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Soto-Montes Z, Medina-Julio D, Solis-Coronado OD, Mendoza-García JG, Tenorio-Aguirre EK, Martínez-Sánchez FD. Ectopic ACTH-secreting pheochromocytoma without typical signs of Cushing syndrome. Oxf Med Case Reports 2025; 2025:omaf005. [PMID: 40162137 PMCID: PMC11952888 DOI: 10.1093/omcr/omaf005] [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: 09/18/2024] [Revised: 12/26/2024] [Accepted: 01/08/2025] [Indexed: 04/02/2025] Open
Abstract
This case report describes a 42-year-old female with a rare pheochromocytoma presenting without classic Cushingoid features but with uncontrolled hypertension, type 2 diabetes, and recurrent headaches. Despite the absence of typical signs, biochemical analysis revealed elevated cortisol and ACTH levels, and imaging showed a 6 cm adrenal mass. The patient was stabilized preoperatively with alpha-blockers and metyrapone before undergoing a successful laparoscopic adrenalectomy. Histopathology confirmed pheochromocytoma with aggressive features. Postoperatively, her blood pressure and symptoms improved, and her cortisol levels normalized. This case underscores the diagnostic challenges of ACTH-secreting pheochromocytomas without classic hypercortisolism signs and emphasizes the need for thorough endocrine and imaging assessments. Surgical resection remains the definitive treatment, with long-term follow-up essential to monitor for recurrence. This case contributes to the limited literature on the coexistence of pheochromocytoma and ectopic ACTH secretion.
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Affiliation(s)
- Zeltzin Soto-Montes
- Department of Endocrinology, Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
| | - David Medina-Julio
- Department of Internal Medicine, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
- Facultad de Medicina, Universidad Nacional Autónoma de México, Escolar 411A, Copilco Universidad, Coyoacán, Ciudad de México 04360, Mexico
| | - Orlando D Solis-Coronado
- Division of Pathological Anatomy, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
| | - Jesús G Mendoza-García
- Department of Internal Medicine, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
| | - Erika K Tenorio-Aguirre
- Department of Internal Medicine, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
| | - Froylan D Martínez-Sánchez
- Department of Internal Medicine, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
- Facultad de Medicina, Universidad Nacional Autónoma de México, Escolar 411A, Copilco Universidad, Coyoacán, Ciudad de México 04360, Mexico
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Tarling JA, Kumar R, Ward LJ, Boot C, Wassif WS. Phaeochromocytoma and paraganglioma. J Clin Pathol 2024; 77:507-516. [PMID: 38453430 DOI: 10.1136/jcp-2023-209234] [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: 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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Li S, Guo X, Wang H, Suo N, Mi X, Jiang S. Ectopic adrenocorticotropic hormone-secreting pheochromocytoma with severe metabolic disturbances: A case report. Int J Surg Case Rep 2024; 116:109341. [PMID: 38340623 PMCID: PMC10943668 DOI: 10.1016/j.ijscr.2024.109341] [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: 01/08/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION The occurrence of hypercortisolism resulting from adrenocorticotropic hormone (ACTH)-secreting pheochromocytoma is exceedingly uncommon, with limited documented instances thus far. PRESENTATION OF CASE We present a case of ectopic ACTH-secreting pheochromocytoma in a patient who suffered from severe metabolic disorders. Our clinical case outlines the diagnostic history, preoperative correction of the patient's metabolic disturbances and surgical strategy for management of a rare ectopic ACTH producing pheochromocytoma. DISCUSSION Ectopic adrenocorticotropic hormone-secreting pheochromocytoma displays multifaceted clinical features and requires prompt diagnosis and multidisciplinary management in order to overcome the related severe clinical derangements. CONCLUSION The combination of biochemical and hormonal testing and imaging procedures is mandatory for the diagnosis of ectopic ACTH secretion, and in the presence of an adrenal mass, the possibility of an ACTH-secreting pheochromocytoma should be taken into account.
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Affiliation(s)
- Shangjian Li
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 9677, Jingshi Road, Lixia District, Jinan City, Shandong Province, China
| | - Xudong Guo
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, China
| | - Hanbo Wang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, China
| | - Ni Suo
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, China
| | - Xiuqing Mi
- Guanxian People's Hospital, No.70 Guanyichun Road, Guan County, Liaocheng City, Shandong Province, China
| | - Shaobo Jiang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, China.
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Rifai K, Toulali F, Iraqi H, Ettaik M, Gharbi MEH. [A rare cause of hypercorticism: ACTH-secreting pheochromocytoma (a case report)]. Pan Afr Med J 2024; 47:88. [PMID: 38737225 PMCID: PMC11087280 DOI: 10.11604/pamj.2024.47.88.36616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 02/04/2024] [Indexed: 05/14/2024] Open
Abstract
Ectopic ACTH-secreting pheochromocytoma is a very rare cause of Cushing´s syndrome, posing diagnostic and therapeutic challenges. We here report the case of a female patient with suspected severe Cushing´s syndrome associated with melanoderma, arterial hypertension resistant to triple therapy and unbalanced diabetes treated with insulin therapy. Biologically, urinary ethoxylated, 24-hour urinary free cortisol and ACTH were very high. Imaging showed a 3.5 cm left adrenal mass. The patient underwent left adrenalectomy after medical preparation, with good clinico-biological outcome. Anatomopathological examination confirmed the diagnosis of pheochromocytoma. This case study highlights the importance of measuring methoxylated derivatives in any patient with ACTH-dependent Cushing´s syndrome associated with an adrenal mass. The aim is to ensure early treatment and avoid life-threatening complications.
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Affiliation(s)
- Kaoutar Rifai
- Service d’Endocrinologie et Maladies Métaboliques, Centre Hospitalo-Universitaire Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohammed V Souissi, Rabat, Maroc
| | - Fatima Toulali
- Service d’Endocrinologie et Maladies Métaboliques, Centre Hospitalo-Universitaire Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohammed V Souissi, Rabat, Maroc
| | - Hinde Iraqi
- Service d’Endocrinologie et Maladies Métaboliques, Centre Hospitalo-Universitaire Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohammed V Souissi, Rabat, Maroc
| | - Meryeme Ettaik
- Service d’Endocrinologie et Maladies Métaboliques, Centre Hospitalo-Universitaire Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohammed V Souissi, Rabat, Maroc
| | - Mohamed El Hassan Gharbi
- Service d’Endocrinologie et Maladies Métaboliques, Centre Hospitalo-Universitaire Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohammed V Souissi, Rabat, Maroc
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Mizutani G, Isshiki M, Shimizu E, Saito D, Shimada A. Pheochromocytoma With High Adrenocorticotropic Hormone Production Capacity Without Pigmentation and Cushingoid Symptoms: A Case Report With a Literature Review. Cureus 2024; 16:e53358. [PMID: 38435205 PMCID: PMC10907887 DOI: 10.7759/cureus.53358] [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] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Pheochromocytoma or paraganglioma (PPGL) originating from chromaffin cells can produce diverse hormones in addition to catecholamines, including adrenocorticotropic hormone (ACTH). In pheochromocytoma, high levels of ACTH might not result in pigmentation as typically observed in Addison's disease, and patients might not exhibit the symptoms of Cushing's syndrome, despite ACTH-dependent hypercortisolism. A 63-year-old male patient with hypertension was admitted to our facility, and computed tomography (CT) revealed a large right adrenal tumor. Despite high plasma ACTH (700-1300 pg/mL) and serum cortisol (90-100 µg/dL) levels, no physical pigmentation or Cushingoid symptoms were observed. Urinary metanephrine and normetanephrine levels reached as high as 16.0 mg and 3.2 mg, respectively. 123I-metaiodobenzylguanidine (MIBG) scintigraphy was negative. Low-dose dexamethasone paradoxically increased ACTH and cortisol levels, indicating the potential positive feedback regulation of both hormones by glucocorticoids. The patient was diagnosed with an ACTH-producing pheochromocytoma and underwent successful laparoscopic surgery to remove the adrenal tumor under the intravenous administration of a high-dose α-blocker and hydrocortisone. The levels of ACTH, cortisol, and urinary metanephrine/normetanephrine returned close to normal after tumor removal. We report a rare case of pheochromocytoma with extremely high ACTH/cortisol production but without pigmentation or Cushingoid symptoms. We also reviewed previous reports of ACTH-producing PPGL regarding the paradoxical regulation of ACTH/cortisol by glucocorticoids, pigmentation, Cushingoid symptoms, and negativity of 123I-MIBG scintigraphy.
