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Wright K, van Rossum EFC, Zan E, Werner N, Harris A, Feelders RA, Agrawal N. Emerging diagnostic methods and imaging modalities in cushing's syndrome. Front Endocrinol (Lausanne) 2023; 14:1230447. [PMID: 37560300 PMCID: PMC10407789 DOI: 10.3389/fendo.2023.1230447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/05/2023] [Indexed: 08/11/2023] Open
Abstract
Endogenous Cushing's syndrome (CS) is a rare disease characterized by prolonged glucocorticoid excess. Timely diagnosis is critical to allow prompt treatment and limit long-term disease morbidity and risk for mortality. Traditional biochemical diagnostic modalities each have limitations and sensitivities and specificities that vary significantly with diagnostic cutoff values. Biochemical evaluation is particularly complex in patients whose hypercortisolemia fluctuates daily, often requiring repetition of tests to confirm or exclude disease, and when delineating CS from physiologic, nonneoplastic states of hypercortisolism. Lastly, traditional pituitary MRI may be negative in up to 60% of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas (termed "Cushing's disease" [CD]) whereas false positive pituitary MRI findings may exist in patients with ectopic ACTH secretion. Thus, differentiating CD from ectopic ACTH secretion may necessitate dynamic testing or even invasive procedures such as bilateral inferior petrosal sinus sampling. Newer methods may relieve some of the diagnostic uncertainty in CS, providing a more definitive diagnosis prior to subjecting patients to additional imaging or invasive procedures. For example, a novel method of cortisol measurement in patients with CS is scalp hair analysis, a non-invasive method yielding cortisol and cortisone values representing long-term glucocorticoid exposure of the past months. Hair cortisol and cortisone have both shown to differentiate between CS patients and controls with a high sensitivity and specificity. Moreover, advances in imaging techniques may enhance detection of ACTH-secreting pituitary adenomas. While conventional pituitary MRI may fail to identify microadenomas in patients with CD, high-resolution 3T-MRI with 3D-spoiled gradient-echo sequence has thinner sections and superior soft-tissue contrast that can detect adenomas as small as 2 mm. Similarly, functional imaging may improve the identification of ACTH-secreting adenomas noninvasively; Gallium-68-tagged corticotropin-releasing hormone (CRH) combined with PET-CT can be used to detect CRH receptors, which are upregulated on corticotroph adenomas. This technique can delineate functionality of adenomas in patients with CD from patients with ectopic ACTH secretion and false positive pituitary lesions on MRI. Here, we review emerging methods and imaging modalities for the diagnosis of CS, discussing their diagnostic accuracy, strengths and limitations, and applicability to clinical practice.
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Affiliation(s)
- Kyla Wright
- New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Elisabeth F. C. van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical College (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Elcin Zan
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Nicole Werner
- New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Alan Harris
- Department of Medicine, Division of Endocrinology, New York University (NYU) Langone Medical Center, New York, NY, United States
| | - Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical College (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nidhi Agrawal
- Department of Medicine, Division of Endocrinology, New York University (NYU) Langone Medical Center, New York, NY, United States
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2
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Castinetti F, Lacroix A. Is Desmopressin Useful in the Evaluation of Cushing Syndrome? J Clin Endocrinol Metab 2022; 107:e4295-e4301. [PMID: 36103267 DOI: 10.1210/clinem/dgac533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Indexed: 02/13/2023]
Abstract
The desmopressin test was first described 30 years ago. Based on the differential secretagogue properties of desmopressin on adrenocorticotropin (ACTH) release between normal and corticotroph tumor cells, this test was intended to facilitate the diagnosis of Cushing syndrome (CS). The distinct expression of the various arginine vasopressin receptors between normal pituitary, corticotroph tumors, or neuroendocrine tumors cells secreting ACTH ectopically suggested that this test could facilitate the etiological diagnosis of ACTH-dependent CS. In this review, we analyze the merits and pitfalls of desmopressin use in the diagnostic procedures of CS. Desmopressin response is not able to completely differentiate the various etiologies of CS; its wider availability has allowed its use for inferior petrosal sinus sampling confirmation of a pituitary source of ACTH excess. In addition, desmopressin can be useful to demonstrate adequate corticotroph tumor resection when its stimulatory effect is lost following pituitary surgery of patients with Cushing disease. Desmopressin response can also be a marker of the risk of longer-term postoperative recurrence. However, this review also highlights the lack of consensual criteria of normal or abnormal response to desmopressin in its various uses and requirement for further research on its usefulness.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology, Aix Marseille University, Assistance Publique-Hopitaux de Marseille, INSERM, Marseille Medical Genetics, Marmara Institute, French Reference Center for Rare Pituitary Diseases, Endo-European Reference Network and EURACAN European Expert Center on Rare Pituitary Tumors, La Conception Hospital, 13385 Marseille Cedex 05, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), H2X 0C1, Montreal, Quebec, Canada
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3
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Guignat L, Bertherat J. Long-term follow-up and predictors of recurrence of Cushing's disease. J Neuroendocrinol 2022; 34:e13186. [PMID: 35979714 DOI: 10.1111/jne.13186] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery is the first-line treatment for Cushing's disease to selectively remove the tumor. The rate of postoperative remission is estimated around 70%-80% in expert centers. However, the long-term remission rate is lower because of recurrence during follow-up that can be observed in 15% to 25% of the patients depending on the studies and duration of follow-up. There is no significant predictive factor of recurrence before surgery, but postoperative corticotroph insufficiency and its duration has been found to be a protective factor for recurrence in many studies. The persistence of a positive response to desmopressin after surgery is associated with a higher rate of recurrence. Long term monitoring for recurrence with annual clinical and hormonal investigations after the hypothalamic-pituitary-adrenal axis postoperative recovery is advised. The biological tests used for the diagnosis of Cushing's syndrome (24 h-urinary-free cortisol [UFC], late-night salivary or serum cortisol, 1 mg dexamethasone suppression test) can be used to screen for recurrence. Several studies report that increased late night cortisol and alterations of dynamic testing can be observed before the increased 24 h-UFC. For this reason it is suggested that late-night salivary cortisol would be a very sensitive tool to diagnose recurrence, pending the realization of several assays in case of borderline or discrepant result. This review will summarize the knowledge about recurrence of Cushing's disease after pituitary surgery and the current recommendations for its monitoring and diagnosis.
