective cohort study was conducted in patients with NFATs diagnosed in Sweden between January 1, 2005, and December 31, 2019, and control participants without adrenal tumors followed up until death or the end of 2019. Individuals with a diagnosis of adrenal hormonal excess or previous malignant tumors were excluded. Sensitivity analyses were performed in subgroups of individuals with a combination of gallbladder, biliary tract, and pancreas diseases (for whom it was assumed that controls would also have undergone computed tomography) and 3- and 12-month survival free of malignant tumors after the NFAT diagnosis. The data were analyzed from September to November 2023. Exposures Diagnosis of NFATs. Main Outcomes and Measures Main study outcomes were prevalence and incidence of fractures after adjustment for sex, age, and comorbidities. Secondary outcomes were fragility fractures, fractures with fall on the same level, and fracture locations (distal arm and vertebral and hip fractures). Fracture incidence after adrenalectomy was also studied. Results Among 20 390 patients, 12 120 (59.4%) were women, and the median (IQR) age was 66 (57-73) years; among 125 392 controls, 69 994 (55.8%) were women, and the median (IQR) age was 66 (57-73) years. Previous fractures were more common in patients diagnosed with NFATs compared with controls (4310 of 20 390 [21.1%] vs 20 323 of 125 392 [16.2%]; odds ratio [OR], 1.39; 95% CI, 1.34-1.45; adjusted OR [AOR], 1.27; 95% CI, 1.23-1.33). During the follow-up period (median [IQR], 4.9 [2.2-8.2] years), incident fractures were more common in patients with NFATs (3127 of 20 390 [15.3%] vs 16 086 of 125 392 [12.8%]; hazard ratio [HR], 1.40; 95% CI, 1.34-1.45; adjusted HR [AHR], 1.27; 95% CI, 1.22-1.33). An association between NFATs and vertebral fractures was found (AOR, 1.51; 95% CI, 1.33-1.72; AHR, 1.83; 95% CI, 1.60-2.09). In men younger than 50 years, NFATs were associated with fractures (AOR, 1.45; 95% CI, 1.21-1.74; AHR, 1.48; 95% CI, 1.20-1.82). There was no association among individuals who had undergone adrenalectomy (AHR, 1.12; 95% CI, 0.90-1.38). The association between NFATs and fractures remained significant and of similar magnitude in all sensitivity analyses. Conclusions and Relevance In this cohort study, NFATs were associated with fractures, particularly among younger men; thus, patients with NFATs should have bone health evaluation with appropriate treatment and monitoring, especially in younger men.
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Affiliation(s)
- Jonatan D. Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jekaterina Patrova
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Södersjukhuset, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Södersjukhuset, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
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24
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Laulhé M, Kuhn E, Bouligand J, Amazit L, Perrot J, Lebigot E, Kamenickỷ P, Lombès M, Fagart J, Viengchareun S, Martinerie L. A novel mutation in the NR3C1 gene associated with reversible glucocorticoid resistance. Eur J Endocrinol 2024; 190:284-295. [PMID: 38584335 DOI: 10.1093/ejendo/lvae031] [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: 11/22/2023] [Revised: 02/02/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE Glucocorticoid resistance is a rare endocrine disease caused by variants of the NR3C1 gene encoding the glucocorticoid receptor (GR). We identified a novel heterozygous variant (GRR569Q) in a patient with uncommon reversible glucocorticoid resistance syndrome. METHODS We performed ex vivo functional characterization of the variant in patient fibroblasts and in vitro through transient transfection in undifferentiated HEK 293T cells to assess transcriptional activity, affinity, and nuclear translocation. We studied the impact of the variant on the tertiary structure of the ligand-binding domain through 3D modeling. RESULTS The patient presented initially with an adrenal adenoma with mild autonomous cortisol secretion and undetectable adrenocorticotropin hormone (ACTH) levels. Six months after surgery, biological investigations showed elevated cortisol and ACTH (urinary free cortisol 114 µg/24 h, ACTH 10.9 pmol/L) without clinical symptoms, evoking glucocorticoid resistance syndrome. Functional characterization of the GRR569Q showed decreased expression of target genes (in response to 100 nM cortisol: SGK1 control +97% vs patient +20%, P < .0001) and impaired nuclear translocation in patient fibroblasts compared to control. Similar observations were made in transiently transfected cells, but higher cortisol concentrations overcame glucocorticoid resistance. GRR569Q showed lower ligand affinity (Kd GRWT: 1.73 nM vs GRR569Q: 4.61 nM). Tertiary structure modeling suggested a loss of hydrogen bonds between H3 and the H1-H3 loop. CONCLUSION This is the first description of a reversible glucocorticoid resistance syndrome with effective negative feedback on corticotroph cells regarding increased plasma cortisol concentrations due to the development of mild autonomous cortisol secretion.
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Affiliation(s)
- Margaux Laulhé
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Emmanuelle Kuhn
- Unité Hypophyse, Hôpital Pitié-Salpêtrière, AP-HP, Paris 75013, France
| | - Jérôme Bouligand
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital Bicêtre APHP Paris Saclay, Le Kremlin Bicêtre 94270, France
| | - Larbi Amazit
- UMS 44/Institut Biomédical du Val de Bièvre, Université Paris-Saclay, Le Kremlin Bicêtre 94276, France
| | - Julie Perrot
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Elise Lebigot
- Service de Biochimie, Hôpital Bicêtre APHP Paris Saclay, Le Kremlin Bicêtre 94270, France
| | - Peter Kamenickỷ
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre APHP Paris Saclay, Le Kremlin-Bicêtre 94270, France
| | - Marc Lombès
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Jérôme Fagart
- Laboratoire de Biologie Structurale de la Cellule, BIOC, Ecole Polytechnique, CNRS, Institut Polytechnique de Paris, 91128 Palaiseau cedex, France
| | - Say Viengchareun
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, 94276 Le Kremlin-Bicêtre, France
- Endocrinologie Pédiatrique, Centre de Référence Maladies Endocriniennes Rares de la Croissance et du Développement, Hôpital Universitaire Robert-Debré APHP Nord, Paris 75019, France
- Faculté de Santé, Université Paris Cité, UFR de Médecine, Paris 75006, France
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25
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Zhu X, Liu S, Yuan Y, Gu N, Sha J, Guo Y, Deng Y. Clinical features and treatment options for pediatric adrenal incidentalomas: a retrospective single center study. BMC Pediatr 2024; 24:186. [PMID: 38491421 PMCID: PMC10943841 DOI: 10.1186/s12887-024-04673-7] [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: 01/16/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The aim of this study was to investigate the clinical features and treatment options for pediatric adrenal incidentalomas(AIs) to guide the diagnosis and treatment of these tumors. METHODS The clinical data of AI patients admitted to our hospital between December 2016 and December 2022 were collected and retrospectively analyzed. All patients were divided into neonatal and nonneonatal groups according to their age at the time of the initial consultation. RESULTS In the neonatal group, 13 patients were observed and followed up, and the masses completely disappeared in 8 patients and were significantly reduced in size in 5 patients compared with the previous findings. Four patients ultimately underwent surgery, and the postoperative pathological diagnosis was neuroblastoma in three patients and teratoma in one patient. In the nonneonatal group, there were 18 cases of benign tumors, including 9 cases of ganglioneuroma, 2 cases of adrenocortical adenoma, 2 cases of adrenal cyst, 2 cases of teratoma, 1 case of pheochromocytoma, 1 case of nerve sheath tumor, and 1 case of adrenal hemorrhage; and 20 cases of malignant tumors, including 10 cases of neuroblastoma, 9 cases of ganglioneuroblastoma, and 1 case of adrenocortical carcinoma. CONCLUSIONS Neuroblastoma is the most common type of nonneonatal AI, and detailed laboratory investigations and imaging studies are recommended for aggressive evaluation and treatment in this population. The rate of spontaneous regression of AI is high in neonates, and close observation is feasible if the tumor is small, confined to the adrenal gland and has no distant metastasis.
