Recurrent Cushing's Disease in Adults: Predictors and Long-Term Follow-Up

Cushing's disease (CD) is characterized by endogenous hypercortisolism that is associated with increased mortality and morbidity. Due to high recurrence rates in CD, the determination of high-risk patients is of paramount importance. In this study, we aimed to determine recurrence rates and clinical, laboratory, and histological predictors of recurrence in a high volume single-center. This retrospective study included 273 CD patients operated in a single pituitary center between 1997 and 2020. The patients with early postoperative remission were further grouped according to recurrence status (recurrent and sustained remission groups). Demographic, radiologic, laboratory, pathologic, and follow-up clinical data of the patients were analyzed and compared between groups. The recurrence rate was 9.6% in the first 5 years; however, the overall recurrence rate was 14.2% in this study. Higher preoperative basal ACTH levels were significantly correlated with CD recurrence even with ACTH levels adjusted for tumor size, Ki-67 levels, and tumoral invasion. Recurrence rates were significantly higher in patients with ACTH levels higher than 55 pg/ml, tumor diameter>9.5 mm, and if adrenal axis recovery was before 6 months. The severity of hypercortisolism, morbidities, and demographic factors except age were not predictive factors of recurrence. Based on our study data, younger age at diagnosis, a diagnosis of osteoporosis, higher preoperative ACTH levels, larger tumor size, invasive behavior, higher Ki 67 index, and early recovery of the adrenal axis during the postoperative period attracted attention as potential predictors of recurrent disease.

Xanthomatous Hypophysitis Secondary to a Ruptured Rathke's Cleft Cyst: A Case Report

Hypophysitis (HP) is a rare disease which develops secondary to chronic or acute inflammation of the pituitary gland and may cause symptoms related to pituitary dysfunction and mass compression. Lymphocytic HP is the most common subtype of primary HP, while xanthomatous HP (XHP) is considered the rarest form, with 35 reported cases, to date. A 35-year-old woman was initially admitted to a Gynecology clinic with a 2-year history of amenorrhea and headache. She was started on cabergoline 0.5 mg twice a week for macroprolactinoma. Due to persistent amenorrhea with low gonadotropins, she was referred to our Endocrinology clinic. Her pituitary function profile revealed panhypopituitarism and a 13×11×12 mm sized sellar mass with diffuse enhancement which sustained toward the infundibulum and dura was observed on the gadolinium-enhanced pituitary MRI. The patient underwent an endoscopic endonasal transsphenoidal approach for tumor resection and thick yellowish fluid draining from the lesion was observed. The histopathological diagnosis was reported as a rupture of an Rathke’s cleft cyst and an XHP. The surgery did not improve the symptoms/pituitary functions, however, headache recovered immediately after the first dose of high dose methylprednisolone treatment. The inflammatory process in a xanthomatous lesion may actually be a secondary response to mucous fluid content release from a ruptured cyst, thus recommended to classify XHP as secondary hypophysitis. Since the differentiation of XHP from other pituitary tumors may be challenging preoperatively, surgery is the major diagnostic tool and also, the most recommended therapeutic option.

A single-center experience with giant cell tumors of sphenoid bone and clivus

OBJECTIVE

To present pathologic, clinical, and treatment findings for giant cell tumors (GCTs) of sphenoid bone and clivus.

METHODS

We describe the optimal treatment algorithm in patients with a histopathologic diagnosis of bone GCT by presenting the effects of denosumab treatment in both pediatric and adult patients with GCT undergoing endoscopic transnasal surgery. Clinicopathologic correlation is crucial for the differential diagnosis of GCT and the choice of treatment modality.

CONCLUSION

GCT of bone is a local aggressive tumor that accounts for about 3%-7% of all bone tumors. GCTs located in the cranium are extremely uncommon neoplasms. There are no defined guidelines for the treatment of GCTs in skull base. Following surgical resection of the tumor, the addition of denosumab treatments to radiotherapy has a significant role in preventing the recurrence of GCT and in promoting regression of residual tumor size.

The association between insulin-like growth factor 1 levels within reference range and early postoperative remission rate in patients with Cushing's disease

INTRODUCTION

The relationship between growth hormone (GH)/insulin-like growth factor 1 (IGF-1) and glucocorticoids (GC) was examined in various studies. Long-term GC treatment was shown to decrease GH concentration and, interestingly, to increase IGF-1 concentration. We performed a retrospective study in order to examine how preoperative IGF-1 concentrations vary within the reference range and if tertiles of age- and sex-adjusted normal IGF-1 are predictive for early postoperative remission in the patients with Cushing's Disease (CD).