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Affiliation(s)
- Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
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4
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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5
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Ferrante E, Barbot M, Serban AL, Ceccato F, Carosi G, Lizzul L, Sala E, Daniele A, Indirli R, Cuman M, Locatelli M, Manara R, Arosio M, Boscaro M, Mantovani G, Scaroni C. Indication to dynamic and invasive testing in Cushing's disease according to different neuroradiological findings. J Endocrinol Invest 2022; 45:629-637. [PMID: 34699044 PMCID: PMC8850245 DOI: 10.1007/s40618-021-01695-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/18/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE Dynamic testing represents the mainstay in the differential diagnosis of ACTH-dependent Cushing's syndrome. However, in case of undetectable or detectable lesion < 6 mm on MRI, bilateral inferior petrosal sinus sampling (BIPSS) is suggested by current guidelines. Aim of this study was to analyze the performance of CRH, desmopressin and high-dose dexamethasone suppression test (HDDST) in the differential diagnosis of ACTH-dependent Cushing's syndrome as well as the impact of invasive and noninvasive tests on surgical outcome in patients affected by Cushing's disease (CD). METHODS Retrospective analysis on 148 patients with CD and 26 patients with ectopic ACTH syndrome. RESULTS Among CD patients, negative MRI/lesion < 6 mm was detected in 97 patients (Group A); 29 had a 6-10 mm lesion (Group B) and 22 a macroadenoma (Group C). A positive response to CRH test, HDSST and desmopressin test was recorded in 89.4%, 91·4% and 70.1% of cases, respectively. Concordant positive response to both CRH/HDDST and CRH/desmopressin tests showed a positive predictive value of 100% for the diagnosis of CD. Among Group A patients with concordant CRH test and HDDST, no difference in surgical outcome was found between patients who performed BIPSS and those who did not (66.6% vs 70.4%, p = 0.78). CONCLUSIONS CRH, desmopressin test and HDDST have high accuracy in the differential diagnosis of ACTH-dependent CS. In patients with microadenoma < 6 mm or non-visible lesion, a concordant positive response to noninvasive tests seems sufficient to diagnose CD, irrespective of MRI finding. In these patients, BIPSS should be reserved to discordant tests.
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Affiliation(s)
- E Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - A L Serban
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - G Carosi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - L Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - E Sala
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - A Daniele
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - R Indirli
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Cuman
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - M Locatelli
- Neurosurgery Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - R Manara
- Department of Neurosciences, University of Padua, Padua, Italy
| | - M Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
| | - G Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 35, 20122, Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padua, Italy
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6
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Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, Casanueva FF, Castinetti F, Chanson P, Findling J, Gadelha M, Geer EB, Giustina A, Grossman A, Gurnell M, Ho K, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Kelly DF, Lacroix A, McCormack A, Melmed S, Molitch M, Mortini P, Newell-Price J, Nieman L, Pereira AM, Petersenn S, Pivonello R, Raff H, Reincke M, Salvatori R, Scaroni C, Shimon I, Stratakis CA, Swearingen B, Tabarin A, Takahashi Y, Theodoropoulou M, Tsagarakis S, Valassi E, Varlamov EV, Vila G, Wass J, Webb SM, Zatelli MC, Biller BMK. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol 2021; 9:847-875. [PMID: 34687601 PMCID: PMC8743006 DOI: 10.1016/s2213-8587(21)00235-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
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Affiliation(s)
| | | | | | | | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, Hôpital Cochin, Paris, France
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | | | | | | | - John D Carmichael
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Felipe F Casanueva
- Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM, Marseille, France; Assistance Publique Hopitaux de Marseille, Marseille, France; Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza B Geer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Ashley Grossman
- University of London, London, UK; University of Oxford, Oxford, UK
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK; NIHR Cambridge Biomedical Research Center, Cambridge, UK; Addenbrooke's Hospital, Cambridge, UK
| | - Ken Ho
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Ursula B Kaiser
- Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - André Lacroix
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ann McCormack
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Alberto M Pereira
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | | | - Hershel Raff
- Medical College of Wisconsin, Milwaukee, WI, USA; Advocate Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Martin Reincke
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | | | - Ilan Shimon
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | | | | | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | | | - Marily Theodoropoulou
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital General de Catalunya, Barcelona, Spain; Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- Churchill Hospital, Oxford, United Kingdom
| | - Susan M Webb
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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Hinojosa-Amaya JM, Cuevas-Ramos D. The definition of remission and recurrence of Cushing's disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101485. [PMID: 33472761 DOI: 10.1016/j.beem.2021.101485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Accurate classification of postsurgical remission, and early recognition of recurrence are crucial to timely treat and prevent excess mortality in Cushing's Disease, yet the criteria used to define remission are variable and there is no consensus to define recurrence. Remission is defined as postsurgical hypocortisolemia, but delayed remission may occur. Recurrence is the return of clinical manifestations with biochemical evidence of hypercortisolism. The proper combination of tests and their timing are controversial. Reliable predicting tools may lead to earlier diagnosis upon recurrence. Many factors have been studied independently for prediction with variable performance. Novel artificial intelligence approaches seek to integrate these variables into risk calculators and machine-learning algorithms with an acceptable short-term predictive performance but lack longer-term accuracy. Prospective studies using these approaches are needed. This review summarizes the evidence behind the definitions of remission and recurrence and provide an overview of the available tools to predict and/or diagnose them.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Pituitary Clinic, Endocrinology Division and Department of Medicine, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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8
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Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
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Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
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9
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Capatina C, Hinojosa-Amaya JM, Poiana C, Fleseriu M. Management of patients with persistent or recurrent Cushing's disease after initial pituitary surgery. Expert Rev Endocrinol Metab 2020; 15:321-339. [PMID: 32813595 DOI: 10.1080/17446651.2020.1802243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Treatment options for persistent and recurrent Cushing's disease (CD) include an individualized approach for repeat surgery, medical treatment, radiation therapy (RT), and bilateral adrenalectomy (BLA). AREAS COVERED In this expert opinion perspective, the authors review the latest treatment(s) for persistent/recurrent CD. A PubMed search was undertaken (English articles through May 2020) and relevant articles discussed. Repeat pituitary surgery should be considered in most patients with proven hypercortisolism; there is potential for cure with low risk of major complications. Medical therapy is valuable either alone, while awaiting the effects of RT, or in preparation for BLA. Medical therapy includes steroidogenesis inhibitors, agents that act at the pituitary or glucocorticoid receptor level, and novel agents in development. Radiation therapy has been used successfully to treat CD, but hypopituitarism risk and delayed efficacy (improved with radiosurgery) are major drawbacks. Laparoscopic BLA is safe and effective in patients with severe, difficult-to-manage hypercortisolism, but long-term follow-up is required as corticotroph tumor progression can develop. EXPERT OPINION Treatment of persistent/recurrent CD is challenging. Most patients require >1 therapy to achieve long-lasting remission. There is currently no ideal single treatment option that provides high and rapid efficacy, low adverse effects, and preserves normal pituitary-adrenal axis function.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
- Endocrinology Division, Department of Medicine, Hospital Universitario Dr. José E. González, Universidad Autónoma De Nuevo León , Monterrey, Nuevo León, Mexico
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
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10
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Pasternak-Pietrzak K, Moszczyńska E, Szalecki M. Treatment challenges in pediatric Cushing's disease: Review of the literature with particular emphasis on predictive factors for the disease recurrence. Endocrine 2019; 66:125-136. [PMID: 31701434 PMCID: PMC6838046 DOI: 10.1007/s12020-019-02036-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Cushing's disease (CD) is a rare endocrine condition caused by a corticotroph pituitary tumor that produces adrenocorticotropic hormone. The current state of knowledge of CD treatment is presented in this article including factors that can be helpful in predicting remission and/or recurrence of the disease. The primary goals in CD treatment are quick diagnosis and effective, prompt treatment as the persistent disease is associated with increased morbidity and mortality. Cooperation of a team consisting of experienced pediatrician/adult endocrinologist, neuroradiologist, transsphenoidal neurosurgeon and (if necessary) radiotherapist contribute to the best treatment effects.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland.