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Affiliation(s)
- Xiaojiang Zhu
- Department of Urology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Saisai Liu
- Department of Urology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Yimin Yuan
- Department of Urology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Nannan Gu
- Department of Urology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Jintong Sha
- Department of Urology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Yunfei Guo
- Department of Urology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Yongji Deng
- Department of Urology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China.
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26
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Tarling JA, Kumar R, Ward LJ, Boot C, Wassif WS. Phaeochromocytoma and paraganglioma. J Clin Pathol 2024:jcp-2023-209234. [PMID: 38453430 DOI: 10.1136/jcp-2023-209234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
Phaeochromocytomas and paragangliomas are rare catecholamine-producing neuroendocrine tumours which can potentially cause catastrophic crises with high morbidity and mortality. This best practice article considers the causes and presentation of such tumours, screening and diagnostic tests, management of these patients and consideration of family members at risk.
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Affiliation(s)
- Julie Ann Tarling
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Louise J Ward
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Christopher Boot
- Blood Sciences, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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27
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Lippert J, Smith G, Appenzeller S, Landwehr LS, Prete A, Steinhauer S, Asia M, Urlaub H, Elhassan YS, Kircher S, Arlt W, Fassnacht M, Altieri B, Ronchi CL. Circulating cell-free DNA-based biomarkers for prognostication and disease monitoring in adrenocortical carcinoma. Eur J Endocrinol 2024; 190:234-247. [PMID: 38451242 DOI: 10.1093/ejendo/lvae022] [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: 10/02/2023] [Revised: 01/11/2024] [Accepted: 02/16/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Adrenocortical carcinoma (ACC) is a rare aggressive cancer with heterogeneous behaviour. Disease surveillance relies on frequent imaging, which comes with significant radiation exposure. The aim of the study was to investigate the role of circulating cell-free DNA (ccfDNA)-related biomarkers (BMs) for prognostication and monitoring of ACC. DESIGN AND METHODS We investigated 34 patients with ACC and 23 healthy subjects (HSs) as controls. Circulating cell-free DNA was extracted by commercial kits and ccfDNA concentrations were quantified by fluorimeter (BM1). Targeted sequencing was performed using a customized panel of 27 ACC-specific genes. Leucocyte DNA was used to discriminate somatic variants (BM2), while tumour DNA was sequenced in 22/34 cases for comparison. Serial ccfDNA samples were collected during follow-up in 19 ACC patients (median period 9 months) and analysed in relationship with standard radiological imaging. RESULTS Circulating cell-free DNA concentrations were higher in ACC than HS (mean ± SD, 1.15 ± 1.56 vs 0.05 ± 0.05 ng/µL, P < .0001), 96% of them being above the cut-off of 0.146 ng/µL (mean HS + 2 SD, positive BM1). At ccfDNA sequencing, 47% of ACC showed at least 1 somatic mutation (positive BM2). A combined ccfDNA-BM score was strongly associated with both progression-free and overall survival (hazard ratio [HR] = 2.63; 95% CI, 1.13-6.13; P = .010, and HR = 5.98; 95% CI, 2.29-15.6; P = .0001, respectively). During disease monitoring, positive BM2 showed the best specificity (100%) and sensitivity (67%) to detect ACC recurrence or progress compared with BM1. CONCLUSION ccfDNA-related BMs are frequently detected in ACC patients and represent a promising, minimally invasive tool to predict clinical outcome and complement surveillance imaging. Our findings will be validated in a larger cohort of ACCs with long-term follow-up.
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Affiliation(s)
- Juliane Lippert
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Wuerzburg, 97080 Wuerzburg, Germany
- Institute of Human Genetics, University of Wuerzburg, 97070 Wuerzburg, Germany
| | - Gabrielle Smith
- Institute of Metabolism and System Research, University of Birmingham, B152TT Birmingham, United Kingdom
| | - Silke Appenzeller
- Core Unit Bioinformatics, Comprehensive Cancer Center Mainfranken, University of Wuerzburg, 97070 Wuerzburg, Germany
| | - Laura-Sophie Landwehr
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Alessandro Prete
- Institute of Metabolism and System Research, University of Birmingham, B152TT Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, B152TT Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, B152GW Birmingham, United Kingdom
| | - Sonja Steinhauer
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Miriam Asia
- Endocrine Department, Queen Elizabeth Hospital Birmingham NHS Trust, B152GW Birmingham, United Kingdom
| | - Hanna Urlaub
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Yasir S Elhassan
- Institute of Metabolism and System Research, University of Birmingham, B152TT Birmingham, United Kingdom
- Endocrine Department, Queen Elizabeth Hospital Birmingham NHS Trust, B152GW Birmingham, United Kingdom
| | - Stefan Kircher
- Department of Pathology, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Wiebke Arlt
- Institute of Metabolism and System Research, University of Birmingham, B152TT Birmingham, United Kingdom
- MRC Laboratory of Medical Sciences, W120TN London, United Kingdom
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Cristina L Ronchi
- Institute of Metabolism and System Research, University of Birmingham, B152TT Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, B152TT Birmingham, United Kingdom
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28
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Piñar-Gutiérrez A, Mangas-Cruz MÁ, de Lara-Rodríguez I, Remón-Ruiz P, Del Can-Sánchez D, Tous Castillo M, Pumar-López A. Familial bilateral macronodular adrenal hyperplasia due to a novel ARMC 5 germline mutation: Clinical status and possible association with other neoplasms. ENDOCRINOL DIAB NUTR 2024; 71:119-123. [PMID: 38555108 DOI: 10.1016/j.endien.2024.03.016] [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: 10/04/2023] [Accepted: 01/14/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION/OBJECTIVES Mutations in the ARMC5 (armadillo repeat containing 5, OMIM 615549) gene, a putative tumor suppressor gene, have recently been identified as a common cause of sporadic and familial bilateral macronodular adrenal hyperplasia (BMAH). Familial BMAH is thought to be caused by two mutations, one germline and the other somatic, as suggested by the 2-hit theory. The objective is to describe a new mutation and develop its clinical characteristics and implications. METHODS, RESULTS AND CONCLUSIONS We present an affected family with 11 members carrying a novel mutation of the ARMC5 gene (NM_001288767.1): c.2162T>C p. (Leu721Pro). Two of the carriers developed clinical Cushing's syndrome (CS), two mild autonomous cortisol secretion (MACS) and one presented with autonomous cortisol secretion (ACS). Four patients developed other tumors, three of whom died from this cause. It is not known whether these tumors could be related to the described mutation.
