1
|
Higgs JA, Quinn AP, Seely KD, Richards Z, Mortensen SP, Crandall CS, Brooks AE. Pathophysiological Link between Insulin Resistance and Adrenal Incidentalomas. Int J Mol Sci 2022; 23:ijms23084340. [PMID: 35457158 PMCID: PMC9032410 DOI: 10.3390/ijms23084340] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 12/22/2022] Open
Abstract
Adrenal incidentalomas are incidentally discovered adrenal masses greater than one centimeter in diameter. An association between insulin resistance and adrenal incidentalomas has been established. However, the pathophysiological link between these two conditions remains incompletely characterized. This review examines the literature on the interrelationship between insulin resistance and adrenal masses, their subtypes, and related pathophysiology. Some studies show that functional and non-functional adrenal masses elicit systemic insulin resistance, whereas others conclude the inverse. Insulin resistance, hyperinsulinemia, and the anabolic effects on adrenal gland tissue, which have insulin and insulin-like growth factor-1 receptors, offer possible pathophysiological links. Conversely, autonomous adrenal cortisol secretion generates visceral fat accumulation and insulin resistance. Further investigation into the mechanisms and timing of these two pathologies as they relate to one another is needed and could be valuable in the prevention, detection, and treatment of both conditions.
Collapse
Affiliation(s)
- Jordan A. Higgs
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT 84738, USA; (J.A.H.); (A.P.Q.); (Z.R.); (S.P.M.); (C.S.C.)
| | - Alyssa P. Quinn
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT 84738, USA; (J.A.H.); (A.P.Q.); (Z.R.); (S.P.M.); (C.S.C.)
| | - Kevin D. Seely
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT 84738, USA; (J.A.H.); (A.P.Q.); (Z.R.); (S.P.M.); (C.S.C.)
- Correspondence:
| | - Zeke Richards
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT 84738, USA; (J.A.H.); (A.P.Q.); (Z.R.); (S.P.M.); (C.S.C.)
| | - Shad P. Mortensen
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT 84738, USA; (J.A.H.); (A.P.Q.); (Z.R.); (S.P.M.); (C.S.C.)
| | - Cody S. Crandall
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT 84738, USA; (J.A.H.); (A.P.Q.); (Z.R.); (S.P.M.); (C.S.C.)
| | - Amanda E. Brooks
- Department of Research and Scholarly Activity, Rocky Vista University, Ivins, UT 84738, USA;
| |
Collapse
|
3
|
Huang WC, Chen YY, Lin YH, Chueh JS. Composite Cardiovascular Outcomes in Patients With Primary Aldosteronism Undergoing Medical Versus Surgical Treatment: A Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:644260. [PMID: 34079522 PMCID: PMC8165438 DOI: 10.3389/fendo.2021.644260] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/12/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Superior outcomes after surgical treatment over medical treatment for primary aldosteronism (PA) has been reported in small-scale clinical studies, but no solid conclusion has been drawn as results of large randomized trials are lacking. METHODS We performed a search of PubMed, MEDLINE, Embase and Cochrane Library for randomized or observational studies that investigated cardiovascular outcomes in patients with PA undergoing medical versus surgical treatment. Meta-analyses of both composite and individual outcomes were conducted. Risks of bias of the included studies were assessed with Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) checklist. Trial sequential analysis (TSA) was performed to control the risk of random errors and assess whether the results in our meta-analysis were conclusive. RESULTS A total of 12 studies, including a total of 6148 PA patients, were included in the meta-analysis. The results of meta-analyses demonstrated lower incidence of composite cardiovascular outcomes among PA patients who underwent surgical treatment over medical treatment (odds ratio (OR): 0.49). Surgical treatment also led to less incidence of persistence of hypertension (OR of non-cure hypertension: 0.31). Fewer major cardiovascular events and mortality events were observed (OR: 0.60) after surgical treatment. TSA result showed that the required information size was 2151 and the cumulative Z curve crossed the futility boundary and reached the required information size. CONCLUSION Superior performance of surgical treatment over medical treatment is confirmed with meta-analyses in terms of lower incidences of composite cardiovascular outcomes and non-cure of hypertension. Hence, adrenalectomy could now be concluded as the treatment of choice for lateralized PA.
