Incidentalomas o no incidentalomas: ¿cuál es la relevancia de los adenomas hipofisarios en el adulto? / Incidentalomas or Non-Incidentalomas: What is the Relevance of Pituitary Adenomas in the Adult?

Introducción: desde el punto de vista anatómico, los adenomas hipofisarios (AH) se observan en el 10% de la población. Son en su mayoría pequeños y no funcionantes. La mayoría de los incidentalomas descubiertos en estudios de imágenes con alta resolución pedidos en situaciones clínicas frecuentes, como el traumatismo craneoencefálico, el accidente cerebrovascular y las demencias, corresponden a AH indolentes. Nos preguntamos cuál es la relevancia clínica de los adenomas hipofisarios. Desarrollo: los AH clínicamente relevantes son tumores en su mayoría benignos que conllevan, en diferentes proporciones, aumento en la morbilidad y/o mortalidad de los pacientes por mecanismos relacionados con la hipersecreción hormonal, la insuficiencia hormonal y/o los efectos de masa ocupante. La prevalencia de los AH clínicamente relevantes es mayor de la que se suponía hace 20 años. Afecta aproximadamente a 1/1000 habitantes. Los más prevalentes son los prolactinomas y los adenomas no funcionantes. La acromegalia, la enfermedad de Cushing y los tumores agresivos se traducen en pacientes complejos con mayor morbimortalidad. El diagnóstico temprano y el tratamiento multimodal proveen una razonable mejoría de la sobrevida. El estudio epidemiológico de los AH clínicamente relevantes es importante para la estimación del impacto en los sistemas de salud. Conclusiones: los estudios por imágenes de mejor resolución continuarán señalando incidentalomas hipofisarios. Una evaluación cuidadosa de los pacientes podrá identificar aquellos AH clínicamente relevantes. (AU)

Introduction: from the anatomical point of view, pituitary adenomas (HA) are observed in 10% of the population. They are mostly small and non-functioning. Most incidentalomas discovered in high-resolution imaging studies ordered in frequent clinical situations, such as head trauma, stroke and dementia, correspond to indolent HA. We wonder what is the clinical relevance of pituitary adenomas. Development: clinically relevant HAs are mostly benign tumors that lead, in different degrees, to an increased morbidity and/or mortality in patients by mechanisms related to hormone hypersecretion, hormone insufficiency and/or occupying mass effects. The prevalence of clinically relevant HA is higher from what was assumed 20 years ago. It affects approximately 1/1000 of the population. The most prevalent are prolactinomas and non-functioning adenomas. Acromegaly, Cushing's disease and aggressive tumors make for complex patients with increased morbidity and mortality. Early diagnosis and multimodal treatment provide a reasonable improvement in survival. Epidemiological study of clinically relevant HAs is important for estimating the impact on health systems. Conclusions: Higher-resolution imaging studies will continue to highlight pituitary incidentalomas. Careful evaluation of patients will identify clinically relevant HAs. (AU)

Determinants of Clinical Behavior and Prognosis in Cushing's Disease: A Quest for Useful Biomarkers

ABSTRACT Cushing's disease (CD) is the most common cause of endogenous hypercortisolemia. The clinical management of this condition is complex and entails multiple therapeutic strategies, treatment of chronic comorbidities, and lifelong surveillance for recurrences and complications. The identification of robust, practical, and reliable markers of disease behavior and prognosis could potentially allow for a tailored and cost-efficient management of each patient, as well as for a reduction of the medical procedure-associated stress. For this purpose, multiple clinical, biochemical, imaging, histopathological, molecular, and genetic features have been evaluated over the years. Only a handful of them, however, have been sufficiently validated for their application in the routine care of patients with CD. This review summarizes the current status of the established and potential biomarkers of CD, bases for their use, proposed and/or established utility, as well as advantages and barriers for their implementation in the clinic.

Approach to the patient with Cushing′s disease with a false negative result in inferior petrosal sinus sampling / 中华内分泌代谢杂志

Bilateral inferior petrosal sinus sampling(BIPSS), with or without desmopressin stimulation, is the gold standard in the diagnosis of Cushing′s disease. A few of patients with Cushing′s disease present a false negative result in BIPSS. These patients are often misdiagnosed as ectopic adrenocorticotropin(ACTH) syndrome(EAS). Here we report a case of Cushing′s disease with a false negative BIPSS, in the hope to aid clinical physicians in the differential diagnosis and treatment of ACTH-dependent Cushing′s syndrome.