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
- The Medicine and Health Sciences Faculty, University of Jan Kochanowski, Al. IX Wieków Kielc 19A, 25-317, Kielce, Poland
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11
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Abellán-Galiana P, Fajardo-Montañana C, Riesgo-Suárez P, Pérez-Bermejo M, Ríos-Pérez C, Gómez-Vela J. Prognostic usefulness of ACTH in the postoperative period of Cushing's disease. Endocr Connect 2019; 8:1262-1272. [PMID: 31394502 PMCID: PMC6733365 DOI: 10.1530/ec-19-0297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To analyze the usefulness of plasma ACTH in predicting CD remission after surgery and to evaluate the prognostic usefulness of ACTH measurement after the cortisol and ACTH nadir (48 h prior to discharge). DESIGN A prospective study was made of 65 patients with CD operated upon between 2005 and 2016. METHODS Postsurgery plasma ACTH and cortisol were measured every 6 h, in the absence of corticosteroid coverage. Hydrocortisone was started in the presence of adrenal insufficiency or cortisol <55.2 nmol/L. Plasma ACTH was again determined before discharge. MAIN OUTCOME MEASURE Usefulness of plasma ACTH in predicting CD remission. RESULTS Remission at 3 months of CD was achieved in 56 of 65 cases, with late recurrence in 18 of 58 cases. Following resection, the ACTH nadir was significantly lower referred to late remission (2.8 vs 6.5 pmol/L; P = 0.031) and higher for recurrence (2.1 vs 4.8 pmol/L; P < 0.001), and identical results were obtained for the ACTH values before discharge. In the analysis of the ROC curves, nadir and before discharge ACTH values <1.9 pmol/L and <2.6 pmol/L were respectively indicative of early remission (AUC 0.827; P < 0.001); <6.2 pmol/L of remission at 3 months (AUC 0.847; P = 0.001) and >3.2 pmol/L of recurrence (AUC 0.810; P < 0.001) in both ACTH values. A time to ACTH nadir <46 h was indicative of early remission (AUC 0.751; P = 0.001), while a time >39 h was indicative of recurrence (AUC 0.773; P = 0.001). CONCLUSIONS We propose an ACTH value <3.3 pmol/L as a good long-term prognostic marker in the postoperative period of CD. Reaching the ACTH nadir in less time is associated to a lesser recurrence rate.
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Affiliation(s)
- Pablo Abellán-Galiana
- Department of Endocrinology, Hospital General Universitari de Castelló, Castellón, Spain
- Department of Medicine, Universidad Cardenal Herrera-CEU, Castellón, Spain
| | - Carmen Fajardo-Montañana
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
- Correspondence should be addressed to C Fajardo-Montañana:
| | - Pedro Riesgo-Suárez
- Department of Neurosurgery, Hospital Universitario de la Ribera, Alzira, Spain
| | | | - Celia Ríos-Pérez
- Centro de Salud Tavernes de la Valldigna, Hospital Comarcal Francesc de Borja, Gandía, Spain
| | - José Gómez-Vela
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
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12
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Hinojosa-Amaya JM, Varlamov EV, McCartney S, Fleseriu M. Hypercortisolemia Recurrence in Cushing's Disease; a Diagnostic Challenge. Front Endocrinol (Lausanne) 2019; 10:740. [PMID: 31787930 PMCID: PMC6856050 DOI: 10.3389/fendo.2019.00740] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/14/2019] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease recurrence following successful pituitary surgery is common and merits prompt and careful diagnosis, as untreated hypercortisolism leads to increased morbidity and mortality. However, an established recurrence definition has not been forthcoming. This poses a diagnostic challenge especially early in the course of returning hypercortisolemia and/or in the presence of non-neoplastic hypercortisolemia. A late-night salivary cortisol (LNSC) test is the first test to reveal abnormal results, however, has limitations related to assay performance as well as individual patient variability. Dexamethasone suppression tests and 24-h urinary free cortisol (UFC) results are next to reveal abnormal results. Other tests including, corticotropin-releasing hormone (CRH) stimulation test and combined CRH-dexamethasone test, as well as desmopressin stimulation test with/without dexamethasone are also used, although, none have proven to be the preeminent diagnostic test for recurrence determination. There is a possible role for these tests in predicting recurrence in patients who have experienced remission, though, this also remains challenging due to lack of established cutoff values. This article details and summarizes evidence about different diagnostic tests currently used to diagnose and predict Cushing's disease recurrence.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Endocrinology Division, Department of Medicine, Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elena V. Varlamov
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Shirley McCartney
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu
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13
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Yamamuro T, Inoue K, Nagai Y, Azuma D, Yamamoto A, Hara K, Kohara M, Iwata T, Nakatsuka S, Morii E, Yamamoto T. A case of ectopic ACTH syndrome due to DDAVP-sensitive but V1b receptor-negative bronchial typical carcinoid with lymphatic metastasis and plasma ProGRP elevation. Endocr J 2018; 65:1161-1169. [PMID: 30232300 DOI: 10.1507/endocrj.ej18-0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ectopic ACTH syndrome (EAS) is a potentially fatal endocrine disease that results from a variety of neuroendocrine tumors (NETs), such as small cell lung cancer (SCLC) and bronchial typical carcinoid. Typical carcinoid is usually slow growing, not associated with plasma progastrin releasing peptide (ProGRP) elevation. Here, we report a 47-year-old female smoker with progressive typical carcinoid and plasma ProGRP elevation. Several types of Cushingoid features were found on physical examination. In addition, laboratory examination showed elevated plasma ACTH and serum cortisol levels. These findings indicated ACTH-dependent Cushing's syndrome. Moreover, the serum cortisol level was not suppressed by overnight high-dose dexamethasone treatment, suggesting the presence of an extra-pituitary tumor. Contrast-enhanced brain MRI revealed no pituitary adenoma, which also supported the idea that EAS occurred in the present case. Strikingly, chest computed tomographic (CT) scan showed a single 18-mm peripheral nodule in the right middle lobe of the lung. Tumor marker analysis revealed an elevation in plasma ProGRP. These data suggested a possibility that SCLC secreted ACTH and caused EAS in this patient. Of note, the plasma ACTH level was increased (1.7 fold) in l-desamino-8-D-arginine vasopressin (DDAVP) test, also suggesting the specific clinical feature in this case. After additional imaging examinations, we performed surgical resection with the suspicion of limited SCLC. As a result, pathological examination revealed a vasopressin receptor Ib (V1b) receptor-negative bronchial typical carcinoid with ACTH production and mediastinal lymphatic metastasis. In summary, we present a case of EAS caused by progressive bronchial typical carcinoid with plasma ProGRP elevation. We propose a novel subtype of lung typical carcinoid.