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Affiliation(s)
- Ana Piñar-Gutiérrez
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Pablo Remón-Ruiz
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Diego Del Can-Sánchez
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - María Tous Castillo
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Alfonso Pumar-López
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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29
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Schlegel N, Meir M, Reibetanz J, Markus C, Wiegering A, Fassnacht M. [Personalized treatment of pheochromocytoma]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:200-206. [PMID: 37957403 PMCID: PMC10879233 DOI: 10.1007/s00104-023-01988-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Pheochromocytoma is a rare but severe disease of the adrenal glands. The aim of this study is to present and discuss recent developments in the diagnosis and treatment of pheochromocytoma. MATERIAL AND METHODS A narrative review article based on the most recent literature is presented. RESULTS AND DISCUSSION The proportion of pheochromocytomas as tumors of adrenal origin is about 5% of incidentally discovered adrenal tumors. The classical symptomatic triad of headaches, sweating, and palpitations occurs in only about 20% of patients, while almost all patients show at least 1 of these symptoms. To diagnose pheochromocytoma, levels of free plasma metanephrines or alternatively, fractionated metanephrines in a 24‑h urine collection is required in a first step. In the second step an imaging procedure, computed tomography (CT) or magnetic resonance imaging (MRI), is performed to localize the adrenal tumor. Functional imaging is also recommended to preoperatively detect potential metastases. Genetic testing should always be offered during the course of treatment as 30-40% of pheochromocytomas are associated with genetic mutations. The dogma of preoperative alpha blockade is increasingly being questioned and has been controversially discussed in recent years. Minimally invasive removal of the adrenal tumor is the standard surgical procedure to cure patients with pheochromocytoma. The transabdominal and retroperitoneal laparoscopic approaches are considered equivalent. The choice of the minimally invasive procedure depends on the expertise and experience of the surgeon and should be tailored accordingly. Individualized and regular follow-up care is important after surgery.
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Affiliation(s)
- Nicolas Schlegel
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - Michael Meir
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christian Markus
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Martin Fassnacht
- Medizinische Klinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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30
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Bonaventura I, Tomaselli A, Angelini F, Ferrari D, De Alcubierre D, Hasenmajer V, Sbardella E, Cozzolino A, Paganini AM, Isidori AM, Minnetti M, Pofi R. Predicting postoperative hypocortisolism in patients with non-aldosterone-producing adrenocortical adenoma: a retrospective single-centre study. J Endocrinol Invest 2024:10.1007/s40618-023-02283-1. [PMID: 38386266 DOI: 10.1007/s40618-023-02283-1] [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: 08/27/2023] [Accepted: 12/14/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Limited information exists on postoperative hypocortisolism and hypothalamus-pituitary-adrenal axis recovery in patients with adrenal incidentaloma following unilateral adrenalectomy. We evaluated frequency of postoperative hypocortisolism and predictors for recovery in non-aldosterone-producing adrenocortical adenoma patients after unilateral adrenalectomy. METHODS A retrospective analysis of 32 adrenal incidentaloma patients originally included in the ITACA trial (NCT04127552) with confirmed non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy from September 2019 to April 2023 was conducted. Preoperative assessments included adrenal MRI, anthropometrics, evaluation of comorbidities, adrenal function assessed via ACTH, urinary free cortisol, and 1 mg dexamethasone suppression test. ACTH and serum cortisol or Short Synacthen test were performed within 6 days, 6 weeks, 6 months, and a year after surgery. RESULTS Six days postoperative, 18.8% of patients had normal adrenal function. Among those with postoperative hypocortisolism, 53.8% recovered by 6 weeks. Patients with earlier adrenal recovery (6 weeks) had lower preoperative 1 mg dexamethasone suppression test (median 1 mg dexamethasone suppression test 76.2 [61.8-111.0] nmol/L vs 260.0 [113.0-288.5] nmol/L, p < 0.001). Univariate analysis showed preoperative 1 mg dexamethasone suppression test negatively related with baseline ACTH levels (r = - 0.376; p = 0.041) and negatively associated with the 6-week baseline (r = - 0.395, p = 0.034) and 30-min cortisol levels during Short Synacthen test (r = - 0.534, p = 0.023). Logistic regression analysis demonstrated preoperative 1 mg dexamethasone suppression test as the only biochemical predictor for 6-week adrenal recovery: ROC curve identified a 1 mg dexamethasone suppression test threshold of 131 nmol/L predicting 6-week recovery with 89.5% sensitivity and 72.7% specificity (AUC 0.87; 95% CI 66.9-98.7, p < 0.001). Other preoperative assessments (tumor size, ACTH levels and anthropometrics) were not associated with postoperative hypothalamus-pituitary-adrenal axis function, but the presence of diabetes was associated with a lower probability of recovery (OR = 24.55, p = 0.036). ACTH levels increased postoperatively in all patients but did not predict hypothalamus-pituitary-adrenal axis recovery. CONCLUSIONS The preoperative 1 mg dexamethasone suppression test cortisol value and presence of diabetes are the only relevant predictor of hypothalamus-pituitary-adrenal axis recovery in patients with non-aldosterone- producing adrenocortical adenoma undergoing surgery, regardless other clinical and biochemical variables. Notably, pre- and postoperative ACTH levels did not predict hypothalamus-pituitary-adrenal axis recovery. These findings point towards the potential for saving resources by optimizing their allocation during follow-up assessments for patients with non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy.
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Affiliation(s)
- I Bonaventura
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Tomaselli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - F Angelini
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Ferrari
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Cancer Research Center of Lyon, Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Lyon, France
| | - V Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Paganini
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Policlinico Umberto I, Centre for Rare Diseases (Endo-ERN Accredited), Rome, Italy
| | - M Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - R Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK.
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31
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Schlötelburg W, Hartrampf PE, Kosmala A, Fuss CT, Serfling SE, Buck AK, Schirbel A, Kircher S, Hahner S, Werner RA, Fassnacht M. Prognostic role of quantitative [18F]FDG PET/CT parameters in adrenocortical carcinoma. Endocrine 2024:10.1007/s12020-024-03695-6. [PMID: 38381353 DOI: 10.1007/s12020-024-03695-6] [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: 10/05/2023] [Accepted: 01/10/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE We aimed to evaluate the prognostic potential of baseline [18F]FDG PET/CT for overall survival (OS) in patients with adrenocortical carcinoma (ACC). METHODS We performed a retrospective analysis of 67 treatment-naïve ACC patients with available [18F]FDG PET/CT at time of initial diagnosis. Pretherapeutic PETs of primary tumors were manually segmented and quantitative parameters (maximum/mean/peak standardized uptake value (SUVmax/mean/peak), metabolic tumor volume (MTV) and tumor lesion glycolysis (TLG, defined as TV*SUVmean) were derived. Based on a visual read, absence (M0) or presence of metastatic disease (M1) were evaluated. Kaplan-Meier and Cox regression analyses were used to determine the prognostic value of the above mentioned markers on overall survival adjusted for established prognostic markers. RESULTS 24/67 patients (36%) presented with M0 based on PET/CT, while the remaining 43/67 (64%) had M1-status. 32/67 patients died during follow-up and median OS was 48 months. In 12% of patients FDG-PET detected additional metastatic lesion not clearly visible by CT only. In univariable analysis, all quantitatively derived PET parameters failed to reach significance (P ≥ 0.1), and only PET/CT-based M1-status and Ki-67 were associated with increased mortality (M1: HR 13.89, 95% CI 4.15-86.32, P < 0.001; Ki-67 HR 1.29, 95% CI 1.16-1.42; P < 0.0001). Using multivariable Cox regression analyses, M1-status (HR 9.69, 95% CI 2.82-60.99) and Ki-67 index (HR 1.29, 95% CI 1.13-1.04; P < 0.05) remained significant associated with OS. CONCLUSION In treatment-naïve ACC patients, the quantitative PET parameter failed to predict OS, but presence of metastases detected by [18F]FDG PET/CT and Ki-67 index were independently associated with shorter OS. Therefore, a simple visual PET-based read-out is of prognostic value at initial diagnosis, while time-consuming PET-based quantification can be omitted.