Collapse
Affiliation(s)
- Wei-Chieh Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Ying-Ying Chen
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jeff S. Chueh
- Glickman Urological and Kidney Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, United States
- *Correspondence: Jeff S. Chueh,
| |
Collapse
|
4
|
J Orrego J, A Chorny J. Aldosterone- and cortisol-cosecreting adrenal adenoma, ovarian hyperthecosis and breast cancer. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200121. [PMID: 33434176 PMCID: PMC7576653 DOI: 10.1530/edm-20-0121] [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: 08/09/2020] [Revised: 08/09/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022] Open
Abstract
SUMMARY We describe a 56-year-old postmenopausal woman with hypertension, hypokalemia and severe alopecia who was found to have a 4.5-cm lipid-poor left adrenal mass on CT scan performed to evaluate her chronic right-sided abdominal pain. Hormonal studies revealed unequivocal evidence of primary aldosteronism and subclinical hypercortisolemia of adrenal origin. Although a laparoscopic left adrenalectomy rendered her normotensive, normokalemic and adrenal insufficient for 2.5 years, her alopecia did not improve and she later presented with facial hyperpigmentation acne, worsening hirsutism, clitoromegaly, and an estrogen receptor-positive breast cancer. Further testing demonstrated markedly elevated serum androstenedione and total and free testosterone and persistently undetectable DHEAS levels. As biochemical and radiologic studies ruled out primary adrenal malignancy and obvious ovarian neoplasms, a bilateral salpingo-oophorectomy was undertaken, which revealed bilateral ovarian hyperthecosis. This case highlights how the clinical manifestations associated with hyperaldosteronism and hypercortisolemia masqueraded the hyperandrogenic findings. It was only when her severe alopecia failed to improve after the resolution of hypercortisolism, hyperandrogenic manifestations worsened despite adrenal insufficiency and an estrogen receptor-positive breast cancer was found, did it becomes apparent that her symptoms were due to ovarian hyperthecosis. LEARNING POINTS As cortisol cosecretion appears to be highly prevalent in patients with primary aldosteronism, the term 'Connshing' syndrome has been suggested. The associated subclinical hypercortisolemia could be the driver for the increased metabolic alterations seen in patients with Conn syndrome. The identification of these dual secretors before adrenal venous sampling could alert the clinician about possible equivocal test results. The identification of these dual secretors before unilateral adrenalectomy could avoid unexpected postoperative adrenal crises. Hyperfunctioning adrenal and ovarian lesions can coexist, and the clinical manifestations associated with hypercortisolemia can masquerade the hyperandrogenic findings.
Collapse
Affiliation(s)
- John J Orrego
- Departments of Endocrinology and Metabolism, Kaiser Foundation Health Plan of Colorado, Denver, Colorado, USA
| | - Joseph A Chorny
- Pathology, Kaiser Foundation Health Plan of Colorado, Denver, Colorado, USA
| |
Collapse
|
5
|
Fallo F, Castellano I, Gomez-Sanchez CE, Rhayem Y, Pilon C, Vicennati V, Santini D, Maffeis V, Fassina A, Mulatero P, Beuschlein F, Reincke M. Histopathological and genetic characterization of aldosterone-producing adenomas with concurrent subclinical cortisol hypersecretion: a case series. Endocrine 2017; 58:503-512. [PMID: 28405879 PMCID: PMC5638684 DOI: 10.1007/s12020-017-1295-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 03/27/2017] [Indexed: 01/01/2023]
Abstract
PURPOSE Aldosterone-producing adenomas with concurrent subclinical cortisol hypersecretion are reported in an increasing number of patients. Five aldosterone-producing adenomas from patients with primary aldosteronism and subclinical hypercortisolism were examined. THE AIMS OF OUR STUDY WERE (1) to analyze pathological features and immunohistochemical expression of CYP11B1 (11β-hydroxylase) and CYP11B2 (aldosterone synthase) in these tumors; (2) to investigate somatic mutations involved in adrenal steroid hypersecretion and/or tumor growth. METHODS Archival micro-dissected paraffin-embedded slides from tumor specimens were used for histological and molecular studies. Immunohistochemistry was performed using monoclonal anti-CYP11B1 and anti-CYP11B2 antibodies. Cellular composition was determined by examining for known features of zona fasciculata and zona glomerulosa, and immunoreactivity for CYP11B1 and CYP11B2 by McCarty H-score. Spot regions for mutations in KCNJ5, ATP1A1, ATP2B3, CACNA1D, PRKACA, and CTNNB1 gene sequences were evaluated. RESULTS Four APAs showed a predominant (≥50%) zona fasciculata-like cell pattern: one tumor had CYP11B1 H-score = 150, no detectable CYP11B2 expression, and harbored a PRKACA p.Leu206Arg mutation (that we have reported previously elsewhere), one had no CYP11B1 expression, CYP11B2 H-score = 40, and no mutations; the remaining two adenomas had high CYP11B1 H-score (160 and 240, respectively) and low CYP11B2 H-score (30 and 15, respectively), with the latter harboring a CTNNB1 p.Ser45Phe activating mutation. One of five aldosterone-producing adenomas had a predominant zona glomerulosa-like pattern, CYP11B1 H-score = 15, CYP11B2 H-score = 180, and no mutations. CONCLUSIONS The majority of aldosterone-producing adenomas with concurrent subclinical cortisol hypersecretion were composed mainly of zona fasciculata-like cells, while CYP11B1 and CYP11B2 immunostaining demonstrated clear heterogeneity. In a subset of cases, different somatic mutations may be involved in hormone excess and tumor formation.