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Affiliation(s)
- Tadashi Yamamuro
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Kana Inoue
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Yasuki Nagai
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Daisuke Azuma
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Aya Yamamoto
- Department of Thoracic and Cardiovascular Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Kantaro Hara
- Department of Thoracic and Cardiovascular Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Masaharu Kohara
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Iwata
- Department of Thoracic and Cardiovascular Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | | | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsunehiko Yamamoto
- Department of Diabetes and Endocrinology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
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14
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Machado MC, Fragoso MCBV, Moreira AC, Boguszewski CL, Vieira Neto L, Naves LA, Vilar L, Araújo LAD, Musolino NRC, Miranda PAC, Czepielewski MA, Gadelha MR, Bronstein MD, Ribeiro-Oliveira A. A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:87-105. [PMID: 29694638 PMCID: PMC10118687 DOI: 10.20945/2359-3997000000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 10/02/2017] [Indexed: 11/23/2022]
Abstract
The treatment objectives for a patient with Cushing's disease (CD) are remission of hypercortisolism, adequate management of co-morbidities, restoration of the hypothalamic-pituitary-adrenal axis, preservation of fertility and pituitary function, and improvement of visual defects in cases of macroadenomas with suprasellar extension. Transsphenoidal pituitary surgery is the main treatment option for the majority of cases, even in macroadenomas with low probability of remission. In cases of surgical failure, another subsequent pituitary surgery might be indicated in cases with persistent tumor imaging at post surgical magnetic resonance imaging (MRI) and/or pathology analysis of adrenocorticotropic hormone-positive (ACTH+) positive pituitary adenoma in the first procedure. Medical treatment, radiotherapy and adrenalectomy are the other options when transsphenoidal pituitary surgery fails. There are several options of medical treatment, although cabergoline and ketoconazole are the most commonly used alone or in combination. Novel treatments are also addressed in this review. Different therapeutic approaches are frequently needed on an individual basis, both before and, particularly, after surgery, and they should be individualized. The objective of the present review is to provide the necessary information to achieve a more effective treatment for CD. It is recommended that patients with CD be followed at tertiary care centers with experience in treating this condition.
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Affiliation(s)
- Márcio Carlos Machado
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Maria Candida Barisson Vilares Fragoso
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Ayrton Custódio Moreira
- Divisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Leonardo Vieira Neto
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brasil
| | - Lucio Vilar
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Pernambuco, Recife, PE, Brasil
| | | | - Nina Rosa Castro Musolino
- Divisão de Neurocirurgia Funcional, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Marcello Delano Bronstein
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Antônio Ribeiro-Oliveira
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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15
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Ambrogio AG, Andrioli M, De Martin M, Cavagnini F, Pecori Giraldi F. Usefulness of desmopressin testing to predict relapse during long-term follow-up in patients in remission from Cushing's disease. Endocr Connect 2017; 6:791-799. [PMID: 29018154 PMCID: PMC5682421 DOI: 10.1530/ec-17-0292] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/08/2022]
Abstract
Recurrence of Cushing's disease after successful transsphenoidal surgery occurs in some 30% of the patients and the response to desmopressin shortly after surgery has been proposed as a marker for disease recurrence. The aim of the present study was to evaluate the response to desmopressin over time after surgery. We tested 56 patients with Cushing's disease in remission after transsphenoidal surgery with desmopressin for up to 20 years after surgery. The ACTH and cortisol response to desmopressin over time was evaluated in patients on long-term remission or undergoing relapse; an increase by at least 27 pg/mL in ACTH levels identified responders. The vast majority of patients who underwent successful adenomectomy failed to respond to desmopressin after surgery and this response pattern was maintained over time in patients on long-term remission. Conversely, a response to desmopressin reappeared in patients who subsequently developed a recurrence of Cushing's disease, even years prior to frank hypercortisolism. It appears therefore that a change in the response pattern to desmopressin proves predictive of recurrence of Cushing's disease and may indicate which patients require close monitoring.
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Affiliation(s)
| | - Massimiliano Andrioli
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Martina De Martin
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesco Cavagnini
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesca Pecori Giraldi
- Neuroendocrinology Research LaboratoryIstituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
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16
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Barbot M, Trementino L, Zilio M, Ceccato F, Albiger N, Daniele A, Frigo AC, Mardari R, Rolma G, Boscaro M, Arnaldi G, Scaroni C. Second-line tests in the differential diagnosis of ACTH-dependent Cushing's syndrome. Pituitary 2016; 19:488-95. [PMID: 27236452 DOI: 10.1007/s11102-016-0729-y] [Citation(s) in RCA: 34] [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] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Diagnosing Cushing's syndrome (CS) can be a challenge, especially in ACTH-dependent CS, when it comes to detecting the origin of ACTH secretion. MATERIALS AND METHODS Retrospective data were collected on 170 patients with ACTH-dependent CS (149 CD, 21 EAS) referring to two endocrinology units, focusing on three non-invasive tests: dexamethasone 8 mg overnight challenge (HDDST); corticotrophin-releasing hormone (CRH) assay and the desmopressin (DDAVP) test. RESULTS Patients with EAS were slightly older and had higher ACTH, serum and urinary cortisol levels than patients with CD (p < 0.01). CD patients had a stronger ACTH and cortisol response after CRH injection (p < 0.0001), and a more pronounced reduction in cortisol levels after HDDST (p < 0.0001). A threshold percentage ACTH increase after CRH stimulation of 72.4 % was able to identify CD with a sensitivity (SE) of 76 % (95 % CI 68-83) and a specificity (SP) of 100 % (95 % CI 83-100). As for HDDST, a cortisol suppression >52.7 % below the basal level suggested a pituitary origin with a SE of 88 % (95 % CI 81-93) and a SP of 90 % (95 % CI 68-99). There were no cases of EAS with positive responses to both these tests. Increases in ACTH and cortisol levels after the DDAVP test were also higher in CD than in EAS (p < 0.01), though the SE and SP were lower. CONCLUSIONS Patients with CD showed a stronger response to HDDST and CRH, and the adopted cut-offs showed a good SE and SP in discriminating them from patients with EAS. Concordant tests indicated CD when positive, whereas no response to either test was highly suggestive of EAS. The DDAVP test was of limited utility in the diagnostic phase. In conclusion, the choice of tests may play an important part in the differential diagnosis of ACTH-dependent CS.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
| | - Laura Trementino
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Nora Albiger
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Andrea Daniele
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital, Padua, Italy
| | | | | | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Giorgio Arnaldi
- Endocrinology Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
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Le Marc'hadour P, Muller M, Albarel F, Coulon AL, Morange I, Martinie M, Gay E, Graillon T, Dufour H, Conte-Devolx B, Chabre O, Brue T, Castinetti F. Postoperative follow-up of Cushing's disease using cortisol, desmopressin and coupled dexamethasone-desmopressin tests: a head-to-head comparison. Clin Endocrinol (Oxf) 2015; 83:216-22. [PMID: 25660243 DOI: 10.1111/cen.12739] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/01/2015] [Accepted: 02/04/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Predicting the outcome of patients operated on for Cushing's disease (CD) is a challenging task. Our objective was to assess the accuracy of immediate postsurgical plasma cortisol, desmopressin test and the coupled dexamethasone-desmopressin test (CDDT) as predictors of outcome. DESIGN AND PATIENTS Sixty-seven patients with initial remission and a minimal postsurgical follow-up greater than 18 months were included in this retrospective bicentre study. MEASUREMENTS Follow-up included 3-6 months followed by yearly 24-h urinary-free cortisol, ACTH and cortisol plasmatic levels, a 1-mg overnight dexamethasone suppression test (1-mg DST), desmopressin test and the CDDT. ROC curves were performed to define the optimal threshold of immediate postsurgical cortisol level and 3- to 6-month desmopressin test and CDDT, as predictors of final outcome in comparison with classical biological markers of recurrence. RESULTS Eleven patients presented recurrence. The patient's median follow-up was 52 months (range, 18-180). As early predictors of outcome, immediate postsurgical plasma cortisol level <35 nmol/l predicted the lack of recurrence with 93% negative predictive value (NPV), whereas predictive positive value (PPV) was 25%. During the follow-up, the CDDT was more precise than the desmopressin test in predicting the lack of recurrence (100% NPV) when performed in the first 3 years after surgery. Positivity of the CDDT was defined based on ROC curves by ACTH and cortisol increments >50%. The CDDT was highly reproducible, as the same response was observed every year in 91% of the patients. CONCLUSIONS Adding the CDDT the first 3 years after surgery to immediate postsurgical cortisol evaluation should allow obtaining an optimal follow-up management of patients operated for Cushing's disease.