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Affiliation(s)
- Gen Mizutani
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Masashi Isshiki
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Eisuke Shimizu
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Daigo Saito
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
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Реброва ДВ, Григорова СИ, Ворохобина НВ, Згода ЕА, Новокшонов КЮ, Феофанова СГ, Русаков ВФ, Краснов ЛМ, Федоров ЕА, Чинчук ИК, Шихмагомедов ШШ, Пушкарук АА, Слепцов ИВ. [Corticotropin-producing pheochromocytoma in multiple endocrine neoplasia type 1]. PROBLEMY ENDOKRINOLOGII 2023; 69:55-64. [PMID: 37968952 PMCID: PMC10680545 DOI: 10.14341/probl13260] [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: 02/17/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 11/17/2023]
Abstract
A clinical case of a man 66 y.o. who was diagnosed with hormone-inactive pituitary macroadenoma complicated by corneal erosion and partial atrophy of the optic nerve of the left eye due to exophthalmos. The increase in prolactin level was regarded due to a «stalk-effect». The patient underwent a transnasal pituitary adenomectomy with subsequent regression of symptoms. After 4 years, against the background of a new coronavirus infection, increasing general weakness, headaches, a crisis increase in blood pressure and tachycardia attacks appeared. Computed tomography (CT) accidentally revealed an adrenal incidentaloma, in laboratory tests - hypercortisolism, elevated ACTH levels, hypokalemia, hyperglycemia, increased levels of metanephrine and normetanephrine. The patient developed acute steroid psychosis, after which an adrenalectomy with a tumor was performed, a pheochromocytoma was histologically confirmed. After surgery, there was a regression of symptoms, the development of adrenal insufficiency with reduced levels of ACTH and cortisol. Upon further examination, a polynodose euthyroid goiter was established, the biopsy of the nodes - Hashimoto's thyroiditis (Bethesda II). Meanwhile, primary hyperparathyroidism was detected. According to ultrasound, scintigraphy with Ts99m-Technetril and CT revealed an increase of left parathyroid gland. A bilateral revision of the neck, removal of the right upper and left upper parathyroid adenomas were performed. In the postoperative period, the levels of calcium and parathyroid hormone were normalized. Given the presence of a combination of multiple tumors of the endocrine system (primary hyperparathyroidism, corticotropin-producing pheochromocytoma, hormone-inactive pituitary macroadenoma, polynodose euthyroid goiter), the MEN1 syndrome was clinically established. The study of 2 and 10 exons of the MEN1 gene revealed no mutations, which does not exclude the presence of a hereditary syndrome. The patient continues observation. In the available literature in Russian and English languages the case of ACTH pheochromocytoma as part of the MEN type 1 syndrome have not been found. Therefore, we consider the presented case to be the first one.
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Affiliation(s)
- Д. В. Реброва
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н. И. Пирогова
| | | | - Н. В. Ворохобина
- Северо-Западный государственный медицинский университет им. И.И. Мечникова
| | - Е. А. Згода
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - К. Ю. Новокшонов
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | | | - В. Ф. Русаков
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Л. М. Краснов
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Е. А. Федоров
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - И. К. Чинчук
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Ш. Ш. Шихмагомедов
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - А. А. Пушкарук
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - И. В. Слепцов
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
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Усеинова ЗТ, Пигарова ЕА, Бельцевич ДГ, Шевэ А, Дзеранова ЛК, Ситкин ИИ, Тарбаева НВ, Хайриева АВ, Дегтярев МВ, Платонова НМ, Трошина ЕА, Бондаренко ЕВ. [Fulminant hypercorticism due to ACTG producing pheochromocytoma]. PROBLEMY ENDOKRINOLOGII 2023; 70:55-66. [PMID: 39069773 PMCID: PMC11334227 DOI: 10.14341/probl13374] [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: 09/21/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 07/30/2024]
Abstract
Endogenous hypercorticism (EH) is a severe symptom complex caused by hypercortisolemia; according to the etiology, ACTH-dependent and ACTH-independent variants are distinguished, which, according to the literature, occur in 70-80% and 20-30% of cases, respectively. A rare cause of ACTH-dependent endogenous hypercorticism is ACTH-ectopic syndrome (ACTH-ES) (about 15-20% of cases). ACTH-ES is a syndrome of adrenocorticotropic hormone (ACTH) hyperproduction by neuroendocrine tumors of extrahypophyseal origin. Various tumors can secrete ACTH: bronchopulmonary carcinoid, small cell lung cancer, less frequently, thymus carcinoid, islet cell tumors and pancreatic carcinoid, medullary thyroid cancer, carcinoid tumors of the intestine, ovaries, as well as pheochromocytoma (PCC).This publication presents a clinical case of rarely detected paraneoplastic ACTH production by pheochromocytoma. The patient had clinical manifestations of hypercorticism, therefore, she applied to the Russian National Research Center of Endocrinology of the Ministry of Health of Russia. During the examination Cushing's syndrome (CS) was confirmed, multispiral computed tomography (MSCT) of the abdominal cavity revealed a voluminous formation of the left adrenal gland. Additional examination recorded a multiple increase in urinary catecholamine levels. Subsequently, the patient underwent left-sided adrenalectomy. The diagnosis of pheochromocytoma was confirmed morphologically, immunohistochemical study demonstrated intensive expression of chromogranin A and ACTH by tumor cells.
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Affiliation(s)
- З. Т. Усеинова
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. А. Пигарова
- Национальный медицинский исследовательский центр эндокринологии
| | - Д. Г. Бельцевич
- Национальный медицинский исследовательский центр эндокринологии
| | - А. Шевэ
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. К. Дзеранова
- Национальный медицинский исследовательский центр эндокринологии
| | - И. И. Ситкин
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. В. Тарбаева
- Национальный медицинский исследовательский центр эндокринологии
| | - А. В. Хайриева
- Национальный медицинский исследовательский центр эндокринологии
| | - М. В. Дегтярев
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. М. Платонова
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. А. Трошина
- Национальный медицинский исследовательский центр эндокринологии
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Birtolo MF, Grossrubatscher EM, Antonini S, Loli P, Mazziotti G, Lania AG, Chiodini I. Preoperative management of patients with ectopic Cushing's syndrome caused by ACTH-secreting pheochromocytoma: a case series and review of the literature. J Endocrinol Invest 2023; 46:1983-1994. [PMID: 37195583 DOI: 10.1007/s40618-023-02105-4] [Citation(s) in RCA: 2] [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: 02/15/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE ACTH-secreting pheochromocytoma is a rare cause of ectopic Cushing's syndrome, posing a clinical challenge for the severity of its clinical presentation, the difficulty in the prevention and the management of surgical complications. Sparse data are currently available about the optimal preoperative management of the severe symptoms due to both hypercortisolism and catecholamine excess, especially regarding the role and timing of medical therapies. METHODS We present a series of three patients with ACTH-secreting pheochromocytoma. A brief review of the available literature evidence on the preoperative management of this rare clinical condition is also conducted. DISCUSSION Patients with ACTH-secreting pheochromocytoma show peculiarities as compared to other forms of ACTH-dependent Cushing's syndrome, in terms of clinical presentation, preoperative management, and peri- and post-surgical short-term outcome. Pheochromocytoma should be ruled out in patient with ectopic CS of unknown origin because of the high anesthesiologic risk of proceeding to surgery with an undiagnosed pheochromocytoma. Proper preoperative recognition of complications of both hypercortisolism and catecholamines excess is the key to prevent the morbidity and mortality of an ACTH-producing pheochromocytoma. In these patients the absolute priority is to control excessive cortisol secretion since the rapid correction of the hypercortisolism is the most effective treatment of all the related comorbidities and it is mandatory to prevent severe complications during surgery, opting if necessary for a "block-and-replace" regimen. CONCLUSION Our additional cases and this literature review could provide a better understanding of the complications to be evaluated at diagnosis and some suggestions on their management during the preoperative period.
