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Nowak E, Vogel F, Albani A, Braun L, Rubinstein G, Zopp S, Ritzel K, Beuschlein F, Theodoropoulou M, Reincke M. Diagnostic challenges in cyclic Cushing's syndrome: a systematic review. Lancet Diabetes Endocrinol 2023:S2213-8587(23)00150-X. [PMID: 37429301 DOI: 10.1016/s2213-8587(23)00150-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 07/12/2023]
Abstract
Cyclic Cushing's syndrome is a subentity of Cushing's syndrome in which phases of biochemical hypercortisolism (peaks) are followed by spontaneous periods of physiological or even hypocortisolaemic cortisol secretion (troughs). To identify common features of cyclic Cushing's syndrome, we systematically reviewed single case reports and case series in MEDLINE from database inception to Oct 10, 2022, and identified 707 articles, of which 149 articles were assessed for eligibility and 118 articles (covering 212 cases) were included in the analysis. Pituitary tumours accounted for 67% of cases of cyclic Cushing's syndrome (n=143), ectopic tumours for 17% (n=36), and adrenal tumours for 11% (n=23). Occult tumours accounted for 2% of cases (n=4), and 3% of cases were unclassified (n=6). We compared the clinical symptoms and comorbidities of patients with cyclic Cushing's syndrome with those of patients with non-cyclic Cushing's syndrome and observed no major difference. In adrenocorticotropic hormone (ACTH)-dependent cyclic Cushing's syndrome, bilateral inferior petrosal sinus sampling had a positive (ie, true pituitary) and negative (ie, true ectopic) predictive value of 100% when performed during periods of hypercortisolism, versus a positive predictive value of 73% and a negative predictive value of 86% when performed, irrespective of cortisolaemic status. Overall, 6% of patients (n=12) with cyclic Cushing's syndrome had unnecessary surgery due to misclassification. Remission rates were significantly lower and the time to remission significantly longer in patients with cyclic Cushing's syndrome compared with patients with non-cyclic Cushing's syndrome (p<0·001). Variations in biochemical test results due to unpredictable cycle duration and frequency might cause diagnostic challenges resulting in misdiagnoses and missed diagnoses.
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Affiliation(s)
- Elisabeth Nowak
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Frederick Vogel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Adriana Albani
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Leah Braun
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - German Rubinstein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stephanie Zopp
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Katrin Ritzel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Felix Beuschlein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany; Department of Endocrinology, Diabetology, and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
| | | | - Martin Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany.
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Nomura C, Nakano Y, Tanaka T, Shima KR, Kometani M, Kanamori T, Ikeda H, Takeshita Y, Yoneda T, Takamura T. Somatostatin Receptor-negative and Fluorodeoxyglucose-positron Emission Tomography-positive Lung Neuroendocrine Tumor G1 Exhibiting Cyclic Cushing's Syndrome. Intern Med 2022; 61:3693-3698. [PMID: 35650126 PMCID: PMC9841091 DOI: 10.2169/internalmedicine.9238-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Localization of ectopic cyclic Cushing's syndrome, which causes life-threatening complications, is challenging. A 70-year-old woman showed cyclic hypokalemia and hyperglycemia and was diagnosed with cyclic ectopic Cushing's syndrome. Although somatostatin-receptor scintigraphy failed to localize the responsible tumor, fluorodeoxyglucose-positron emission tomography (FDG-PET) showed the uptake of tracer in a lung tumor. Lobectomy resulted in remission. The resected adrenocorticotropic hormone (ACTH)-producing neuroendocrine tumor had Ki-67<2% and negative staining for somatostatin receptors. This is the first case assessed both radiological findings and pathological findings in cyclic ectopic Cushing's syndrome. Subsequent FDG-PET is recommended if somatostatin-receptor scintigraphy is negative.
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Affiliation(s)
- Chiaki Nomura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Yujiro Nakano
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Takeo Tanaka
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Kosuke Robert Shima
- Department of Diabetes, Endocrinology and Metabolism, Koseiren Takaoka Hospital, Japan
| | - Mitsuhiro Kometani
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Takehiro Kanamori
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Hiroko Ikeda
- Department of Diagnostic Pathology, Kanazawa University Hospital, Japan
| | - Yumie Takeshita
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Toshinari Takamura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Japan
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