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Affiliation(s)
- Pauline Le Marc'hadour
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Marie Muller
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Frederique Albarel
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Anne-Laure Coulon
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Isabelle Morange
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Monique Martinie
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Emmanuel Gay
- Department of Neurosurgery, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Thomas Graillon
- Department of Neurosurgery, CHU La Timone, Marseille, France
| | - Henri Dufour
- Department of Neurosurgery, CHU La Timone, Marseille, France
| | - Bernard Conte-Devolx
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Olivier Chabre
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Thierry Brue
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Frederic Castinetti
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 282] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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van Rijn SJ, Hanson JM, Zierikzee D, Kooistra HS, Penning LC, Tryfonidou MA, Meij BP. The prognostic value of perioperative profiles of ACTH and cortisol for recurrence after transsphenoidal hypophysectomy in dogs with corticotroph adenomas. J Vet Intern Med 2015; 29:869-76. [PMID: 25959680 PMCID: PMC4895417 DOI: 10.1111/jvim.12601] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 03/04/2015] [Accepted: 03/23/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Transsphenoidal hypophysectomy is an effective treatment for dogs with pituitary-dependent hypercortisolism (PDH). However, long-term recurrence of hypercortisolism is a well-recognized problem, indicating the need for reliable prognostic indicators. OBJECTIVES The aim of this study was to evaluate the prognostic value of perioperative plasma ACTH and cortisol concentrations for identifying recurrence of hypercortisolism after transsphenoidal hypophysectomy. ANIMALS A total of 112 dogs with PDH that underwent transsphenoidal hypophysectomy met the inclusion criteria of the study. METHODS Hormone concentrations were measured preoperatively and 1-5 hours after surgery. Both absolute hormone concentrations and postoperative concentrations normalized to preoperative concentrations were included in analyses. The prognostic value of hormone concentrations was studied with Cox's proportional hazard analysis. RESULTS Median follow-up and disease-free period were 1096 days and 896 days, respectively. Twenty-eight percent of patients had recurrence, with a median disease-free period of 588 days. Both absolute and normalized postoperative cortisol concentrations were significantly higher in dogs with recurrence than in dogs without recurrence. High ACTH 5 hours after surgery, high cortisol 1 and 4 hours after surgery, high normalized ACTH 3 hours after surgery, high normalized cortisol 4 hours after surgery and the random slope of cortisol were associated with a shorter disease-free period. CONCLUSIONS AND CLINICAL IMPORTANCE Individual perioperative hormone curves provide valuable information about the risk of recurrence after hypophysectomy. However, because no single cutoff point could be identified, combination with other variables, such as the pituitary height/brain area (P/B) ratio, is still needed to obtain a good estimate of the risk for recurrence of hypercortisolism after hypophysectomy.
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Affiliation(s)
- S J van Rijn
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - J M Hanson
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - D Zierikzee
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - H S Kooistra
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - L C Penning
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - M A Tryfonidou
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - B P Meij
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
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Pendharkar AV, Sussman ES, Ho AL, Hayden Gephart MG, Katznelson L. Cushing's disease: predicting long-term remission after surgical treatment. Neurosurg Focus 2015; 38:E13. [DOI: 10.3171/2014.10.focus14682] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cushing's disease (CD) is a state of excess glucocorticoid production resulting from an adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma. The gold-standard treatment for CD is transsphenoidal adenomectomy. In the hands of an experienced neurosurgeon, gross-total resection is possible in the majority of ACTH-secreting pituitary adenomas, with early postoperative remission rates ranging from 67% to 95%. In contrast to the strong data in support of resection, the clinical course of postsurgical persistent or recurrent disease remains unclear. There is significant variability in recurrence rates, with reports as high as 36% with a mean time to recurrence of 15–50 months. It is therefore important to develop biochemical criteria that define postsurgical remission and that may provide prognosis for long-term recurrence. Despite the use of a number of biochemical assessments, there is debate regarding the accuracy of these tests in predicting recurrence. Here, the authors review the various biochemical criteria and assess their utility in predicting CD recurrence after resection.
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Affiliation(s)
| | | | | | | | - Laurence Katznelson
- Departments of 1Neurosurgery and
- 2Medicine, Stanford University School of Medicine, Stanford, California
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21
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Abstract
A case of possible recurrent Cushing's disease (CD) is presented and data on current definitions of CD remission, persistence, and recurrence are reviewed. While prevailing guidelines recommend the use of serum cortisol in the first post-operative week for defining initial remission and predicting sustained remission, with the use of 24 h urinary free cortisol measurements if serum cortisol values are equivocal, there is debate as to which methods and thresholds best define CD remission and predict successful outcomes. Other methods used to define remission (and hence persistence and recurrence) include restoration of cortisol suppression after dexamethasone and physiologic diurnal cortisol rhythm as measured by midnight salivary free cortisol. However, the number and degree of abnormal test results needed to define recurrence, and the determination of which biochemical test has more significance when there are discrepancies between markers is inconsistent among studies. Further inquiry is warranted to examine if patients in apparent CD remission who have subtle hypothalamic pituitary adrenal (HPA) axis abnormalities represent distinctive remission subtypes versus mild or early recurrence. Additional investigation could also explore the degree to which these HPA axis abnormalities, such as alterations in cortisol circadian rhythm or partial resistance to dexamethasone, are associated with persistence of CD morbidities, including neuropsychiatric impairments, alterations in body composition, and cardiovascular risk.
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Affiliation(s)
- Eliza B. Geer
- Assistant Professor of Medicine and Neurosurgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1055, New York, NY 10029, Tel: 212-241-6139, Faxt: 212-423-0508,
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22
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[Cushing syndrome: When to suspect and how to confirm?]. Presse Med 2014; 43:366-75. [PMID: 24656297 DOI: 10.1016/j.lpm.2014.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/11/2014] [Accepted: 02/13/2014] [Indexed: 11/24/2022] Open
Abstract
Cushing's syndrome includes all the clinical manifestations induced by chronic glucocorticoid excess. The endogenous Cushing's syndrome is rare, but its prevalence, although difficult to define, is much higher in populations at risk. Data suggest that early and effective management would reduce morbidity and mortality after correction of hypercortisolism. It is not recommended to widespread test for Cushing's syndrome but targeted screening is indicated especially in the following indications: facio-troncular obesity, hypercatabolism signs, pituitary and adrenal tumor. In case of potential but less specific manifestation of Cushing's syndrome (diabetes, hypertension, osteoporosis, hypogonadism…), but unusual for age, familial background, or severity, particular attention will be paid to the clinical examination to search for signs of modest hypercortisolism which may justify screening. The positive diagnosis of Cushing's syndrome is based on two stages approach with the first tests simple and sensitive, and the second tests more specific, with investigations to determine the cause following a positive diagnosis.