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Affiliation(s)
- M F Birtolo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy
| | - E M Grossrubatscher
- Endocrine Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - S Antonini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy
| | - P Loli
- Endocrinology, Clinica San Carlo, Via Ospedale 21, 20037 Paderno Dugnano, Milan, Italy
| | - G Mazziotti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy
| | - A G Lania
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy.
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56 Rozzano, 20089, Milan, Italy.
| | - I Chiodini
- Endocrine Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20122, Milan, Italy
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Mishra AK, Gupta P, Yadav R, Parajuli N. Adrenal adenoma associated with raised metanephrine level: A case report. Int J Surg Case Rep 2023; 109:108498. [PMID: 37453323 PMCID: PMC10366464 DOI: 10.1016/j.ijscr.2023.108498] [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: 06/03/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Adrenal adenomas are benign neoplasms of the adrenal cortex which can be functional or non-functional. The functional tumors manifest as Cushing syndrome. Rarely, they are associated with high levels of metanephrine due to pheochromocytoma. Here, we report an extremely rare case of adrenal adenoma associated with raised metanephrine, but no histopathological evidence of medullary changes. CASE PRESENTATION A 30-year female with diabetes, hypothyroidism, and hypertension was admitted for resistant hypertension, severe refractory hypokalemia, decreased sleep, fearfulness, anxiety, and palpitation. Facial puffiness, ecchymoses on upper and lower limbs, and bilateral pedal edema were present. Laboratory investigation revealed raised 24-hour-urine cortisol (52.5 μmol/dL) and metanephrine (56.00 μmol/24 h), very low ACTH (<5.0 pg/mL), and negative dexamethasone suppression test. MRI brain findings were normal. CT scan of the abdomen revealed a well-defined soft tissue lesion in the right adrenal gland and diffuse osteopenia vertebrae. Hence, diagnosis of Cushing Syndrome secondary to adrenal adenoma, and pheochromocytoma was made, and laparoscopic adrenalectomy was done under pheochromocytoma protocol. The patient improved dramatically, thereafter. Histopathological findings showed adrenocortical adenoma only; no evidence of pheochromocytoma was found. CLINICAL DISCUSSION We came across many articles reporting adrenal adenoma associated with high levels of metanephrine due to co-existing pheochromocytomas either in the ipsilateral or contralateral adrenal gland. But, in our case, the adrenal adenoma was associated with high metanephrine levels with no histopathologic features of pheochromocytoma. CONCLUSION Cushing syndrome due to Cortisol secreting Adrenal adenoma can be associated with biochemical and clinical features suggestive of Pheochromocytoma which could resolve after adrenalectomy.
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Affiliation(s)
- Amit Kumar Mishra
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | - Prahlad Gupta
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Radheshyam Yadav
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Naresh Parajuli
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Eid M, Foukal J, Sochorová D, Tuček Š, Starý K, Kala Z, Mayer J, Němeček R, Trna J, Kunovský L. Management of pheochromocytomas and paragangliomas: Review of current diagnosis and treatment options. Cancer Med 2023. [PMID: 37145019 DOI: 10.1002/cam4.6010] [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: 12/18/2022] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023] Open
Abstract
Pheochromocytomas (PCCs) are rare neuroendocrine tumors derived from the chromaffin cells of the adrenal medulla. When these tumors have an extra-adrenal location, they are called paragangliomas (PGLs) and arise from sympathetic and parasympathetic ganglia, particularly of the para-aortic location. Up to 25% of PCCs/PGLs are associated with inherited genetic disorders. The majority of PCCs/PGLs exhibit indolent behavior. However, according to their affiliation to molecular clusters based on underlying genetic aberrations, their tumorigenesis, location, clinical symptomatology, and potential to metastasize are heterogenous. Thus, PCCs/PGLs are often associated with diagnostic difficulties. In recent years, extensive research revealed a broad genetic background and multiple signaling pathways leading to tumor development. Along with this, the diagnostic and therapeutic options were also expanded. In this review, we focus on the current knowledge and recent advancements in the diagnosis and treatment of PCCs/PGLs with respect to the underlying gene alterations while also discussing future perspectives in this field.
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Affiliation(s)
- Michal Eid
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jakub Foukal
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Dana Sochorová
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Štěpán Tuček
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Karel Starý
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Mayer
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Radim Němeček
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Trna
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Lumír Kunovský
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- 2nd Department of Internal Medicine - Gastroenterology and Geriatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
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11
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Guia Lopes ML, Bello C, Carvalho L, Limbert C, Sequeira Duarte J. A Rare Cause of Cushing's Syndrome: an Adrenocorticotropic Hormone (ACTH)-Secreting Pheochromocytoma. Cureus 2023; 15:e37883. [PMID: 37223141 PMCID: PMC10202664 DOI: 10.7759/cureus.37883] [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] [Accepted: 04/20/2023] [Indexed: 05/25/2023] Open
Abstract
Cushing's syndrome (CS) is a rare clinical entity that results from prolonged exposure to supraphysiological levels of glucocorticoids. It may result from adrenocorticotropic hormone (ACTH)-dependent or nondependent stimuli. In very rare cases, ACTH production does not derive from the pituitary gland but is of an ectopic origin. We present a case of a 51-year-old woman with cushingoid physical features, who was admitted to the emergency department with a hypertensive crisis, hyperglycemic state, and severe hypokalemia. During the diagnostic workup, the unequivocal confirmation of hypercortisolism status and ACTH elevation led to the suspicion of Cushing's disease. However, additional testing with a corticotropin-releasing hormone test and inferior petrosal sinus sampling suggested against this etiology. Surprisingly, a body computerized tomography scan incidentally revealed the presence of a left adrenal mass with a high uptake in a 68Ga-DOTANOC positron emission tomography scan. The further investigation documented elevated urinary metanephrines and normetanephrines. The patient was referred for surgical resection of the adrenal gland, and the anatomopathological report revealed the diagnosis of ACTH-secreting pheochromocytoma without local invasion or malignant features. Diabetes mellitus, hypertension, hypokalemia, and cushingoid stigmata were remitted soon after surgery. ACTH-secreting pheochromocytomas are extremely rare causes of CS. This diagnosis demands a high level of clinical suspicion and should be equated in the presence of severe metabolic changes overlapping CS's physical features. The total reversal of metabolic and clinical symptoms after surgical resection highlights the need to remember this etiology when performing a CS workup.