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Affiliation(s)
- Wiebke Schlötelburg
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
| | - Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Aleksander Kosmala
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Carmina T Fuss
- Division of Endocrinology and Diabetes, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Sebastian E Serfling
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Stefan Kircher
- Institute for Pathology, University of Würzburg, Würzburg, Germany
| | - Stefanie Hahner
- Division of Endocrinology and Diabetes, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Goethe University Frankfurt, University Hospital, Department of Nuclear Medicine, Clinic for Radiology and Nuclear Medicine, Frankfurt, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
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32
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Amar L, Harbuz-Miller I, Turcu AF. Adrenal Incidentaloma-Innocent Bystander or Intruder? J Clin Endocrinol Metab 2024; 109:e1303-e1304. [PMID: 37622650 PMCID: PMC10876404 DOI: 10.1210/clinem/dgad504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Laurence Amar
- Centre de Soins, de Recherche et Enseignement en Hypertension Artérielle, Hôpital Européen Georges Pompidou, Université de Paris, 75015 Paris, France
| | - Inga Harbuz-Miller
- Department of Medicine, Endocrine/Metabolism, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Adina F Turcu
- Division of Endocrinology, Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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33
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Chen AX, Radhakutty A, Drake SM, Kiu A, Thompson CH, Burt MG. Cardiovascular Risk Markers in Adults With Adrenal Incidentaloma and Mild Autonomous Cortisol Secretion. J Clin Endocrinol Metab 2024; 109:e1020-e1028. [PMID: 37967229 DOI: 10.1210/clinem/dgad665] [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: 08/18/2023] [Revised: 11/06/2023] [Accepted: 11/13/2023] [Indexed: 11/17/2023]
Abstract
CONTEXT Many adrenal adenomas exhibit mild autonomous cortisol secretion (MACS). Although MACS is associated with increased cardiovascular mortality, the underlying mechanisms are not fully defined. OBJECTIVE To investigate mechanisms that may link MACS and cardiovascular mortality in adults with adrenal adenoma. DESIGN Cross-sectional study. PATIENTS Twenty adults with adrenal adenoma and MACS and 20 controls with nonfunctioning adrenal adenoma. METHODS Reactive hyperemia index (RHI) was measured by peripheral artery tonometry and 24-hour ambulatory blood pressure monitoring (24h AMBP) was performed. Indices of insulin secretion and sensitivity were estimated by measuring glucose and insulin fasting and following a mixed meal. MAIN OUTCOME MEASURE The primary outcome was the difference in RHI between participants with MACS vs nonfunctioning adrenal adenoma. RESULTS The average cortisol after 1-mg dexamethasone and urinary free cortisol were higher in patients with MACS. There was no significant difference in fasting RHI (2.0 [interquartile range (IQR) 1.6-2.4] vs 2.0 [IQR 1.7-2.2, P = .72), but postprandial RHI was higher in patients with MACS (2.2 [1.8-2.7] vs 1.8 [1.5-2.2], P = .04). 24-hour ambulatory blood pressure monitoring and Matsuda index were not significantly different in the groups. Fasting glucose and glucose area under the curve after the mixed meal were higher and insulinogenic index was lower in participants with MACS. CONCLUSION Adults with adrenal adenoma and MACS do not have fasting endothelial dysfunction and postprandial endothelial function may be better. These patients have fasting and postprandial hyperglycemia with lower insulin secretion, which may underlie the association between MACS and increased cardiovascular mortality.
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Affiliation(s)
- Angela X Chen
- Department of Endocrinology, Flinders Medical Centre, Bedford Park 5042, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park 5042, Australia
| | - Anjana Radhakutty
- Department of Medicine, Lyell McEwin Hospital, Elizabeth Vale 5112, Australia
- Faculty of Medicine and Health Sciences, University of Adelaide, Adelaide 5000, Australia
| | - Sophie M Drake
- Department of Endocrinology, Flinders Medical Centre, Bedford Park 5042, Australia
| | - Andrew Kiu
- College of Medicine and Public Health, Flinders University, Bedford Park 5042, Australia
- Department of Endocrine Surgery, Flinders Medical Centre, Bedford Park 5042, Australia
| | - Campbell H Thompson
- Faculty of Medicine and Health Sciences, University of Adelaide, Adelaide 5000, Australia
- Department of Medicine, Royal Adelaide Hospital, Adelaide 5000, Australia
| | - Morton G Burt
- Department of Endocrinology, Flinders Medical Centre, Bedford Park 5042, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park 5042, Australia
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Lightman SL. Clinical Endocrinology-Time for a Reset? J Endocr Soc 2024; 8:bvae024. [PMID: 38440109 PMCID: PMC10910589 DOI: 10.1210/jendso/bvae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 03/06/2024] Open
Abstract
Measurement of blood levels of circulating hormones has always been the cornerstone of the biochemical diagnosis of endocrine diseases, with the objective of detecting hormone excess or insufficiency. Unfortunately, the dynamic nature of hormone secretion means single-point measurements of many hormones often lack diagnostic validity. Endocrinologists have devised complex dynamic tests as indirect assessments of the functioning of the hormone system under investigation. Recent advances in the measurement of dynamic hormone changes across the day now offer an opportunity to reconsider whether there might be better ways both to diagnose and to monitor the therapy of endocrine conditions.
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Affiliation(s)
- Stafford L Lightman
- Translational Health Sciences, The Medical School, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol BS1 3NY, UK
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35
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Bozic Antic I, Djurisic I, Nikolic S. Adrenal Cysts: To Operate or Not to Operate? J Clin Med 2024; 13:846. [PMID: 38337539 PMCID: PMC10856713 DOI: 10.3390/jcm13030846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Adrenal cysts are uncommon and usually asymptomatic, and therefore are usually incidentally discovered adrenal lesions. They have a broad pathohistological spectrum that includes pseudocysts and endothelial (vascular), parasitic, and epithelial (mesothelial) cysts. Although most adrenal cysts are benign and hormonally non-functional lesions, some can have ambiguous imaging appearances and mimic malignant adrenal neoplasms. On the other hand, the actual malignant neoplasms could undergo cystic transformation. Additionally, immune cell infiltrations, thrombosis, or haemorrhage seen in sepsis can frequently cause adrenal cyst development, raising a question about the possible connection between severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) and adrenal cystic lesions. Due to the disease's rarity, the likelihood of malignancy, and the lack of specific guidelines, the management of adrenal cysts is always challenging especially in a young person. This review discusses the important diagnostic and the current treatment possibilities for adrenal cystic lesions. Aiming to emphasize clinical dilemmas and help clinicians navigate the challenges when encountering a patient with an adrenal cyst in everyday practice, we based our review on a practical question-answer framework centred around the case of a young woman with an incidentally discovered large adrenal cyst.