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Abellán Galiana P, Fajardo Montañana C, Riesgo Suárez PA, Gómez Vela J, Escrivá CM, Lillo VR. Factores pronósticos de remisión a largo plazo tras cirugía transesfenoidal en la enfermedad de Cushing. ACTA ACUST UNITED AC 2013; 60:475-82. [DOI: 10.1016/j.endonu.2012.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/06/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022]
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Barbot M, Albiger N, Koutroumpi S, Ceccato F, Frigo AC, Manara R, Fassina A, Gardiman MP, Scanarini M, Mantero F, Scaroni C. Predicting late recurrence in surgically treated patients with Cushing's disease. Clin Endocrinol (Oxf) 2013; 79:394-401. [PMID: 23278711 DOI: 10.1111/cen.12133] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 11/06/2012] [Accepted: 12/17/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Cushing's disease (CD) has an uncertain prognosis because patients achieving remission after transsphenoidal pituitary neurosurgery (TSS) may relapse. We aimed to identify factors predicting relapse, focusing on desmopressin (DDAVP) and corticotropin-releasing hormone (CRH) tests after surgery. MATERIALS AND METHODS Fifty-seven patients with CD (mean age 36 years) after TSS experienced remission (24 cases), late relapse (LR) (15 cases), or persistent disease (18 cases). RESULTS The median time to relapse was 40 months. ACTH levels increased after both DDAVP and CRH stimulation, with a significantly higher response in the late recurrence group, showing this to be an indicator of increased risk of relapse. In the logistic regression model, a rise in ACTH >9 pg/ml after DDAVP and >36·7 pg/ml after CRH showed a sensitivity of 93% and 73%, respectively, a specificity of 82% and 76% in LR group. The area under the curve was 0·91 for DDAVP, 0·80 for CRH and 0·95 for DDAVP+CRH test, i.e. the combined tests performed better than each test alone, but not to a statistically significant degree. A response to both tests resulted in a positive predictive value (PPV) of 100%, while no response to either test in a negative predictive value (NPV) of 100%. CONCLUSIONS ACTH hyper-responsiveness to DDAVP stimulation proved a valuable indicator of relapsing patients with high sensitivity and specificity; in selected cases when a clear high increment of ACTH level is not evident, the CRH test might be used as additional tool to confirm the risk of future relapses.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
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25
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Castinetti F, Morange I, Conte-Devolx B, Brue T. Cushing's disease. Orphanet J Rare Dis 2012; 7:41. [PMID: 22710101 PMCID: PMC3458990 DOI: 10.1186/1750-1172-7-41] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 06/18/2012] [Indexed: 11/29/2022] Open
Abstract
Cushing’s disease, or pituitary ACTH dependent Cushing’s syndrome, is a rare disease responsible for increased morbidity and mortality. Signs and symptoms of hypercortisolism are usually non specific: obesity, signs of protein wasting, increased blood pressure, variable levels of hirsutism. Diagnosis is frequently difficult, and requires a strict algorithm. First-line treatment is based on transsphenoidal surgery, which cures 80% of ACTH-secreting microadenomas. The rate of remission is lower in macroadenomas. Other therapeutic modalities including anticortisolic drugs, radiation techniques or bilateral adrenalectomy will thus be necessary to avoid long-term risks (metabolic syndrome, osteoporosis, cardiovascular disease) of hypercortisolism. This review summarizes potential pathophysiological mechanisms, diagnostic approaches, and therapies.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology and Reference Center for Rare Pituitary Diseases La Timone Hospital, Aix-Marseille University, Marseille, France.
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26
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Bou Khalil R, Baudry C, Guignat L, Carrasco C, Guibourdenche J, Gaillard S, Bertagna X, Bertherat J. Sequential hormonal changes in 21 patients with recurrent Cushing's disease after successful pituitary surgery. Eur J Endocrinol 2011; 165:729-37. [PMID: 21885674 DOI: 10.1530/eje-11-0424] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe the sequence of hormonal changes during recurrence of Cushing's disease (CD) after successful transsphenoidal surgery (TSS). DESIGN Retrospective study in a single center. PATIENTS AND METHODS We studied 101 of the 127 patients treated by TSS for CD between 1996 and 2009, who had hypocortisolism or eucortisolism for at least 3 months post-TSS. We arbitrarily defined 'overt recurrence', as presence of two classical parameters of excess cortisol (increased midnight--either serum or salivary--and 24 h urinary cortisol (UC)), leading to further specific therapeutic action, and 'mild recurrence', as presence of a single classical parameter, leading to simple surveillance. RESULTS Of the 101 patients, 21 (20.8%) presented with recurrence, 'mild' or 'overt', during long-term follow-up (median 50.4 months, range 7-99). Recurrence occurred less frequently (16.8 vs 50%, P=0.02), and later (mean 44.7 months, median 43, range 7-94 vs mean 21.5 months, median 17, range 3-61, P=0.05), in patients with early post-TSS hypocortisolism compared with those with eucortisolism. Increase in midnight cortisol occurred in a mean time of 38.2 months, while UC elevation was observed at 50.6 months. Vasopressin analogs and CRH tests were eventually positive in 85 and 93% of all patients respectively; a positive response to one of the two dynamic tests preceded the increase in midnight cortisol or UC in 71 and 64% of the patients respectively. CONCLUSION A positive response to vasopressin analogs and/or CRH tests occurs early in recurrence, followed by an increase in midnight cortisol, while UC elevation is at a later stage.
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Affiliation(s)
- Roula Bou Khalil
- Centre de Référence des Maladies Rares de la Surrénale, Service des Maladies Endocriniennes et Métaboliques, Hôpital Cochin, 27, rue du Faubourg St-Jacques, 75014 Paris, France
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27
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Losa M, Bianchi R, Barzaghi R, Giovanelli M, Mortini P. Persistent adrenocorticotropin response to desmopressin in the early postoperative period predicts recurrence of Cushing's disease. J Clin Endocrinol Metab 2009; 94:3322-8. [PMID: 19584185 DOI: 10.1210/jc.2009-0844] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Patients with Cushing's disease (CD) often show an ACTH and cortisol response to desmopressin (DDAVP). OBJECTIVE We tested whether persistence of a positive response to DDAVP after successful surgery identifies patients at risk of CD recurrence. DESIGN We prospectively included all CD patients who had a positive response to DDAVP before successful surgery from 1995 through 2007. SETTING The study was performed at a university hospital. PATIENTS One hundred seventy-four patients with CD, 148 women and 26 men, mean age 36.1 +/- 0.8 yr, were studied. The median follow-up after surgery was 58 months (interquartile range 22-93 months). INTERVENTION DDAVP test was performed immediately before and after surgery. MAIN OUTCOME MEASURE An ACTH and cortisol increment of at least 30 and 20% above baseline, respectively, were considered as a positive response to DDAVP. The risk of CD recurrence was analyzed according to the postoperative hormonal response to DDAVP. RESULTS Recurrence of CD occurred in 19 patients (10.9%). The recurrence-free survival at 5 yr was 89.8% [95% confidence interval (CI) 84.2-95.4]. Patients with a positive ACTH response had a 5-yr recurrence-free survival of 82.6% (95% CI 70.6-94.6%) as compared with 94.0% (95% CI 88.2-99.8%; P < 0.01) in patients without it. Multivariate analysis showed that persistence of a positive ACTH response to DDAVP was significantly associated with CD recurrence. CONCLUSION Positive ACTH response to DDAVP after surgery is associated with an increased risk of CD recurrence. However, the specificity and predictive value of this finding are low.