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Affiliation(s)
| | - Carlos Bello
- Endocrinology Department, Hospital da Luz Lisboa, Lisbon, PRT
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12
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Wydra A, Cylke-Falkowska K, Czajka-Oraniec I, Kolasińska-Ćwikła A, Ćwikła J, Zgliczyński W, Stelmachowska-Banaś M. Severe ectopic Cushing syndrome in a transgender man with a metastatic gastrinoma and an adrenal tumor-A case report and review of the literature. Front Endocrinol (Lausanne) 2023; 14:1135016. [PMID: 37008936 PMCID: PMC10061007 DOI: 10.3389/fendo.2023.1135016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
A 38-year-old transgender man with advanced metastatic functional pancreatic neuroendocrine neoplasm (PanNEN) gastrinoma was admitted to the Department of Endocrinology due to severe ACTH-dependent hypercortisolemia. An ectopic production of ACTH by PanNEN was suspected. The patient qualified for bilateral adrenalectomy after preoperative treatment with metyrapone. Finally, the patient underwent resection of the left adrenal gland with the tumor only, which surprisingly resulted in a significant decrease in ACTH and cortisol levels, leading to clinical improvement. Pathology report revealed an adenoma of the adrenal cortex with positive ACTH staining. The result of the simultaneous liver lesion biopsy confirmed a metastatic NEN G2 with positive ACTH immunostaining as well. We looked for a correlation between gender-affirming hormone treatment and the onset of the disease and its rapid progression. This may be the first case describing the coexistence of gastrinoma and ectopic Cushing disease in a transsexual patient.
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Affiliation(s)
- Arnika Wydra
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | | | - Agnieszka Kolasińska-Ćwikła
- Department of Oncology and Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center, Warsaw, Poland
- Department of Radiology, Maria Skłodowska-Curie Memorial Cancer Center, Warsaw, Poland
| | - Jarosław Ćwikła
- Department of Cardiology and Internal Medicine, Medical School University of Warmia and Mazury, Olsztyn, Poland
- Diagnostic and Therapy Center – Gammed, Warsaw, Poland
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
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13
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Saishouji F, Maeda S, Hamada H, Kimura N, Tamanoi A, Nishida S, Sakaguchi M, Igata M, Yokoo K, Kawakami F, Araki E, Kondo T. Ectopic ACTH-producing neuroendocrine tumor occurring with large recurrent metastatic pheochromocytoma: a case report. BMC Endocr Disord 2022; 22:184. [PMID: 35854271 PMCID: PMC9297627 DOI: 10.1186/s12902-022-01090-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Ectopic ACTH-dependent Cushing syndrome is rarely caused by pheochromocytoma (PCC). Glucocorticoid-regulated positive feedback loops in ACTH and catecholamines were proposed in some similar cases. CASE PRESENTATION We present here an 80-year-old man who had previously undergone surgery for a left adrenal PCC and newly developed severe hypertension, hypokalemia, and typical Cushingoid manifestations. Investigations revealed hyperglycemia, hypokalemia, and extremely high catecholamines and their metabolites, ACTH and cortisol. Imaging modalities showed a recurrent large left adrenal mass positively visualized with 123I-metaiodobenzylguanidine as well as somatostatin receptor scintigraphy. Surgical interventions were not indicated; thus, metyrapone, phentolamine, and doxazocin were initiated, which successfully controlled his symptoms and biochemical conditions. With the evidence that metyrapone administration decreased ACTH and catecholamine levels, the existence of positive feedback loops was speculated. During the terminal stages of the disease, additional metyrosine treatment successfully stabilized his physiological and biochemical conditions. Upon the patient's death, pathological autopsy was performed. Immunohistochemical analysis indicated that the tumor appeared to be co-positive with tyrosine hydroxylase (TH) as well as ACTH in most tumor cells in both PCC and liver metastasis. Most cells were clearly positive for somatostatin receptor 2 staining in the membrane compartment. The dense immunostaining of ACTH, TH, dopamine-β-hydroxylase and the large tumor size with positive feedback loops may be correlated with high levels of ACTH and catecholamines in the circulation. CONCLUSIONS We experienced a case of severe ectopic ACTH producing the largest reported recurrent malignant left PCC with liver metastases that presented positive feedback loops in the ACTH/cortisol and catecholamine/cortisol axes. Clinicians should be aware of the paradoxical response of ACTH on metyrapone treatment and possible steroid-induced catecholamine crisis.
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Affiliation(s)
- Fumi Saishouji
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Sarie Maeda
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Hideaki Hamada
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Noriko Kimura
- Department of Diagnostic Pathology, Department of Clinical Research, National Hospital Organization, Hakodate Hospital, 16-18 Kawahara, Hakodate, Hokkaido, 041-8512, Japan
| | - Ai Tamanoi
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Saiko Nishida
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Masaji Sakaguchi
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Motoyuki Igata
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Kiho Yokoo
- Department of Diagnostic Pathology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Fumi Kawakami
- Department of Diagnostic Pathology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan
| | - Tatsuya Kondo
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ward, Kumamoto, 860-8556, Japan.
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14
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Gezer E, Cantürk Z, Çetinarslan B, Selek A, Sözen M, Vural Ç, Cantürk N, Okay I. CUSHING'S SYNDROME DUE TO PRIMARY BILATERAL MACRONODULAR ADRENAL HYPERPLASIA AND METACHRONOUS PHEOCHROMOCYTOMA. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2022; 18:361-367. [PMID: 36699163 PMCID: PMC9867822 DOI: 10.4183/aeb.2022.361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Introduction Primary bilateral macronodular adrenal hyperplasia (PBMAH) is one of the uncommon causes of endogenous Cushing's syndrome (CS).Pheochromocytoma (PCC) is another adrenal tumor which is derived from neural crest arising in the adrenal medulla. Here we are reporting a case with recurrent overt CS due to PBMAH, 2 years after unilateral adrenalectomy, concomitant with recently developed PCC. Case Presentation A 43-year-old woman was admitted to our clinic with a 30 kg weight gain, proximal muscle weakness, menstrual irregularity, easy bruising and excessive hair growth on face and body.The lab results were compatible with a diagnosis of solely ACTH-independent CS. Screening showed bilateral macronodular lesions and she underwent right adrenalectomy. Postoperatively, she had lost weight and her well-being had improved; 2 years later, she developed CS and paroxysmal hypertension. The left adrenal gland was laparoscopically removed. Histopatologically, the lesion was reported as a typical PCC and macronodular-micronodular hyperplasia of the adrenal tissue surrounding that lesion. Conclusions Pheochromocytoma with synchronous ACTH-independent CS originating from the same adrenal gland is very rare. To the best of our knowledge,our case is the first one describing the coexistence of overt ACTH-independent CS due to PBMAH and metachronous PCC.The importance of detailed re-evaluation of patients with recurrent ACTH-independent CS is highlighted here.