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Affiliation(s)
- Ivana Bozic Antic
- Department of Endocrinology, Euromedik General Hospital, 11000 Belgrade, Serbia
- Faculty of Dentistry Pancevo, University Business Academy, 21000 Novi Sad, Serbia
| | - Igor Djurisic
- Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia
| | - Srdjan Nikolic
- Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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Athar F, Karmani M, Templeman N. Metabolic hormones are integral regulators of female reproductive health and function. Biosci Rep 2024; 44:BSR20231916. [PMID: 38131197 PMCID: PMC10830447 DOI: 10.1042/bsr20231916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/29/2023] [Accepted: 12/21/2023] [Indexed: 12/23/2023] Open
Abstract
The female reproductive system is strongly influenced by nutrition and energy balance. It is well known that food restriction or energy depletion can induce suppression of reproductive processes, while overnutrition is associated with reproductive dysfunction. However, the intricate mechanisms through which nutritional inputs and metabolic health are integrated into the coordination of reproduction are still being defined. In this review, we describe evidence for essential contributions by hormones that are responsive to food intake or fuel stores. Key metabolic hormones-including insulin, the incretins (glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1), growth hormone, ghrelin, leptin, and adiponectin-signal throughout the hypothalamic-pituitary-gonadal axis to support or suppress reproduction. We synthesize current knowledge on how these multifaceted hormones interact with the brain, pituitary, and ovaries to regulate functioning of the female reproductive system, incorporating in vitro and in vivo data from animal models and humans. Metabolic hormones are involved in orchestrating reproductive processes in healthy states, but some also play a significant role in the pathophysiology or treatment strategies of female reproductive disorders. Further understanding of the complex interrelationships between metabolic health and female reproductive function has important implications for improving women's health overall.
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Affiliation(s)
- Faria Athar
- Department of Biology, University of Victoria, Victoria, British Columbia V8P 5C2, Canada
| | - Muskan Karmani
- Department of Biology, University of Victoria, Victoria, British Columbia V8P 5C2, Canada
| | - Nicole M. Templeman
- Department of Biology, University of Victoria, Victoria, British Columbia V8P 5C2, Canada
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Favero V, Eller-Vainicher C, Morelli V, Cairoli E, Salcuni AS, Scillitani A, Corbetta S, Casa SD, Muscogiuri G, Persani L, Chiodini I. Increased Risk of Vertebral Fractures in Patients With Mild Autonomous Cortisol Secretion. J Clin Endocrinol Metab 2024; 109:e623-e632. [PMID: 37738555 PMCID: PMC10795935 DOI: 10.1210/clinem/dgad560] [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: 08/01/2023] [Revised: 09/07/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023]
Abstract
CONTEXT The risk of vertebral fractures (VFx) in patients with adrenal incidentalomas (AI) and mild autonomous cortisol secretion (MACS) is debated. OBJECTIVE To evaluate the VFx prevalence and incidence in patients with AI and MACS. METHODS This cross-sectional and longitudinal study using retrospective data from 4 Italian endocrinology units included 444 patients (cross-sectional arm) and 126 patients (longitudinal arm, 24.9 ± 5.3 months follow-up) to evaluate prevalent and incident VFx, respectively, in patients with MACS (MACS-yes) and without MACS (MACS-no). The main outcome measures were serum cortisol after a 1-mg dexamethasone test (F-1mgDST), bone mineral density (BMD) by dual-energy x-ray absorptiometry at spine (LS) and femur (FN), and VFx presence by x-ray. RESULTS Cross-sectional arm: 214 and 230 patients were MACS-yes and MACS-no, respectively, based on F-1mgDST >1.8 µg/dL (50 nmol/L). Patients with MACS had higher VFx prevalence (62.6%) than those without MACS (22.9%, P < .001); MACS was associated with prevalent VFx (odds ratio, 5.203; 95% CI, 3.361-8.055; P < .001; relative risk [RR] 2.07), regardless of age, body mass index, gender distribution, LS-BMD, and presence of type 2 diabetes mellitus (T2D). Longitudinal arm: 66 and 60 patients were MACS-no and MACS-yes, respectively. Patients without MACS showed higher number of incident VFx (36.4%) than patients without MACS (10.0%, P < .001); MACS was associated with the presence of an incident VFx (RR 4.561; 95% CI, 1.600-13.003; P = .005) regardless of age, LS-BMD, gender distribution, presence of prevalent VFx, and T2D. Results were confirmed in women and men when separately evaluated. CONCLUSION Women and men with AI and MACS are at higher risk of VFx.
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Affiliation(s)
- Vittoria Favero
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
| | - Cristina Eller-Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, 20100 Milan, Italy
| | - Valentina Morelli
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Elisa Cairoli
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Antonio Stefano Salcuni
- Unit of Endocrinology and Metabolism, University-Hospital S. Maria Della Misericordia, 33100 Udine, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology, “Casa Sollievo della Sofferenza,” Hospital, IRCCS, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Sabrina Corbetta
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20100 Milan, Italy
| | - Silvia Della Casa
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00100 Rome, Italy
| | - Giovanna Muscogiuri
- Dipartimento di Medicina Clinica e Chirurgia, Unità di Endocrinologia, Andrologia e Diabetologia - University of Naples “Federico II”, 80131 Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, 80131 Naples, Italy
| | - Luca Persani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
- Unit of Endocrinology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
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Herrera-Martínez AD, Román ÁR, Corrales EP, Idrobo C, Ramírez PP, Rojas PM, Lázaro CR, Araujo-Castro M. Adrenal incidentalomas, cortisol secretion and cancer: is there a real crosstalk? Front Endocrinol (Lausanne) 2024; 14:1335202. [PMID: 38264281 PMCID: PMC10804881 DOI: 10.3389/fendo.2023.1335202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/11/2023] [Indexed: 01/25/2024] Open
Abstract
Background Cortisol has immunomodulatory effects that increase the risk and evolution of several diseases. Cancer is characterized by a proinflammatory state in which cells exert impaired function and proliferation. The relation between cortisol secretion and increased risk of malignant neoplasm, or their behavior, has not been fully elucidated. Aim To determine the relation between cortisol secretion and the prevalence and clinical outcome of malignant neoplasms in patients with adrenal incidentalomas (AIs). Methods Multicenter retrospective study that included 935 patients with AIs. Cortisol secretion was defined by a cortisol post-dexamethasone suppression test > 1.8 µg/dL, and nonfunctioning AIs (NFAIs) as a value ≤ 1.8 µg/dL. Results Cortisol secretion was evident in 30.8% of the patients and cancer in 23.6% (especially breast, colorectal, prostate and thyroid cancer). No differences in the cancer prevalence were found between patients with cortisol secretion and NFAIs (63.6% vs. 63.4%, p=0.10). After adjusting by age, cortisol secretion was not associated with the presence of cancer (OR 1.29, CI 0.93-1.78). However, cortisol secretion was significantly associated with stage IV of cancer at diagnosis (OR 2.68, CI 1.19- 6.00) and mortality (OR 3.2, CI 1.28- 7.97). Patients with NFAI and breast cancer required treatment with chemo- and radio-therapy more frequently that patients with cortisol secreting AI (90% vs 10% and 92.9% vs 7.1% respectively, p<0.05), similarly patients with prostate cancer required radiotherapy more frequently (90.9% vs 9.1%, p=0.05); also, patients with colorectal cancer and NFAI, tended to require chemotherapy more frequently(76.5% vs 23.5%, p=0.06). Conclusion Cortisol secretion does not increase the risk of malignant neoplasm, but it affects its clinical course, treatment requirements and mortality, leading to a worst prognosis and higher mortality when compared with patients with NFAIs.