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Affiliation(s)
- Marco Losa
- Pituitary Unit, Department of Neurosurgery, Istituto Scientifico San Raffaele, Università Vita-Salute, 20132 Milano, Italy.
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Batista DL, Oldfield EH, Keil MF, Stratakis CA. Postoperative testing to predict recurrent Cushing disease in children. J Clin Endocrinol Metab 2009; 94:2757-65. [PMID: 19470618 PMCID: PMC2730862 DOI: 10.1210/jc.2009-0302] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Postoperative testing after transsphenoidal surgery (TSS) for Cushing disease (CD) in children and its usefulness in predicting residual disease or recurrence are not well studied. OBJECTIVE The objective of the study was to identify which one of three tests that are routinely performed in our institution after TSS performs better in the identification of noncured patients or predict relapse for CD. DESIGN This was a retrospective review of clinical data of 72 children who received surgery for CD (age range 5.8-18.3 yr). SETTING The study was conducted at a tertiary care center. METHODS After TSS, plasma ACTH and serum cortisol (at 0800 h), urinary free cortisol (UFC) values and an ovine CRH (oCRH) stimulation test were obtained. Patients were followed up for 24-120 months by a formal protocol. RESULTS Of 72 children with CD, 66 (94%) achieved sustained remission after TSS. Two children had persistent disease after TSS, whereas four children appeared cured at first but relapsed later. All four had low or undetectable UFCs that were not different from cured patients (P > 0.0.1). Children who remained in remission had significantly lower morning ACTH and cortisol levels after TSS compared with those who relapsed (P < 0.001). During an oCRH stimulation test, ACTH and cortisol values were higher in patients who relapsed vs. those in remission (P <0.001). Lack of histological confirmation of an adenoma, normal serum cortisol or ACTH, a normal response to oCRH, and glucocorticoid replacement for less than 6 months after surgery were associated with relapse. CONCLUSION In pediatric patients with CD, low UFCs after TSS are not good predictors of sustained remission; morning ACTH and cortisol values and/or an oCRH test after TSS predicted patients that recurred.
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Affiliation(s)
- Dalia L Batista
- Section on Endocrinology and Genetics, Program in Developmental Endocrinology and Genetics, National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
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29
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Castinetti F, Martinie M, Morange I, Dufour H, Sturm N, Passagia JG, Conte-Devolx B, Chabre O, Brue T. A combined dexamethasone desmopressin test as an early marker of postsurgical recurrence in Cushing's disease. J Clin Endocrinol Metab 2009; 94:1897-903. [PMID: 19276234 DOI: 10.1210/jc.2008-2234] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Recurrence of Cushing's disease (CD) after transsphenoidal surgery (TSS) occurs in about 25% of cases. Twenty percent of patients with immediate postsurgical corticotroph deficiency will present late recurrence. OBJECTIVE The aim of the study was to evaluate a coupled dexamethasone desmopressin test (CDDT) as a predictor of recurrence of CD. DESIGN We conducted a prospective bicenter study (Marseille and Grenoble, France). PATIENTS We studied 38 patients treated by TSS for CD with a mean follow-up of 60 months. INTERVENTION(S) We evaluated 24-h urinary free cortisol, ACTH, and cortisol plasmatic levels and performed low-dose dexamethasone suppression test and CDDT 3 to 6 months after surgery and then yearly. MAIN OUTCOME MEASURES After CDDT, ACTH ratio (ACTHr) was defined as (PeakACTH - BaseACTH)/BaseACTH. Cortisol ratio (Cortisolr) was defined as (PeakCortisol - BaseCortisol)/BaseCortisol. Basal values were observed after low-dose dexamethasone suppression test. Receiver operator characteristics curve defined ACTHr and Cortisolr giving the best sensitivity and specificity associated with recurrence. RESULTS Ten patients presented recurrence. ACTHr and Cortisolr were superior or equal to 0.5 in all patients with recurrence and in three of 28 patients in remission (100% sensitivity, 89% specificity). The test became positive in eight of 10 patients with recurrence 6-60 months before classical markers of hypercortisolism. Six patients with immediate postsurgical corticotroph deficiency presented recurrence. All of them presented CDDT positivity during the 3 yr after surgery, and recurrence 6 to 60 months after CDDT positivity. CONCLUSIONS CDDT is an early predictor of recurrence of CD and could be of particular interest in the first 3 yr after surgery, by selecting patients at high risk of recurrence despite falsely reassuring classical hormonal markers.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology, Hôpital de la Timone, 264 rue St. Pierre, Cedex 5, Marseille 13385, France.
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Ambrosi B, Malavazos AE, Passeri E, Dall'Asta C. Desmopressin test may predict the risk of recurrence in Cushing's disease. Clin Endocrinol (Oxf) 2009; 70:811. [PMID: 18771561 DOI: 10.1111/j.1365-2265.2008.03406.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pivonello R, De Martino MC, De Leo M, Tauchmanovà L, Faggiano A, Lombardi G, Colao A. Cushing's syndrome: aftermath of the cure. ACTA ACUST UNITED AC 2008; 51:1381-91. [PMID: 18209877 DOI: 10.1590/s0004-27302007000800025] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 10/26/2007] [Indexed: 11/22/2022]
Abstract
Cushing's syndrome (CS) is a chronic and systemic disease caused by endogenous or exogenous hypercortisolism, associated with an increase of mortality rate due to the clinical consequences of glucocorticoid excess, especially cardiovascular diseases. After cure, usually obtained by the surgical removal of the tumor responsible for the disease, the normalization of cortisol secretion is not constantly followed by the recovery of the clinical complications developed during the active disease, and it is often followed by the development of novel clinical manifestations induced by the fall of cortisol levels. These evidences were mostly documented in patients with pituitary-dependent CS, after surgical resection of the pituitary tumor. Indeed, despite an improvement of the mortality rate, metabolic syndrome and the consequent cardiovascular risk have been found to partially persist after disease remission, strictly correlated to the insulin resistance. Skeletal diseases, mainly osteoporosis, improve after normalization of cortisol levels but require a long period of time or the use of specific treatment, mainly bisphosphonates, to reach the normalization of bone mass. A relevant improvement or resolution of mental disturbances has been described in patients cured from CS, although in several cases, cognitive decline persisted and psychological or psychiatric improvement was erratic, delayed, or incomplete. On the other hand, development or exacerbation of autoimmune disorders, mainly thyroid autoimmune diseases, was documented in predisposed patients with CS after disease remission. The totality of these complications persisting or occurring after successful treatment contribute to the impairment of quality of life registered in patients with CS after disease cure.
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Affiliation(s)
- Rosario Pivonello
- Department of Molecular and Clinical Endocrinology and Oncology, Federico II University of Naples, Italy.