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Affiliation(s)
- E. Gezer
- Endocrinology and Metabolism, Kocaeli University, Kocaeli, Turkey
| | - Z. Cantürk
- Endocrinology and Metabolism, Kocaeli University, Kocaeli, Turkey
| | - B. Çetinarslan
- Endocrinology and Metabolism, Kocaeli University, Kocaeli, Turkey
| | - A. Selek
- Endocrinology and Metabolism, Kocaeli University, Kocaeli, Turkey
| | - M. Sözen
- Endocrinology and Metabolism, Kocaeli University, Kocaeli, Turkey
| | - Ç. Vural
- Pathology, Kocaeli University, Kocaeli, Turkey
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15
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Kishlyansky D, Kline G, Mahajan A, Koro K, Pasieka JL, Champagne P. Ectopic Cushing's syndrome from an ACTH-producing pheochromocytoma with a non-functioning pituitary adenoma. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0189. [PMID: 35319487 PMCID: PMC9002181 DOI: 10.1530/edm-21-0189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/17/2022] [Indexed: 12/21/2022] Open
Abstract
Summary An adrenocorticotropic hormone (ACTH)-producing pheochromocytoma (PCC)/paraganglioma is the cause of ectopic Cushing's syndrome (CS) in 5.2% of cases reported in the literature. We present a previously healthy 43-year-old woman admitted to our hospital with cushingoid features and hypertensive urgency (blood pressure = 200/120 mmHg). Her 24-h urinary free cortisol was >4270 nmol/day (reference range (RR) = 100-380 nmol/day) with a plasma ACTH of 91.5 pmol/L (RR: 2.0-11.5 pmol/L). Twenty-four-hour urinary metanephrines were increased by 30-fold. Whole-body CT demonstrated a 3.7-cm left adrenal mass with a normal-appearing right adrenal gland. Sellar MRI showed a 5-mm sellar lesion. MIBG scan revealed intense uptake only in the left adrenal mass. She was managed pre-operatively with ketoconazole and phenoxybenzamine and underwent an uneventful left laparoscopic adrenalectomy, which resulted in biochemical resolution of her hypercortisolemia and catecholamine excess. Histology demonstrated a PCC (Grading System for Adrenal Pheochromocytoma and Paraganglioma score 5) with positive ACTH staining by immunohistochemistry. A PCC gene panel showed no mutations and there has been no evidence of recurrence at 24 months. This case highlights the difficult nature of localizing the source of CS in the setting of a co-existing PCC and sellar mass. Learning points An adrenocorticotropic hormone (ACTH)-producing pheochromocytoma (PCC) is an important item to be considered in all patients presenting with ectopic Cushing's syndrome (CS). In exceptionally rare cases, patients with ectopic CS may present with multiple lesions, and a systematic approach considering all potential sources is crucial to avoid misdiagnosis. CS with a large adrenal mass but lacking contralateral adrenal atrophy should raise suspicion of an ACTH-dependent process. In patients with clinical suspicion of PCC, clinicians should be mindful of the use of steroids and beta-blockers without appropriate alpha blockade as they may precipitate an adrenergic crisis.
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Affiliation(s)
- David Kishlyansky
- Division of Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Kline
- Divison of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amita Mahajan
- Divison of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Konstantin Koro
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Divison of Endocrine surgery, Surgical Oncology and Endocrinology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Champagne
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
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16
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Kimura N, Motoyama T, Saito J, Nishikawa T. Mixed corticomedullary tumor of the adrenal gland. Front Endocrinol (Lausanne) 2022; 13:1026918. [PMID: 36187098 PMCID: PMC9524188 DOI: 10.3389/fendo.2022.1026918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/30/2022] [Indexed: 11/21/2022] Open
Abstract
Mixed corticomedullary tumor (MCMT) of the adrenal gland is an extremely rare tumor characterized by an admixture of steroidogenic cells and chromaffin cells in a single tumor mass simultaneously producing adrenocortical hormones and catecholamines; it is associated with ectopic adrenocorticotropic hormone (ACTH) in some cases. We reviewed and summarized clinicopathological data of 28 MCMTs, including four metastatic tumors in 26 previous reports. These reports included 21 females and 7 males, and the average tumor sizes were 4.8 ± 2.5 cm and 12.6 ± 6.4 cm in the non-metastatic and metastatic groups, respectively (P<0.001). The clinical manifestations and laboratory data were as follows: Cushing or subclinical Cushing syndrome, 58% (14/24); hypertension, 71% (17/24); elevated adrenocortical hormones, 75% (18/24); elevated catecholamines, 75% (18/24); and ectopic ACTH, 71% (10/14). All four patients with metastatic MCMTs had poor prognoses and elevated adrenocortical hormone levels; however, only two patients had elevated catecholamine levels. Immunohistochemistry was essential for the pathologic diagnosis of MCMTs. In this study, using an improved technique, we detected ectopic ACTH-producing cells in the same paraffin-embedded sections reported to be negative in our previous reports. As MCMT is composed of cells with embryologically different origins, its pathogenesis has been explained by various hypotheses. We compared MCMT to the adrenal gland of birds and the early stage of human fetuses, in which nests of chromaffin cells and steroidogenic cells admix without the formation of cortex and medulla. MCMT is characterized by the immaturity of organogenesis and might be classified as an adrenal embryonal tumor.
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Affiliation(s)
- Noriko Kimura
- Department of Clinical Research, National Hospital Organization Hakodate Hospital, Hakodate, Japan
- Department of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
- *Correspondence: Noriko Kimura,
| | - Teiich Motoyama
- Department of Pathology, Yamagata University School of Medicine, Yamagata, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
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17
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Miura K, Sunahara H, Sakai Y, Isshiki S, Hasegawa M, Oda M. Effective treatment with mitotane for a canine case of presumed ectopic Cushing's syndrome-related pheochromocytoma. Open Vet J 2022; 12:762-767. [PMID: 36589399 PMCID: PMC9789766 DOI: 10.5455/ovj.2022.v12.i5.22] [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: 06/08/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background In humans, ectopic Cushing's syndrome (ECS) is characterized by hypercortisolemia, which is caused by small lung carcinoma, bronchial carcinoids, and pheochromocytoma. In dogs, only a few cases of ECS associated with pheochromocytoma have been reported to date. Case Description Herein, we describe a canine case of malignant pheochromocytoma that is presumed to be the cause of ECS. An 11-year-old, castrated, male Toy Poodle with hypercortisolemia was diagnosed with an adrenal tumor (AT) and treated with mitotane. Although repeated adrenocorticotropic hormone stimulation tests revealed improvement in the dog's condition by mitotane treatment, its condition started declining 197 days post-diagnosis, and he died on day 280. The necropsy revealed the AT was a pheochromocytoma, not an adrenocortical tumor. However, because of no pathological change in the pituitary gland and the other adrenal gland, pheochromocytoma was presumed to be the cause of ECS. Conclusion This is the first report that describes the effectiveness of mitotane against presumed ECS-related pheochromocytoma.
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Affiliation(s)
- Konatsu Miura
- Oda Animal Hospital, Hiroshima, Japan,Corresponding Author: Konatsu Miura. Oda Animal Hospital, Hiroshima, Japan.
| | - Hiroshi Sunahara
- Laboratory of Surgery, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Yusuke Sakai
- Laboratory of Veterinary Pathology, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Saneyuki Isshiki
- Laboratory of Veterinary Pathology, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Moe Hasegawa
- Laboratory of Veterinary Pathology, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi, Japan
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18
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Yoshida S, Babaya N, Ito H, Hiromine Y, Taketomo Y, Niwano F, Imamura S, Yamazaki Y, Sasano H, Kawabata Y, Noso S, Ikegami H. Mixed Corticomedullary Tumor Accompanied by Unilateral Aldosterone-Producing Adrenocortical Micronodules: a Case Report. J Endocr Soc 2021; 5:bvab140. [PMID: 34514278 PMCID: PMC8415316 DOI: 10.1210/jendso/bvab140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Indexed: 12/27/2022] Open
Abstract
Mixed corticomedullary tumors (MCMTs) are rare and comprise medullary and cortical cells in a single adrenal tumor. The mechanisms underlying their development have not been fully elucidated. Here, we report a case of MCMT in a 42-year-old woman. Based on the preoperative clinical findings, the patient was diagnosed as having a pheochromocytoma with subclinical Cushing syndrome. Postoperative pathological diagnosis revealed that the tumor demonstrated morphologically distinct medullary and cortical components, which produced catecholamines and cortisol, respectively. Hybrid tumor cells producing both catecholamines and cortisol were not detected. Adrenocorticotropin (ACTH)-positive tumor cells were identified to be present in the pheochromocytoma. This ectopic production of ACTH can contribute to an autonomous cortisol production in a paracrine manner. In addition, micronodules producing aldosterone were detected in the adrenal tissue adjacent to the tumor. The simultaneous development of these 2 lesions may not be correlated with each other; however, this case confirms the importance of a detailed histopathological examination of the adrenal lesions harboring complicated hormonal abnormalities by providing pivotal and indispensable information on their pathogenesis and the possible interaction of the hormones produced in the adrenal gland.