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Affiliation(s)
- Aura D. Herrera-Martínez
- Endocrinology & Nutrition Department, Hospital Reina Sofia, Córdoba, Spain
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
| | - Ángel Rebollo Román
- Endocrinology & Nutrition Department, Hospital Reina Sofia, Córdoba, Spain
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
| | - Eider Pascual Corrales
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Cindy Idrobo
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | | | | | | | - Marta Araujo-Castro
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
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Saini J, Navin P, Rivera M, Bancos I. Gynecomastia in a Man With Adrenal Mass. JCEM CASE REPORTS 2024; 2:luad143. [PMID: 38192879 PMCID: PMC10773200 DOI: 10.1210/jcemcr/luad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Indexed: 01/10/2024]
Abstract
Estrogen-secreting adrenocortical carcinoma (ACC) is exceedingly rare, representing 1% to 2% of all ACCs. We present a case of a 65-year-old man diagnosed with an estrogen-secreting, 4.3-cm right adrenal mass discovered during work-up for bilateral gynecomastia. Gynecomastia and hyperestrogenism resolved after laparoscopic adrenalectomy, and pathology was reported as adrenocortical adenoma. However, 5 years later, he again developed bilateral gynecomastia because of recurrent hyperestrogenism. Imaging revealed multiple metastases in the abdomen. Urine steroid profiling demonstrated increased androgen precursors, androgen metabolites, and glucocorticoid precursors. Ultrasound-guided biopsy of one of the metastases confirmed ACC. Initial therapy included debulking surgery with removal of metastatic lesions. Mitotane therapy was initiated 4 weeks later along with hydrocortisone for anticipated mitotane-induced adrenal insufficiency. Histopathology from the adrenalectomy specimen 5 years earlier was rereviewed and confirmed ACC. Estrogen-secreting adrenal tumors are exceedingly rare, and the majority are malignant. This case underlines the importance of making an initial accurate diagnosis of adrenal malignancy that allows better surgical planning and appropriate monitoring. Indeterminate imaging characteristics of the adrenal mass, as well as the presentation with estrogen excess, suggested an elevated risk for ACC. Initial pathology-based misdiagnosis illustrates the need for an expert adrenal pathologist to review these rare tumors.
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Affiliation(s)
- Jasmine Saini
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Patrick Navin
- Division of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael Rivera
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
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Bioletto F, Ghigo E, Parasiliti-Caprino M. Nonfunctional Adrenal Adenomas and Increased Risk of Mortality. JAMA Intern Med 2024; 184:113. [PMID: 37930679 DOI: 10.1001/jamainternmed.2023.5695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Fabio Bioletto
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mirko Parasiliti-Caprino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
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41
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Patrova J, Lindh JD, Falhammar H. Nonfunctional Adrenal Adenomas and Increased Risk of Mortality-Reply. JAMA Intern Med 2024; 184:113-114. [PMID: 37930663 DOI: 10.1001/jamainternmed.2023.5698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Jekaterina Patrova
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Södersjukhuset, Stockholm, Sweden
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
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Kocic S, Vukomanovic V, Djukic A, Saponjski J, Saponjski D, Aleksic V, Ignjatovic V, Vuleta Nedic K, Markovic V, Vojinovic R. Can MDCT Enhancement Patterns Be Helpful in Differentiating Secretory from Non-Functional Adrenal Adenoma? MEDICINA (KAUNAS, LITHUANIA) 2023; 60:72. [PMID: 38256333 PMCID: PMC10819253 DOI: 10.3390/medicina60010072] [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: 11/14/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Primary adrenal tumors (AT) are a heterogeneous group of neoplasms due to their functional heterogeneity, which results in the diverse clinical presentation of these tumors. The purpose of this study was to examine cross-sectional imaging characteristics using multi-detector computed tomography (MDCT) to provide insight into the lesion characterization and functional status of these tumors. The radionuclide imaging using Technetium-99m radiolabeled hydrazinonicotinylacid-d-phenylalanyl1-tyrosine3-octreotide (99mTc-HYNIC-TOC), was also used in the diagnostic evaluation of these tumors. Materials and Methods: This cross-sectional study included 50 patients with confirmed diagnoses of AT (21 hormone-secreting and 29 non-functional) at the University Clinical Center, Kragujevac, Serbia, during the 2019-2022 year period. The morphological and dynamic characteristics using MDCT were performed, using qualitative, semi-quantitative, and quantitative analysis. Absolute washout (APW) and relative washout (RPW) values were also calculated. A semi-quantitative analysis of all visual findings with 99mTc-HYNIC-TOC was performed to compare the tumor to non-tumor tracer uptake. Results: A statistically significant difference was found in the MDCT values in the native phase (p < 0.05), the venous phase (p < 0.05), and the delayed phase (p < 0.001) to detect the existence of adrenal tumors. Most of these functional adrenocortical lesions (n = 44) can be differentiated using the delayed phase (p < 0.05), absolute percentage washout (APW) (p < 0.05), and relative percentage washout (RPW) (p < 0.001). Furthermore, 99mTc-HYNIC-TOC could have a high diagnostic yield to detect adrenal tumor existence (p < 0.001). There is a positive correlation between radionuclide imaging scan and APW to detect all AT (p < 0.01) and adrenocortical adenomas as well (p < 0.01). Conclusions: The results can be very helpful in a diagnostic algorithm to quickly and precisely diagnose the expansive processes of the adrenal glands, as well as to learn about the advantages and limitations of the mentioned imaging modalities.
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Affiliation(s)
- Svetlana Kocic
- Department of Radiology, Clinical Hospital Center Zemun, 11070 Belgrade, Serbia;
| | - Vladimir Vukomanovic
- Department of Nuclear Medicine, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia; (V.I.); (K.V.N.)
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
| | - Aleksandar Djukic
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
- Department of Pathophysiology, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Jovica Saponjski
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (J.S.); (D.S.)
- University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dusan Saponjski
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (J.S.); (D.S.)
- University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Vuk Aleksic
- Department of Neurosurgery, Clinical Hospital Center Zemun, 11070 Belgrade, Serbia;
| | - Vesna Ignjatovic
- Department of Nuclear Medicine, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia; (V.I.); (K.V.N.)
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
| | - Katarina Vuleta Nedic
- Department of Nuclear Medicine, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia; (V.I.); (K.V.N.)