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Carrasco CA, Coste J, Guignat L, Groussin L, Dugué MA, Gaillard S, Bertagna X, Bertherat J. Midnight salivary cortisol determination for assessing the outcome of transsphenoidal surgery in Cushing's disease. J Clin Endocrinol Metab 2008; 93:4728-34. [PMID: 18728161 DOI: 10.1210/jc.2008-1171] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Midnight salivary cortisol (MSC) is now recognized as a reliable index for Cushing's syndrome diagnosis but has to be validated for the follow-up of treated patients. OBJECTIVE Our objective was to evaluate MSC for assessing the outcome of transsphenoidal surgery (TSS) in patients with Cushing's disease (CD). DESIGN We conducted a retrospective cohort study in a single center. PATIENTS AND METHODS Sixty-eight patients treated by TSS between 1996 and 2006 and followed for at least 6 months with postoperative MSC were included. Mean follow-up (+/- sd) was 45 +/- 31 months. Morning plasma cortisol was determined 5 d after TSS, and MSC and urinary cortisol (UC) were determined 6-12 months after surgery. The remission group included hypocortisolic (morning plasma cortisol < 50 ng/ml and/or insufficient response to cosyntropin) and eucortisolic (midnight plasma cortisol < 75 ng/ml and normal UC) patients. Patients in the treatment failure group had high midnight plasma cortisol and UC concentrations. RESULTS Fifty patients (74%) were in remission. Mean MSC was 0.7 +/- 0.4 ng/ml (range, 0.4-2.1 ng/ml) and 6.5 +/- 6.5 ng/ml (range, 2.1-27.2 ng/ml) for the remission and treatment failure groups, respectively (P = 0.001). A cutoff of 2 ng/ml for MSC gave a sensitivity of 100% and a specificity of 98% for treatment failure diagnosis, whereas UC less than 90 microg/d had a sensitivity of 71% and specificity of 98%. Postsurgical morning plasma cortisol less than or equal to 18 ng/ml had a sensitivity of 93% and specificity of 74%. CONCLUSIONS MSC is a simple, robust marker of remission after TSS for CD.
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Affiliation(s)
- Carmen A Carrasco
- Service des Maladies Endocriniennes et Métaboliques, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
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Romanholi DJPC, Machado MC, Pereira CC, Danilovic DS, Pereira MAA, Cescato VAS, Cunha Neto MBC, Musolino NRC, de Mendonça BB, Salgado LR. Role for postoperative cortisol response to desmopressin in predicting the risk for recurrent Cushing's disease. Clin Endocrinol (Oxf) 2008; 69:117-22. [PMID: 18182093 DOI: 10.1111/j.1365-2265.2007.03168.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED In the early postoperative period of Cushing's disease patients, desmopressin may stimulate ACTH secretion in the remnant corticotrophic tumour, but not in nontumour suppressed cells. OBJECTIVE The aim of this study is to evaluate the serum cortisol responses to desmopressin after pituitary surgery, establishing an optimal cut-off for absolute increment (Delta) of serum cortisol (F) suitable to predict recurrence risk. DESIGN Retrospective case record study. PATIENTS Fifty-seven Cushing's disease patients submitted to pituitary surgery and desmopressin stimulation in the early postoperative with a long-term follow-up (20-161 months) were studied. METHODS AND MEASUREMENTS Serum cortisol levels after desmopressin test (10 microg i.v.) 15-30 days after adenomectomy were used to determine DeltaF (absolute increment of F: F peak - F baseline). Sensitivity and specificity of DeltaF were calculated and a ROC curve was performed to establish an optimal cut-off for DeltaF to predict recurrence risk. RESULTS Fifteen patients had immediate postoperative failure (basal F > 165 nmol/l; 6 microg/dl) and one patient was lost during the follow-up. Forty-one patients achieved initial remission and were followed-up. Five of 11 patients who recurred had DeltaF > 193 nmol/l (7 microg/dl), but none of 30 patients who remained in prolonged remission showed DeltaF > 193 nmol/l after postoperative desmopressin stimulation. CONCLUSIONS Persistence of cortisol response (DeltaF > 193 nmol/l) to desmopressin in the early postoperative period can help to identify Cushing's disease patients with initial remission who present risk for later recurrence.
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Reimondo G, Pia A, Bovio S, Allasino B, Daffara F, Paccotti P, Borretta G, Angeli A, Terzolo M. Laboratory differentiation of Cushing's syndrome. Clin Chim Acta 2007; 388:5-14. [PMID: 18053807 DOI: 10.1016/j.cca.2007.10.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 10/16/2007] [Accepted: 10/31/2007] [Indexed: 11/20/2022]
Abstract
Cushing's syndrome (CS) is a complex of signs and symptoms due to chronic glucocorticoid excess from a variety of causes. Although CS is considered a rare disease, recent studies have suggested that it may be more frequent than previously expected in various clinical settings (i.e. subjects suffering from diabetes, osteoporosis or metabolic syndrome). If confirmed in large population-based studies, more widespread screening for CS may be warranted. Missed diagnosis of CS may have detrimental consequences because hypercortisolism, even if not clinically apparent, increases the probability of future cardiovascular events through induction/amplification of several risk factors (hypertension, central adiposity, thrombophilic state, etc.). Identifying CS has represented one of the most challenging problems for the clinical endocrinologist since no test is 100% sensitive and specific. This review article will be focus on diagnostic laboratory procedures that support a rationale approach in the screening evaluation and in the differential diagnosis of the endogenous CS. Notwithstanding the difficulties derived from laboratory reliability and the adoption of a hormonal cut-off close to the sensitivity of many commercially available assays, an increasing amount of data have provided novel information aimed to meet the demand of inexpensive, convenient and reliable laboratory procedures.
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Affiliation(s)
- Giuseppe Reimondo
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Medicina Interna I, ASO San Lugi, Orbassano (TO), Italy.
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Czepielewski MA, Rollin GA, Casagrande A, Ferreira NP. Criteria of cure and remission in Cushing's disease: an update. ACTA ACUST UNITED AC 2007; 51:1362-72. [DOI: 10.1590/s0004-27302007000800023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 10/30/2007] [Indexed: 11/22/2022]
Abstract
We review the clinical and biochemical criteria used for evaluation of the transsphenoidal pituitary surgery results in the treatment of Cushing's disease (CD). Firstly, we discuss the pathophysiology of the hypothalamic-pituitary-adrenal axis in normal subjects and patients with CD. Considering the series published in the last 25 years, we observed a significant variation in the remission or cure criteria, including the choice of biochemical tests, timing, threshold values to define remission, and the interference of glucocorticoid replacement or previous treatment. In this context we emphasize serum cortisol levels obtained early (from hours to 12 days) in the postoperative period without any glucocorticoid replacement or treatment. Our experience demonstrates that: (i) early cortisol < 5 to 7 µg/dl, (ii) a period of glucocorticoid dependence > 6 mo, (iii) absence of response of cortisol/ACTH to CRH or DDAVP, (iv) return of dexamethasone suppression, and circadian rhythm of cortisol are appropriate indices of remission of CD. In patients with undetectable cortisol levels early after surgery, recurrence seems to be low. Finally, although certain biochemical patterns are more suggestive of remission or surgical failure, none has been proven to be completely accurate, with recurrence observed in approximately 10 to 15% of the patients in long-term follow-up. We recommended that patients with CD should have long-term monitoring of the CRH-ACTH-cortisol axis and associated co-morbidities, especially hypopituitarism, diabetes mellitus, hypertension, cardiovascular disturbances, and osteoporosis.
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Abstract
Cushing's syndrome results from lengthy and inappropriate exposure to excessive glucocorticoids. Untreated, it has significant morbidity and mortality. The syndrome remains a challenge to diagnose and manage. Here, we review the current understanding of pathogenesis, clinical features, diagnostic, and differential diagnostic approaches. We provide diagnostic algorithms and recommendations for management.
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Affiliation(s)
- John Newell-Price
- Division of Clinical Sciences, University of Sheffield, Northern General Hospital, Sheffield, UK.
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