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Affiliation(s)
- Sawa Yoshida
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Naru Babaya
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Hiroyuki Ito
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Yoshihisa Hiromine
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Yasunori Taketomo
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Fumimaru Niwano
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Shuzo Imamura
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi 980-8575, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi 980-8575, Japan
| | - Yumiko Kawabata
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
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19
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Leader N, Ushinsky A, Malone CD. Adrenal vein sampling for ACTH-producing pheochromocytomas. Radiol Case Rep 2021; 16:2672-2675. [PMID: 34345329 PMCID: PMC8319476 DOI: 10.1016/j.radcr.2021.06.055] [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: 06/14/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/04/2022] Open
Abstract
Adrenocorticotropic hormone (ACTH)-producing pheochromocytoma can cause a variety of clinical manifestations of excess catecholamine and corticosteroid. Anatomic localization of this source of ectopic ACTH is critical to facilitate unilateral adrenalectomy and prevent adrenal insufficiency due to bilateral adrenalectomy. Although nuclear scintigraphy remains the diagnostic gold standard, recent radiotracer supply shortages have necessitated alternative diagnostic paradigms to localize adrenal pheochromocytomas. We present a case where adrenal vein sampling (AVS) was utilized to lateralize an adrenal pheochromocytoma and discuss the approach and nuance as it differs from routine AVS for hyperaldosteronism or hypercortisolism.
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Affiliation(s)
- Nicholas Leader
- Department of Internal Medicine, Washington University School of Medicine in Saint Louis. 660 S. Euclid Ave, CB 8066, Saint Louis, MO. USA
| | - Alexander Ushinsky
- Interventional Radiology Section, Mallinckrodt Institute of Radiology at Washington University School of Medicine in Saint Louis. 510 South Kingshighway Boulevard, Saint Louis, MO, USA
| | - Christopher D Malone
- Interventional Radiology Section, Mallinckrodt Institute of Radiology at Washington University School of Medicine in Saint Louis. 510 South Kingshighway Boulevard, Saint Louis, MO, USA
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Granberg D, Juhlin CC, Falhammar H. Metastatic Pheochromocytomas and Abdominal Paragangliomas. J Clin Endocrinol Metab 2021; 106:e1937-e1952. [PMID: 33462603 PMCID: PMC8063253 DOI: 10.1210/clinem/dgaa982] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGLs) are believed to harbor malignant potential; about 10% to 15% of pheochromocytomas and up to 50% of abdominal paragangliomas will exhibit metastatic behavior. EVIDENCE ACQUISITION Extensive searches in the PubMed database with various combinations of the key words pheochromocytoma, paraganglioma, metastatic, malignant, diagnosis, pathology, genetic, and treatment were the basis for the present review. DATA SYNTHESIS To pinpoint metastatic potential in PPGLs is difficult, but nevertheless crucial for the individual patient to receive tailor-made follow-up and adjuvant treatment following primary surgery. A combination of histological workup and molecular predictive markers can possibly aid the clinicians in this aspect. Most patients with PPGLs have localized disease and may be cured by surgery. Plasma metanephrines are the main biochemical tests. Genetic testing is important, both for counseling and prognostic estimation. Apart from computed tomography and magnetic resonance imaging, molecular imaging using 68Ga-DOTATOC/DOTATATE should be performed. 123I-MIBG scintigraphy may be performed to determine whether 131I-MIBG therapy is a possible option. As first-line treatment in patients with metastatic disease, 177Lu-DOTATATE or 131I-MIBG is recommended, depending on which shows best expression. In patients with very low proliferative activity, watch-and-wait or primary treatment with long-acting somatostatin analogues may be considered. As second-line treatment, or first-line in patients with high proliferative rate, chemotherapy with temozolomide or cyclophosphamide + vincristine + dacarbazine is the therapy of choice. Other therapies, including sunitinib, cabozantinib, everolimus, and PD-1/PDL-1 inhibitors, have shown modest effect. CONCLUSIONS Metastatic PPGLs need individualized management and should always be discussed in specialized and interdisciplinary tumor boards. Further studies and newer treatment modalities are urgently needed.
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Affiliation(s)
- Dan Granberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Carl Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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Elliott PF, Berhane T, Ragnarsson O, Falhammar H. Ectopic ACTH- and/or CRH-Producing Pheochromocytomas. J Clin Endocrinol Metab 2021; 106:598-608. [PMID: 32710791 DOI: 10.1210/clinem/dgaa488] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT The characteristics of catecholamine-secreting pheochromocytomas have been well studied. However, less is known about the characteristics, management and outcome in patients with ectopic adrenocorticotropic hormone (ACTH) and/or corticotrophin-releasing hormone (CRH)-secreting pheochromocytomas. OBJECTIVE To review the characteristics and outcomes of ACTH- and/or CRH-secreting pheochromocytomas. DATA SOURCE A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 February 2020. STUDY SELECTION Original articles, including case reports and case series, reporting individual patient data from patients with ACTH- and/or CRH-secreting pheochromocytomas. DATA EXTRACTION Information on sex, age, symptoms at presentation, comorbidities, biochemistry, imaging, histopathology, and outcomes was extracted. DATA SYNTHESIS We identified 91 articles reporting on 99 cases of ACTH- and/or CRH-secreting pheochromocytomas (CRH-secreting n = 4). Median age at diagnosis was 49 years (interquartile range 38-59.5) with a 2:1 female to male ratio. Most patients presented with clinical Cushing syndrome (n = 79; 81%), hypertension (n = 87; 93%), and/or diabetes (n = 50; 54%). Blood pressure, glucose control, and biochemical parameters improved in the vast majority of patients postoperatively. Infections were the most common complication. Most cases (n = 70, 88%) with reported long-term outcome survived to publication (median follow-up 6 months). CONCLUSION Ectopic ACTH- and/or CRH-secreting pheochromocytoma should be considered in patients presenting with ACTH-dependent Cushing syndrome and adrenal mass. Despite the challenge in diagnosis, patient outcomes appear favorable.
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Affiliation(s)
| | - Thomas Berhane
- Department of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, Australia
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Rahmani F, Tohidi M, Dehghani M, Broumand B, Hadaegh F. Recurrence of a neuroendocrine tumor of adrenal origin: a case report with more than a decade follow-up. BMC Endocr Disord 2021; 21:9. [PMID: 33413271 PMCID: PMC7791754 DOI: 10.1186/s12902-020-00673-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neuroendocrine tumor (NET) with adrenocorticotropic hormone (ACTH) secretion are very rare. To our knowledge, no follow-up study is published for ACTH-secreting NET, regardless of the primary site, to show second occurrence of tumor after a long follow-up, following resection of primary tumor. CASE PRESENTATION Here, we describe a 49-year-old-man with cushingoid feature, drowsiness and quadriparesis came to emergency department at December 2005. Laboratory tests revealed hyperglycemia, metabolic alkalosis, severe hypokalemia, and chemical evidence of an ACTH-dependent hypercortisolism as morning serum cortisol of 57 μg /dL without suppression after 8 mg dexamethasone suppression test, serum ACTH level of 256 pg/mL, and urine free cortisol of > 1000 μg /24 h. Imaging showed only bilateral adrenal hyperplasia, without evidence of pituitary adenoma or ectopic ACTH producing tumors. Importantly, other diagnostic tests for differentiating Cushing disease (CD) from ectopic ACTH producing tumor, such as inferior petrosal sinus sampling (IPSS), corticotropin releasing hormone (CRH) stimulation test, octreotide scan or fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan were not available in our country at that time. Therefore, bilateral adrenalectomy was performed that led to clinical and biochemical remission of hypercortisolism and decreased ACTH level to < 50 pg/mL, findings suggestive of a primary focus of NET in adrenal glands. After 11 years uncomplicated follow up, the ACTH level elevated up to 341 pg/mL and re-evaluation showed a 2 cm nodule in the middle lobe of the right lung. Surgical excision of the pulmonary nodule yielded a carcinoid tumor with positive immunostaining for ACTH; leading to decrease in serum ACTH level to 98 pg/mL. Subsequently after 7 months, serum ACHT levels rose again. More investigation showed multiple lung nodules with metastatic bone lesions accompanied by high serum chromogranin level (2062 ng/mL), and the patient managed as a metastatic NET, with bisphosphonate and somatostatin receptor analogues. CONCLUSION This case of surgically-treated NET showing a secondary focus of carcinoid tumor after one decade of disease-free follow-up emphasizes on the importance of long-term follow-up of ACTH-secreting adrenal NET.