Lesiones sincrónicas selares: adenoma hipofisario y quiste de la bolsa de Rathke / Collision sellar lesions: pituitary adenoma and Rathke cleft cyst

Resumen El quiste de la bolsa de Rathke (QBR) es una entidad benigna de crecimiento lento que proviene del remanente del ectodermo primitivo. Presenta un origen común con los adenomas hipofisarios (AH), sin embargo, la presentación sincrónica de un AH y un QBR es infrecuente. Presentamos el caso de una mujer de 41 años con enfermedad de Cushing. Se realizó resonancia magnética con el hallazgo de dos lesiones en región selar. Se hizo un abordaje transnasal endoscópico, con exéresis completa de ambas. El informe de anatomía patológica reveló un AH corticotropo y un QBR. Tuvo una remisión clínica analítica endocrinológica a los seis meses postquirúrgicos. Ante el hallazgo de una imagen quística a nivel selar concomitante con un adenoma hipofisario, debe ser considerada la posibilidad diagnóstica de un QBR.

Abstract Rathke's cleft cyst (RCC) are a slow-growing, benign, cystic lesions that arises from the remnants of the primitive ectoderm and Rathke's pouch. They present a common origin with pituitary adenomas (PA), however, the concomitant presentation of a PA and a RCC rarely occur. We present a case of a 41-year-old female with Cushing's disease. Magnetic resonance imaging (MRI) showed two synchronic lesions in the sellar region. An endoscopic transnasal approach was performed, with complete excision of both. The histological studies revealed an ACTH secreting PA and a RCC. The patient presented clinical and endocrinological remission six months after surgery. With the presence of cystic lesion at the sellar region, and the concomitant finding of a pituitary adenoma, RCC should be considered.

Diagnosis and management of Cushing′s syndrome in pregnant women / 中华内分泌代谢杂志

Cushing′s syndrome during pregnancy is a very rare clinical condition, but can be seriously detrimental to mothers and fetuses. The gestation could lead to an increase of endogenous adrenal cortisol which could mimick the symptoms of Cushing′s syndrome and also cause difficulty in biochemical diagnosis. Moreover, the therapy of Cushing′s syndrome need to be optimized based on the classification of the pathogenesis, the timing of terminating pregnancy should be considered prudently and comprehensively in this condition. This article mainly reviews the diagnosis and therapies of Cushing′s syndrome concomitant with pregnancy and provides possible suggestions for the management of this condition.

Adrenocorticotropic Hormone-Secreting Esthesioneuroblastoma with Ectopic Cushing's Syndrome

Esthesioneuroblastoma as a source of ectopic Cushing's syndrome is rare, and to the best of our knowledge, only 20 cases have been reported worldwide. A 46-year-old healthy man visited a local clinic for general weakness and hyposmia, and underwent examination with serial endocrinological workup and brain imaging. ⁶⁸Gallium-DOTA-TOC positron emission tomography scan was helpful where diagnosis of sellar MRI and inferior petrosal sinus sampling were discordant. Combined transcranial and endoscopic endonasal approach surgery was performed, and a diagnosis of esthesioneuroblastoma was given.

Long-term outcome after bilateral adrenalectomy in Cushing's disease with focus on Nelson's syndrome

ABSTRACT Objective We analyzed the clinical, biochemical, and imaging findings of adrenalectomized patients with Cushing's disease (CD) in order to compare the characteristics of those who developed Nelson's syndrome (NS) versus those who did not develop this complication (NNS), aiming to identify possible predictive factors for its occurrence. Subjects and methods We performed a retrospective review of the clinical records of a group of patients with CD who underwent TBA between 1974 and 2011. Results Out of 179 patients with CD, 13 (7.3%) underwent TBA. NS occurred in 6 of them (46%) after a mean of 24 months from the total bilateral adrenalectomy (TBA). Age at diagnosis, duration of Cushing's syndrome (CS) until TBA, and steroid replacement doses were similar in both groups. Initial urinary cortisol levels (24-hour urinary free cortisol [UFC]) were significantly higher in the NS group than in the NNS group (p = 0.009). Four patients in the NS group and three of those in the NNS group received radiotherapy before TBA (p = 0.26). Three patients in the NS group presented residual tumors before TBA, compared with none in the NNS group (p = 0.04). At 1 year after TBA, the median ACTH level was 476 ng/L (240-1500 ng/L) in the NS group and 81 ng/L (48-330 ng/L) in the NNS group (p = 0.0007). Conclusion In conclusion, a residual tumor before TBA, higher 24-hour UFC at diagnosis, and increasing ACTH levels within 1 year after TBA emerged as predictive factors of development of NS.