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
| | - Vladan Markovic
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
- Department of Radiology, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Radisa Vojinovic
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
- Department of Radiology, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia
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Kimpel O, Altieri B, Dischinger U, Fuss CT, Kurlbaum M, Fassnacht M. Early Detection of Recurrence and Progress Using Serum Steroid Profiling by LC-MS/MS in Patients with Adrenocortical Carcinoma. Metabolites 2023; 14:20. [PMID: 38248823 PMCID: PMC10819433 DOI: 10.3390/metabo14010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 01/23/2024] Open
Abstract
Serum liquid chromatography-tandem mass spectrometry (LC-MS/MS) steroid profiling is used for the diagnosis of adrenocortical carcinoma (ACC). Guidelines recommend endocrine work-up in addition to radiological imaging for follow-up in ACC, but data on this topic are scarce. Patients were included in this retrospective study if pre-therapeutic hormone values, regular tumour evaluation by imaging, steroid measurements by LC-MS/MS, and details on therapies were available. The utility of steroid profiles in detecting recurrence or disease progression was assessed, whereby "endocrine progress" was defined by an elevation of at least 3 of 13 analysed hormones. Cohort A included 47 patients after R0 resection, of whom 15 experienced recurrence and 32 did not. In cohort B, 52 patients with advanced disease (including 7 patients of cohort A with recurrence) could be evaluated on 74 visits when progressive disease was documented. In 20 of 89 cases with documented disease progression, "endocrine progress" was detectable prior to radiological progress. In these cases, recurrence/progression was detected at a median of 32 days earlier by steroid measurement than by imaging, with 11-deoxycortisol and testosterone being the most sensitive markers. Notably, these patients had significantly larger tumour burden. In conclusion, steroid profiling by LC-MS/MS is of value in detecting recurrent/progressive disease in ACC.
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Affiliation(s)
- Otilia Kimpel
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (C.T.F.); (M.K.); (M.F.)
| | - Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (C.T.F.); (M.K.); (M.F.)
| | - Ulrich Dischinger
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (C.T.F.); (M.K.); (M.F.)
| | - Carmina Teresa Fuss
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (C.T.F.); (M.K.); (M.F.)
| | - Max Kurlbaum
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (C.T.F.); (M.K.); (M.F.)
- Core Unit Clinical Mass Spectrometry, Central Laboratory, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (C.T.F.); (M.K.); (M.F.)
- Core Unit Clinical Mass Spectrometry, Central Laboratory, University Hospital Würzburg, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, 97080 Würzburg, Germany
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Gadelha M, Gatto F, Wildemberg LE, Fleseriu M. Cushing's syndrome. Lancet 2023; 402:2237-2252. [PMID: 37984386 DOI: 10.1016/s0140-6736(23)01961-x] [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] [Received: 06/01/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
Endogenous Cushing's syndrome results from excess glucocorticoid secretion, which leads to a myriad of clinical manifestations, comorbidities, and increased mortality despite treatment. Molecular mechanisms and genetic alterations associated with different causes of Cushing's syndrome have been described in the last decade. Imaging modalities and biochemical testing have evolved; however, both the diagnosis and management of Cushing's syndrome remain challenging. Surgery is the preferred treatment for all causes, but medical therapy has markedly advanced, with new drug options becoming available. Nevertheless, several comorbidities remain even after patient remission, which can affect quality of life. Accurate and timely diagnosis and treatment are essential for mitigating chronic complications of excess glucocorticoids and improving patient quality of life. In this Seminar, we aim to update several important aspects of diagnosis, complications, and treatment of endogenous Cushing's syndrome of all causes.
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Affiliation(s)
- Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Molecular Genetics Laboratory, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
| | - Federico Gatto
- Endocrinology Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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Nazari MA, Hasan R, Haigney M, Maghsoudi A, Lenders JWM, Carey RM, Pacak K. Catecholamine-induced hypertensive crises: current insights and management. Lancet Diabetes Endocrinol 2023; 11:942-954. [PMID: 37944546 DOI: 10.1016/s2213-8587(23)00256-5] [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] [Received: 06/01/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 11/12/2023]
Abstract
Phaeochromocytomas and paragangliomas (PPGLs) release catecholamines leading to catecholamine-induced hypertensive (CIH) crises, with blood pressure greater than or equal to 180/120 mm Hg. CIH crises can be complicated by tachyarrhythmias, hypotension, or life-threatening target organ damage while treatment remains undefined, often requiring co-management between endocrinologists and cardiologists. Furthermore, biochemical diagnosis of a PPGL as a cause of a CIH crisis can be difficult to identify or confounded by comorbid conditions, potentially resulting in misdiagnosis. Here, we combine relevant evidence, 60 years of collective clinical experience, insights derived from assessing over 2600 patients with PPGL, and supplementary outcomes from 100 patients (treated at the National Institutes of Health) with a CIH crisis to inform diagnosis and treatment of CIH crises. Recognising that disparities exist between availability, cost, and familiarity of various agents, flexible approaches are delineated allowing for customisation, given institutional availability and provider preference. A CIH crisis and its complications are readily treatable with available drugs, with effective intervention defining an avenue for mitigating consequent morbidity and mortality in patients with PPGL.
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Affiliation(s)
- Matthew A Nazari
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Rockyb Hasan
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Mark Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Division of Cardiology, Department of Medicine, Walter Reed National Military Medical Center and Herbert School of Medicine, Bethesda, MD, USA
| | - Alireza Maghsoudi
- Department of Cardiovascular Disease, INOVA Heart and Vascular Institute, Fairfax, VA, USA
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Department of Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Robert M Carey
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
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Ha J, Park JH, Kim KJ, Kim JH, Jung KY, Lee J, Choi JH, Lee SH, Hong N, Lim JS, Park BK, Kim JH, Jung KC, Cho J, Kim MK, Chung CH. 2023 Korean Endocrine Society Consensus Guidelines for the Diagnosis and Management of Primary Aldosteronism. Endocrinol Metab (Seoul) 2023; 38:597-618. [PMID: 37828708 PMCID: PMC10765003 DOI: 10.3803/enm.2023.1789] [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: 07/25/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023] Open
Abstract
Primary aldosteronism (PA) is a common, yet underdiagnosed cause of secondary hypertension. It is characterized by an overproduction of aldosterone, leading to hypertension and/or hypokalemia. Despite affecting between 5.9% and 34% of patients with hypertension, PA is frequently missed due to a lack of clinical awareness and systematic screening, which can result in significant cardiovascular complications. To address this, medical societies have developed clinical practice guidelines to improve the management of hypertension and PA. The Korean Endocrine Society, drawing on a wealth of research, has formulated new guidelines for PA. A task force has been established to prepare PA guidelines, which encompass epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and follow-up care. The Korean clinical guidelines for PA aim to deliver an evidence-based protocol for PA diagnosis, treatment, and patient monitoring. These guidelines are anticipated to ease the burden of this potentially curable condition.