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Affiliation(s)
- Fatemeh Rahmani
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran
| | - Maryam Tohidi
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran
| | - Maryam Dehghani
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran
| | - Behrooz Broumand
- Emeritus Professor of Medicine, Iran University of Medical Sciences, Pars Advanced and Minimally Invasive Manners Research Center, Pars General Hospital, Keshavarz Blvd, Tehran, Iran
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Yamen Street, Velenjak, Tehran, Iran.
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23
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From ACTH-Dependent to ACTH-Independent Cushing's Syndrome from a Malignant Mixed Corticomedullary Adrenal Tumor: Potential Role of Embryonic Stem Cells. Case Rep Endocrinol 2020; 2020:4768281. [PMID: 32426170 PMCID: PMC7218959 DOI: 10.1155/2020/4768281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/21/2020] [Accepted: 02/22/2020] [Indexed: 12/28/2022] Open
Abstract
Objective To report the immunohistochemical and molecular evaluation of a patient with ectopic ACTH syndrome (EAS) from a MCAT which has single cells with features of both 96 medullary and cortical differentiation. Case Description and Methods. A 16-year-old woman presented with severe EAS and a large right MCAT composed of ACTH-secreting cells resembling pheochromocytoma and another lineage similar to adrenal carcinoma. Immunohistochemistry (IHC) showed positivity for medullary (ACTH, chromogranin A, synaptophysin, and PS-100) and epithelial components (inhibin, melan-A, and calretinin). Embryonic stem cell markers were evaluated using RT/PCR and immunofluorescence. After initial surgery, the tumor recurred shifting to rapidly progressive ACTH-independent liver metastasis. Results Histopathology and IHC revealed two distinct and intermingled cellular patterns, while some cells immunostained for both medullary and cortical markers. Demonstration of all stem cell biomarkers by RT/PCR and immunofluorescence was predominantly localized to the nucleus, whereas SOX2 immunoreactivity was evident in the cytoplasm as well. Conclusion The expression of cancer stem cell biomarkers points towards the involvement of primitive embryonic cells as the origin of this neoplasm and maybe to the clinically aggressive and biochemically changing behavior.
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Zaman S, Patel B, Glynne P, Vanderpump M, Alsafi A, Khan S, Flora R, Palazzo F, Wernig F. A rare cause of severe Cushing's syndrome. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200011. [PMID: 32168466 PMCID: PMC7077516 DOI: 10.1530/edm-20-0011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/26/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Ectopic adrenocorticotropic hormone (ACTH) production is an uncommon cause of Cushing's syndrome and, rarely, the source can be a phaeochromocytoma. A 55-year-old man presented following an episode of presumed gastroenteritis with vomiting and general malaise. Further episodes of diarrhoea, joint pains and palpitations followed. On examination, he was hypertensive with no clinical features to suggest hypercortisolaemia. He was subsequently found to have raised plasma normetanephrines of 3.98 nmol/L (NR <0.71) and metanephrines of 0.69 nmol/L (NR <0.36). An adrenal CT showed a 3.8 cm right adrenal nodule, which was not MIBG-avid but was clinically and biochemically consistent with a phaeochromocytoma. He was started on alpha blockade and referred for right adrenalectomy. Four weeks later, on the day of admission for adrenalectomy, profound hypokalaemia was noted (serum potassium 2.0 mmol/L) with non-specific ST-segment ECG changes. He was also diagnosed with new-onset diabetes mellitus (capillary blood glucose of 28 mmol/L). He reported to have gained weight and his skin had become darker over the course of the last 4 weeks. Given these findings, he underwent overnight dexamethasone suppression testing, which showed a non-suppressed serum cortisol of 1099 nmol/L. Baseline serum ACTH was 273 ng/L. A preliminary diagnosis of ectopic ACTH secretion from the known right-sided phaeochromocytoma was made and he was started on metyrapone and insulin. Surgery was postponed for 4 weeks. Following uncomplicated laparoscopic adrenalectomy, the patient recovered with full resolution of symptoms. LEARNING POINTS Phaeochromocytomas are a rare source of ectopic ACTH secretion. A high clinical index of suspicion is therefore required to make the diagnosis. Ectopic ACTH secretion from a phaeochromocytoma can rapidly progress to severe Cushing's syndrome, thus complicating tumour removal. Removal of the primary tumour often leads to full recovery. The limited literature suggests that the presence of ectopic Cushing's syndrome does not appear to have any long-term prognostic implications.
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Affiliation(s)
- Shamaila Zaman
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Bijal Patel
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Ali Alsafi
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sairah Khan
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Rashpal Flora
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Fausto Palazzo
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Florian Wernig
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Y-Hassan S, Falhammar H. Clinical features, complications, and outcomes of exogenous and endogenous catecholamine-triggered Takotsubo syndrome: A systematic review and meta-analysis of 156 published cases. Clin Cardiol 2020; 43:459-467. [PMID: 32125009 PMCID: PMC7244299 DOI: 10.1002/clc.23352] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 02/19/2020] [Indexed: 12/25/2022] Open
Abstract
Innumerable physical stress factors including externally administered catecholamines, and pheochromocytomas and paragangliomas (PPGLs) have been reported to trigger Takotsubo syndrome (TS). A systematic search of PubMed/MEDLINE identified 156 patients with catecholamine‐induced TS up to December 2017. Data were compared within the catecholamine‐induced TS cohort, but some comparisons were also done to a previously published large all‐TS cohort (n = 1750). The mean age was 46.4 ± 16.4 years (72.3% women). The clinical presentation was dramatic with high complication rates in (68.2%, n = 103; multiple complications 34.6%, n = 54). The most common TS ballooning pattern was apical or mid‐apical (45.2%, n = 69), followed by basal pattern (28.8%, n = 45), global pattern (16.0%, n = 25), mid‐ventricular (8.3%, n = 13), focal (0.6%, n = 1), and unidentified pattern (1.9%, n = 3). There was an increase in the prevalence of apical sparing ballooning pattern compared to all‐TS population (37.7% vs 18.3%, P < .00001). Higher complication rates were observed in TS with global ballooning pattern compared to apical ballooning pattern (23/25, 92% vs 38/65, 58.5%; P = .0022). Higher complication rates were observed in patients with age < 50 years than patients >50 years (73/92, 79.3% vs 29/56, 51.8%, P = 0.0009). Recurrence occurred exclusively in patients with PPGL‐induced TS (18/107 patients, 16.8%). PPGL‐induced TS was characterized by more global ballooning's pattern (22/104, 21.2% vs 3/49, 6.1%, P = 0.02), and lower left ventricular ejection fraction (25.54 ± 11.3 vs 31.82 ± 9.93, P = 0.0072) compared to exogenous catecholamine‐induced TS. In conclusion, catecholamine‐induced TS was characterized by a dramatic clinical presentation with extensive left ventricular dysfunction, and high complication rate.