Study of management strategies in ACTH secreting pituitary microadenoma of Cushing disease

Background: Pituitary Microadenomas can be defined as small lesions less than 1 cm in the pituitary and detected as incidentalomas. Partial development or late development around puberty leads to maldevelopment of secondary sexual characteristics due to pituitary adenomas. Clinically this may manifest as secondary amenorrhoea and may lead to hyperprolactinaemia, galactorrhoea and Amenorrhoea. ACTH secreting micro adenomas of the Pituitary Gland is a clinical entity where the role of surgery is contemplated. This study attempted to explore the management options and strategies for pituitary microadenomas. The aim of the study: To highlight the characteristics of Cushing’s disease and discuss the management strategies including trans-sphenoidal surgery to treat ACTH secreting pituitary microadenomas. Materials and methods: This was a non-randomised prospective observational study involving all adrenal tumors from 2007-2017 in Madras Medical College, Chennai. Two adrenocortical adenomas M.S. Senthil Kumar, Rajan Ganesan, A. Nithyanandham, V. Kannan, T. Suresh Babu, K. Prabhakaran. Study of management strategies in ACTH secreting pituitary microadenoma of Cushing’s disease. IAIM, 2019; 6(3): 253-258. Page 254 with virilising features were ruled out and 8 ACTH secreting Cushing's disease with microadenomas were identified. 3 Patients with ACTH secreting microadenomas of Cushing's disease underwent surgery whereas 3 underwent medical treatment based on which this paper attempted to discuss management strategies for Cushings disease. Results: ACTH levels were measurable with an average of 136.71pg/ml (normal 7.2-63.3 pg/ml) Corticotrophin releasing hormone test was planned to evaluate an exaggerated response of serum cortisol consistent with pituitary disease. It was not carried out and inferior petrosal sampling also was not done. Biochemical evaluation confirmed pituitary dependent Cushing’s disease. MRI revealed a prominent circumscribed lesion suggestive of a Pituitary Micro Adenoma in All 6 Cases. Conclusion: Pituitary micro adenomas are operable and in Cushing’s disease offer an effective cure. The outcome is good with minimal complications, but surgeons must have a thorough knowledge of the surrounding anatomy and potential complications.

Retroperitoneal laparoscopic operation for the treatment of Cushing disease: a report of 38 cases / 中华泌尿外科杂志