PATIENTS AND METHODS

Patients diagnosed with CD were retrospectively evaluated. After the exclusion of 67 patients, a final cohort of 250 CD patients were included. Age- and sex-adjusted normal IGF-1 levels were divided into tertiles (T1, T2 and T3). Early postoperative remission was defined as a nadir morning cortisol concentration measured within the first 3 consecutive days following surgery of less than 5 µg/dL (138 nmol/L).

RESULTS

Early postoperative remission rate was the lowest in T1 and highest in T3; 49.1% (n = 28) versus 77.3% (n = 75), p = .001, respectively. Binary logistic regression analysis showed the remission rate in T3 was three times higher than that in T1 (p = .003). Cortisol and ACTH concentration were significantly higher and GH concentrations were significantly lower in T1 compared to those in the other two tertiles.

CONCLUSIONS

As the first study evaluating the correlation between early postoperative remission rate in patients with CD and the tertiles of normal age- and sex-adjusted IGF-1 levels, we have shown that higher IGF-1 levels could predict better outcome in CD.

The levels of bioactive compounds found in raw and cooked Canadian pulses

The effect of cooking on the levels of bioactive compounds (oligosaccharides, polyphenols and saponins, and vicine/convicine for faba bean only) were examined in a wide range of Canadian pulses. The total oligosaccharide concentrations were reduced ∼40% for chickpea, 11-81% for lentils, 41-43% for faba beans, 10-51% for beans, and 20-44% for peas. Individual oligosaccharides, raffinose, ciceritol, stachyose and verbascose, increased or decreased in the cooked samples depending on each pulse sample. Cooking reduced the total polyphenol content by 13-25% for chickpeas, 0-83% for lentils, 47-54% for faba beans, 47-54% for beans, and 48-70% for peas. And, the total saponin concentrations were reduced by 11-30% for chickpeas, 0-40% for lentils, 32-46% for beans, 14-30% for peas and increased by 8-26% in faba bean. The vicine and convicine levels in faba bean were reduced by 26-38% with cooking. The reduction in bioactive compounds after cooking depended on the specific compound and specific type of pulse. This large analyses of 20 different pulse samples allows for comparison between and within different types of pulses.

Cushing's disease due to a pituitary adenoma as a component of collision tumor: A case report and review of the literature

Background

The coexistence of two morphologically different tumors attached to each other creates a very rare type of tumor called a collision tumor. Collision tumors containing pituitary adenoma–sellar meningioma have only been described in four cases to date; we discuss a fifth case harboring a collision tumor comprising a pituitary corticotroph adenoma and a sellar meningioma in the same anatomic position.

Case presentation

A 34-year-old Caucasian woman presented with menstrual irregularity, severe weakness of the proximal muscles, and 10–15 kg weight gain within a year. Basal plasma cortisol and adrenocorticotrophic hormone levels were 17.7 mg/dL and 58 pg/mL, respectively. Her diurnal cortisol rhythm was impaired (plasma cortisol at 23:00, 18.2 mg/dL) and after a 48-hour, 2-mg dexamethasone suppression test, plasma cortisol level was 13.6 mg/dL. The results were consistent with a diagnosis of Cushing’s syndrome. We then performed a nocturnal 8-mg dexamethasone suppression test and the suppression of cortisol was not greater than 50% (21.4 to 19.3). A pituitary magnetic resonance imaging revealed a tuberculum sellae meningioma arising from within the sellar region. An operation was chosen in order to examine whether the tumor was an adrenocorticotrophic hormone/corticotropin-releasing hormone-secreting lesion or if there were any microadenomas that could be observed during the operation. Via an extended endoscopic endonasal approach the meningioma was resected successfully. Unexpectedly, our patient complained of nausea and vomiting postoperatively. Plasma cortisol was 2.6 mg/dL and orally administered hydrocortisone treatment was initiated immediately. Histopathological examination revealed that the tumor generally consisted of a pituitary corticotroph adenoma infiltrated by meningioma. Our patient maintained hydrocortisone treatment for 11 months. At the latest visit, she had lost 12 kg, and her hypertension, menstrual irregularity, and weakness of the proximal muscles had disappeared. Her mental and physical wellbeing were restored.

Conclusions

To the best of our knowledge, this is the first report of Cushing’s disease due to a pituitary corticotroph adenoma adjacent to a meningioma. Even if a high-dose dexamethasone suppression test fails to suppress basal cortisol level, the importance of considering a suprasellar/sellar meningioma a possible component of a collision tumor presenting as adrenocorticotrophic hormone-dependent Cushing’s syndrome is highlighted here.