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Affiliation(s)
- Shams Y-Hassan
- Coronary Artery Disease Area, Heart and Vascular Theme, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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26
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Adrenal Adenoma Anarchy: A Case of an ACTH-Secreting Pheochromocytoma. Case Rep Endocrinol 2020; 2020:4869467. [PMID: 32181024 PMCID: PMC7063192 DOI: 10.1155/2020/4869467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/06/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction. Pheochromocytomas are rare neuroendocrine tumors that arise from sympathetic adrenomedullary chromaffin tissue. Depending on the amount of catecholamines they secrete, they have variable presentations. There have been reported cases of adrenocorticotrophic (ACTH) secreting pheochromocytomas that present with severe Cushing syndrome. Here, we present a pheochromocytoma with adrenocorticotrophic hormone (ACTH) cosecretion, which due to its rarity and variable presentation, may be a diagnostic challenge. Presentation. A 64-year-old woman with history of colon cancer presented with new-onset diabetes, worsening hot flashes, and hypertension. On CT imaging she had an enlarging right adrenal nodule (1.7 cm) with 60 Hounsfield units of attenuation and no PET avidity. Biochemical evaluation showed elevated urinary and plasma metanephrines, elevated plasma cortisol levels despite dexamethasone suppression, elevated late-night salivary cortisol, and high-normal adrenocorticotrophic hormone. The patient underwent laproscopic right adrenalectomy, and pathology confirmed pheochromocytoma. Her lab abnormalities and symptoms of hot flashes and hypertension improved postoperatively. Conclusion. This case demonstrates an unusual ACTH-secreting pheochromocytoma with subtle presentation and highlights the importance of obtaining a complete biochemical evaluation of incidental adrenal adenomas.
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Lee S, Lee A, Chai SH, Lee S, Kweon OK, Kim WH. Ectopic Cushing's syndrome associated with a pheochromocytoma in a dog: a case report. BMC Vet Res 2020; 16:35. [PMID: 32014021 PMCID: PMC6998063 DOI: 10.1186/s12917-020-2244-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/16/2020] [Indexed: 11/26/2022] Open
Abstract
Background Ectopic Cushing’s syndrome (ECS) associated with malignant tumors, such as small cell lung carcinoma, bronchial carcinoids, and pheochromocytoma, has been reported in human medicine. However, ECS related to pheochromocytoma has not been reported in dogs. Case presentation An 11-year-old castrated, male Scottish terrier was diagnosed with a left adrenal mass. Cushing’s syndrome was suspected based on clinical signs, including pot belly, polyuria, polydipsia, bilateral alopecia, recurrent pyoderma, and calcinosis cutis. Cushing’s syndrome was diagnosed on the basis of consistent clinical signs and repeated adrenocorticotropic hormone (ACTH) stimulation tests. In addition, tests for fractionated plasma metanephrine/normetanephrine suggested a pheochromocytoma. Unilateral adrenalectomy was performed after medical management with trilostane and phenoxybenzamine. Histopathology confirmed a diagnosis of pheochromocytoma without cortical lesions. After surgery, fractionated metanephrine/normetanephrine and the findings of low-dose dexamethasone suppression and ACTH stimulation tests were within the normal ranges without any medication. There were no clinical signs or evidence of recurrence and metastasis on thoracic and abdominal X-rays and ultrasonography up to 8 months after surgery. Conclusions Pheochromocytoma should be considered a differential diagnosis for dogs with Cushing’s syndrome with an adrenal tumor. A good prognosis can be expected with prompt diagnosis and surgical intervention.
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Affiliation(s)
- Sungin Lee
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea
| | - Aeri Lee
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea
| | - Suh-Hyun Chai
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea
| | - Seulji Lee
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea
| | - Oh-Kyeong Kweon
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea
| | - Wan Hee Kim
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea.
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Kruljac I, Dabelić N, Marjan D, Blaslov K, Perić B, Mirošević G, Vagić D, Vrkljan M. Cushing's Disease in a Patient with MEN 2B Syndrome. Am J Med 2020; 133:e46-e47. [PMID: 31421068 DOI: 10.1016/j.amjmed.2019.07.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Ivan Kruljac
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sestre Milosrdnice," University of Zagreb School of Medicine, Croatia.
| | - Nina Dabelić
- Department of Oncology and Nuclear Medicine, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Domagoj Marjan
- Department of Radiology, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Kristina Blaslov
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sestre Milosrdnice," University of Zagreb School of Medicine, Croatia
| | - Božidar Perić
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sestre Milosrdnice," University of Zagreb School of Medicine, Croatia
| | - Gorana Mirošević
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sestre Milosrdnice," University of Zagreb School of Medicine, Croatia
| | - Davor Vagić
- Department of Otorinolaringology and Head and Neck Surgery, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia; University of Zagreb School of Medicine, Croatia
| | - Milan Vrkljan
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sestre Milosrdnice," University of Zagreb School of Medicine, Croatia; University of Zagreb School of Medicine, Croatia
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Rossini A, Perticone F, Frosio L, Schiavo Lena M, Lanzi R. Somatostatin analog challenge test in the pre-surgical management of ACTH-secreting pheochromocytoma. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190123. [PMID: 31765327 PMCID: PMC6893305 DOI: 10.1530/edm-19-0123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/06/2019] [Indexed: 11/24/2022] Open
Abstract
SUMMARY ACTH-secreting pheochromocytoma is a very rare cause of Cushing's syndrome, with a high morbidity and mortality risk due to both cortisol and catecholamines excess. We report the case of a 45-year-old female patient with a 3 cm, high-density, left adrenal mass, diagnosed as an ACTH-secreting pheochromocytoma. The biochemical sensitivity of the tumor to somatostatin analogues was tested by a 100 μg s.c. octreotide administration, which led to an ACTH and cortisol reduction of 50 and 25% respectively. In addition to alpha and beta blockers, preoperative approach to laparoscopic adrenalectomy included octreotide, a somatostatin analogue, together with ketoconazole, in order to achieve an adequate pre-surgical control of cortisol release. Histopathological assessment confirmed an ACTH-secreting pheochromocytoma expressing type 2 and 5 somatostatin receptors (SSTR-2 and -5). LEARNING POINTS ACTH-secreting pheochromocytomas represent a rare and severe condition, characterized by high morbidity and mortality risk. Surgical removal of the adrenal mass is the gold standard treatment, but adequate medical therapy is required preoperatively to improve the surgical outcome and to avoid major complications. Somatostatin analogs, in addition to other medications, may represent a useful therapeutic option for the presurgical management of selected patients. In this sense, the octreotide challenge test is a useful tool to predict favorable therapeutic response to the treatment.
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Affiliation(s)
- Alessandro Rossini
- Endocrinology and Diabetes Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
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30
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Abstract
Takotsubo syndrome (TS), also known as neurogenic stunned myocardium or broken heart syndrome, is a recognized acute cardiac syndrome. In about 70% of cases, the syndrome is preceded by an emotional or a physical stressor. Among the innumerable physical trigger factors that may induce TS are pheochromocytomas and paragangliomas (PPGLs). PPGL-associated cardiovascular complications as "myocarditis", "myocardial infarction", "reversible cardiomyopathies", and "transient repolarization electrocardiographic changes" have been described since more than 70 years. During the last two decades, dozens of cases of PPGL-induced TS have been reported. PPGLs display increased catecholamine levels, sometimes massively elevated, which may trigger TS, most likely through hyperactivation of sympathetic nervous system including the cardiac sympathetic nerve terminal disruption with norepinephrine seethe and spillover. PPGL-induced TS is characterized by a dramatic clinical presentation with hemodynamic compromise and high complication rates. The prevalence of global and apical sparing pattern of TS in PPGL-induced TS is significantly higher than in other TS populations. In this report, the associations of PPGL-induced cardiovascular complications are analyzed, and clinical features, complications, outcome and treatment of PPGL-induced TS are reviewed.
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Affiliation(s)
- Shams Y-Hassan
- Coronary Artery Disease Area, Heart and Vascular Theme, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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