Collapse
Affiliation(s)
- Francesco Fallo
- Clinica Medica 3, Department of Medicine, University of Padova, Padova, Italy.
| | - Isabella Castellano
- Division of Pathology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Celso E Gomez-Sanchez
- Endocrine Section, G.V. (Sonny) Montgomery VA Medical Center and University of Mississipi Medical Center, Jackson, MS, USA
| | - Yara Rhayem
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Catia Pilon
- Clinica Medica 3, Department of Medicine, University of Padova, Padova, Italy
| | | | - Donatella Santini
- Pathology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Valeria Maffeis
- Cytopathology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Ambrogio Fassina
- Cytopathology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
7
|
Arlt W, Lang K, Sitch AJ, Dietz AS, Rhayem Y, Bancos I, Feuchtinger A, Chortis V, Gilligan LC, Ludwig P, Riester A, Asbach E, Hughes BA, O'Neil DM, Bidlingmaier M, Tomlinson JW, Hassan-Smith ZK, Rees DA, Adolf C, Hahner S, Quinkler M, Dekkers T, Deinum J, Biehl M, Keevil BG, Shackleton CH, Deeks JJ, Walch AK, Beuschlein F, Reincke M. Steroid metabolome analysis reveals prevalent glucocorticoid excess in primary aldosteronism. JCI Insight 2017; 2:93136. [PMID: 28422753 PMCID: PMC5396526 DOI: 10.1172/jci.insight.93136] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/14/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Adrenal aldosterone excess is the most common cause of secondary hypertension and is associated with increased cardiovascular morbidity. However, adverse metabolic risk in primary aldosteronism extends beyond hypertension, with increased rates of insulin resistance, type 2 diabetes, and osteoporosis, which cannot be easily explained by aldosterone excess. METHODS We performed mass spectrometry-based analysis of a 24-hour urine steroid metabolome in 174 newly diagnosed patients with primary aldosteronism (103 unilateral adenomas, 71 bilateral adrenal hyperplasias) in comparison to 162 healthy controls, 56 patients with endocrine inactive adrenal adenoma, 104 patients with mild subclinical, and 47 with clinically overt adrenal cortisol excess. We also analyzed the expression of cortisol-producing CYP11B1 and aldosterone-producing CYP11B2 enzymes in adenoma tissue from 57 patients with aldosterone-producing adenoma, employing immunohistochemistry with digital image analysis. RESULTS Primary aldosteronism patients had significantly increased cortisol and total glucocorticoid metabolite excretion (all P < 0.001), only exceeded by glucocorticoid output in patients with clinically overt adrenal Cushing syndrome. Several surrogate parameters of metabolic risk correlated significantly with glucocorticoid but not mineralocorticoid output. Intratumoral CYP11B1 expression was significantly associated with the corresponding in vivo glucocorticoid excretion. Unilateral adrenalectomy resolved both mineralocorticoid and glucocorticoid excess. Postoperative evidence of adrenal insufficiency was found in 13 (29%) of 45 consecutively tested patients. CONCLUSION Our data indicate that glucocorticoid cosecretion is frequently found in primary aldosteronism and contributes to associated metabolic risk. Mineralocorticoid receptor antagonist therapy alone may not be sufficient to counteract adverse metabolic risk in medically treated patients with primary aldosteronism. FUNDING Medical Research Council UK, Wellcome Trust, European Commission.
Collapse
Affiliation(s)
- Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Katharina Lang
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Alice J Sitch
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Anna S Dietz
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Yara Rhayem
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Annette Feuchtinger
- Research Unit Analytical Pathology, Helmholtz Zentrum Munich, Oberschleißheim, Germany
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Ludwig
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Evelyn Asbach
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Beverly A Hughes
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Donna M O'Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Zaki K Hassan-Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - D Aled Rees
- Neurosciences and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Christian Adolf
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stefanie Hahner
- Department of Medicine I, Endocrine and Diabetes Unit, University Hospital Würzburg, Würzburg, Germany
| | | | - Tanja Dekkers
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Michael Biehl
- Johann Bernoulli Institute for Mathematics and Computer Science, University of Groningen, Groningen, Netherlands
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital South Manchester, Manchester, United Kingdom
| | - Cedric Hl Shackleton
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,University of California at San Francisco Benioff Children's Hospital, Oakland, California, USA
| | - Jonathan J Deeks
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Axel K Walch
- Research Unit Analytical Pathology, Helmholtz Zentrum Munich, Oberschleißheim, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| |
Collapse
|