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Affiliation(s)
- Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyoung Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Yeun Jung
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Jeongmin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Han Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Soo Lim
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung Kwan Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeong Cheon Jung
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jooyoung Cho
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Mi-kyung Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Choon Hee Chung
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - The Committee of Clinical Practice Guideline of Korean Endocrine Society
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - The Korean Adrenal Study Group of Korean Endocrine Society
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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47
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Tritos NA. Incidentally Found Adrenal Masses: When Should We Worry? Endocr Pract 2023; 29:1023-1024. [PMID: 37879432 DOI: 10.1016/j.eprac.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
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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48
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Farinelli DG, Oliveira KC, Hayashi LF, Kater CE. Overnight 1-mg Dexamethasone Suppression Test for Screening Cushing Syndrome and Mild Autonomous Cortisol Secretion (MACS): What Happens when Serum Dexamethasone Is Below Cutoff? How Frequent Is it? Endocr Pract 2023; 29:986-993. [PMID: 37734596 DOI: 10.1016/j.eprac.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To determine the frequency of "invalid" 1-mg overnight dexamethasone (Dex) suppression tests (DSTs) (1-mg DST) on a large series of patients investigated for hypercortisolism and examine the interference of substances and clinical conditions that may explain low serum Dex levels. METHODS A retrospective analysis of 1300 Dex-controlled 1-mg DST applied to patients screened for Cushing syndrome or mild autonomous cortisol secretion in a single center for which there were identified invalid tests and distinctive characteristics that may have interfered with the outcome. RESULTS Among all tests, 146 (11.2%) were considered invalid (serum Dex levels <140 ng/dL, 36 [24.7%] of which were undetectable [<19.5 ng/dL]). In the Dex-undetectable group, 17% failed to take Dex correctly, 25% were on glucocorticoids (GCs), and 20% were on anticonvulsants and moderate CYP3A4 inducers. In the remaining 110 tests (serum Dex 20-140 ng/dL), 6.5% did not take Dex or were using GC, 22% were on anticonvulsants or CYP3A4 inducers, and another 13% had previous gastrointestinal tract abnormalities impairing drug absorption. CONCLUSION Inappropriately low serum Dex levels during the 1-mg DST may lead to false-positive results. This is associated with recurrent use of CYP3A4-inducing drugs and/or gastrointestinal abnormalities. When serum Dex is undetectable, the key reason is failure to take the medication or the use of GC (when cortisol is suppressed). Simultaneous measurement of serum cortisol and Dex allows for DST validation, improving its accuracy and avoiding unnecessary repetitions. Adherence to verbal/written recommendations and actual use of medication are critical for interpreting the test.
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Affiliation(s)
- Denise G Farinelli
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil
| | - Kelly C Oliveira
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil
| | - Lilian F Hayashi
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil
| | - Claudio E Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil.
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49
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Kishimoto S, Maruhashi T, Kajikawa M, Mizobuchi A, Yamaji T, Harada T, Nakano Y, Goto C, Yusoff FM, Nakashima A, Higashi Y. Impact of overnight 1 mg dexamethasone on vascular function in patients with nonfunctioning adrenal adenomas. Sci Rep 2023; 13:20975. [PMID: 38017255 PMCID: PMC10684497 DOI: 10.1038/s41598-023-48295-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 11/30/2023] Open
Abstract
The purpose of this study was to evaluate the effects of administration of overnight 1 mg dexamethasone on vascular function in patients with nonfunctioning adrenal adenomas (NFA). Flow-mediated vasodilation (FMD) and nitroglycerine-induced vasodilation (NID) were measured to assess vascular function in 22 patients with NFA who had hypertension and/or diabetes mellitus (DM) and 272 patients without adrenal incidentalomas who had hypertension and/or DM (control patients with hypertension and/or DM). FMD and NID were measured in the morning before and after administration of 1 mg of dexamethasone at 2300 h in 18 patients with NFA. There were no significant differences in FMD and NID between control patients with hypertension and/or DM and patients with NFA who had hypertension and/or DM (3.4 ± 2.8% vs. 2.9 ± 1.9% and 11.5 ± 5.7% vs. 11.4 ± 4.3%, P = 0.46, and P = 0.99, respectively). There were no significant differences in vascular function between control patients with hypertension and/or DM and patients with NFA who had hypertension and/or DM even after adjustment for cardiovascular risk factors. Overnight 1 mg dexamethasone increased FMD from 2.4 ± 1.9% to 5.3 ± 3.2% (P < 0.01) and increased NID from 12.1 ± 4.2% to 14.0 ± 2.8% (P < 0.01) in patients with NFA. The overnight 1 mg dexamethasone suppression test does not impair FMD and NID in patients with NFA. Decreases in circulating levels of cortisol may improve vascular function.Clinical Trial Registration: This study was approved by principal authorities and ethical issues in Japan (URL for Clinical Trial: http://www.umin.ac.jp/ctr/index.htm Registration Number for Clinical Trial: UMIN000039512).
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Affiliation(s)
- Shinji Kishimoto
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Tatsuya Maruhashi
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Masato Kajikawa
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Aya Mizobuchi
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Takayuki Yamaji
- Center for Radiation Disaster Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Takahiro Harada
- Center for Cause of Death Investigation Research, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Chikara Goto
- Department of Rehabilitation, Faculty of General Rehabilitation, Hiroshima International University, Hiroshima, Japan
| | - Farina Mohamad Yusoff
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Ayumu Nakashima
- Department of Nephrology, Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yukihito Higashi
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan.
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan.
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50
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Crawford M, McDonald B, Chen W, Chowdhry H, Contreras R, Reyes IAC, Dhakal E, Villanueva T, Barzilay JI, Vaughn CF, Czerwiec FS, Katz DA, Adams AL, Gander JC. Dexamethasone Suppression Testing in a Contemporary Cohort with Adrenal Incidentalomas in Two U.S. Integrated Healthcare Systems. Biomedicines 2023; 11:3167. [PMID: 38137386 PMCID: PMC10740617 DOI: 10.3390/biomedicines11123167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
Autonomous cortisol secretion (ACS) from an adrenal adenoma can increase the risk for comorbidities and mortality. The dexamethasone suppression test (DST) is the standard method to diagnose ACS. A multi-site, retrospective cohort of adults with diagnosed adrenal tumors was used to understand patient characteristics associated with DST completion and ACS. Time to DST completion was defined using the lab value and result date; follow-up time was from the adrenal adenoma diagnosis to the time of completion or censoring. ACS was defined by a DST > 1.8 µg/dL (50 nmol/L). The Cox proportional hazards regression model assessed associations between DST completion and patient characteristics. In patients completing a DST, a logistic regression model evaluated relationships between elevated ACS and covariates. We included 24,259 adults, with a mean age of 63.1 years, 48.1% obese, and 28.7% with a Charlson comorbidity index ≥ 4. Approximately 7% (n = 1768) completed a DST with a completion rate of 2.36 (95% CI 2.35, 2.37) per 100 person-years. Fully adjusted models reported that male sex and an increased Charlson comorbidity index were associated with a lower likelihood of DST completion. Current or former smoking status and an increased Charlson comorbidity index had higher odds of a DST > 1.8 μg/dL. In conclusion, clinical policies are needed to improve DST completion and the management of adrenal adenomas.
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Affiliation(s)
- Mackenzie Crawford
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA 30305, USA
| | - Bennett McDonald
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA 30305, USA
| | - Wansu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Hina Chowdhry
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Iris Anne C. Reyes
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Eleena Dhakal
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA 30305, USA
| | - Tish Villanueva
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Joshua I. Barzilay
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA 30305, USA
- Southeastern Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, GA 30305, USA
| | - Candace F. Vaughn
- Southeastern Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, GA 30305, USA
| | | | | | - Annette L. Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA 30305, USA
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