Objective To evaluate the feasibility and clinical efficacy of retroperitoneal laparoscopic adrenalectomy for the treatment of Cushing disease.Methods Clinical data collected from 38 cases retroperitonel laparoscopic adrenalectomy for Cushing disease,from February 2006 to February 2017 were analyzed retrospectively.Among them,there were 6 males and 32 females aged from 13 to 66 years old,with an average age of 38 years old.The disease history ranged from 2 to 96 months,with an average of 28.3 months.Besides,there were 32 cases that had previous history of transsphenoidal pituitary tumor surgery and or radiotherapy.All 38 cases underwent retroperitoneal laparoscopic adrenalectomy therapy.There were 8 cases accepted right adrenalectomy and left subtotal adrenalectomy at the same time,24 cases accepted unilateral adrenalectomy,another 6 cases of pituitary tumors without lesions in medical imaging underwent unilateral adrenalectomy.Results All operations were completed sucessfully without conversion to open surgery and mortality.There was no blood transfusion during the period of operation.The operation time ranged from 30 min to 270 min (mean 88.3 min),the amount of bleeding was among the range of 10 ml to 200 ml (mean 38.33 ml).During 2 to 13 years of the follow up (mean 7 years),the 24 h urine cortisol concentration in the first day after surgery of piatients with subtotal resection was 90.35-220.84 μg/24h (mean 102.83 μg/24h),and 6 cases were in the normal range.After surgery 6-11 months,the clinical symptoms completely disappeared.The hormone replacement therapy was discontinued 1-3 months after surgery.However,There were 3 cases treated with residual adrenalectomy because of the recurrence after 1,3.5,5.0 years respectively.30 cases underwent unilateral adrenalectomy,whose 24 h urine cortisol concentration in the first day after surgery was 99.80-550.84 μg/24h (mean 372.83 μg/24h),among which 24 cases were beyond normal range,and another 6 cases were within the normal range.Reviewing 24 h urine cortisol concentration one month later after operation,it was 382.16-520.34 μg/24h (mean 461.62 μg/24h),with the results of all cases being higher than the normal range,the clinical symptoms were not relieved satisfactorily.During 2 to 7 months after surgery,there were 22 cases further underwent contralateral subtotal adrenalectomy (80％),the remaining 8 cases underwent contralateral adrenalectomy and autologous transplantation of adrenal tissue.Immediately one day after surgery,the 24 h urine cortisol concentration level of patients was ranged from 62.58 to 182.34 μg/24h (mean 92.83 μg/24h),and all 22 cases were within the normal range.The clinical symptoms completely disappeared during next 6 to 9 months after surgery,and hormone replacement therapy was discontinued 3 months after surgery.There were 2 cases received residual adrenalectomy because of the recurrence.Lifelong hormone replacement therapy after surgery occurred in 13 cases and 5 cases developed Nelson syndrome.Conclusions Retroperitoneal laparoscopic of unilateral adrenalectomy and contralateral subtotal adrenalectomy for the treatment of Cushing disease was safe and effective.The contralateral adrenal subtotal resection could be performed at an appropriate time in the case of that the clinical symptoms not obvious.By doing so,it could significantly alleviate the clinical symptoms as well as avoiding lifelong hormone replacement therapy.Once recurrence,residual adrenalectomy can be considered.

Midnight salivary cortisol for the diagnosis of Cushing's syndrome in a Chinese population

INTRODUCTION@#Cushing's syndrome is defined as chronic excess free cortisol in circulation. According to recent studies, midnight salivary cortisol is an accurate and non-stress method for screening and diagnosing Cushing's syndrome. However, there is limited data on midnight salivary cortisol for diagnosing Cushing's syndrome in the Chinese population.@*METHODS@#Among 61 suspected Chinese patients, 48 patients were confirmed to have Cushing's syndrome. We evaluated the midnight salivary cortisol, midnight serum cortisol and 24-hour urine free cortisol excretion for diagnosis. Midnight salivary cortisol was collected from 21 healthy volunteers for control purposes.@*RESULTS@#In the patient group, mean urine free cortisol excretion and midnight salivary cortisol levels were 296.50 ± 47.99 µg/day and 10.18 ± 1.29 ng/mL, respectively. Among the control group and normal participants, mean midnight salivary cortisol level was 0.53 ± 0.13 ng/mL and 0.50 ± 0.12 ng/mL, respectively. The cut-off value for midnight salivary cortisol was 1.7 ng/mL for diagnosing Cushing's syndrome, with a sensitivity of 98% and specificity of 100%. The diagnostic performance of midnight salivary cortisol (area under the curve [AUC] = 0.99) was superior to that of urine free cortisol (AUC = 0.89).@*CONCLUSION@#Our study confirmed the good diagnostic performance of midnight salivary cortisol for diagnosing Cushing's syndrome in a Chinese population. Correlation between midnight salivary cortisol and either urine free cortisol or midnight serum cortisol was good. Midnight salivary cortisol is a convenient and precise tool for diagnosing Cushing's syndrome and can be the screening test of choice for Chinese populations.

A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism

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.

Comparison of 3D Volumetric Subtraction Technique and 2D Dynamic Contrast Enhancement Technique in the Evaluation of Contrast Enhancement for Diagnosing Cushing's Disease

PURPOSE: The purpose of this study is to compare the performance of the T1 3D subtraction technique and the conventional 2D dynamic contrast enhancement (DCE) technique in diagnosing Cushing's disease. MATERIALS AND METHODS: Twelve patients with clinically and biochemically proven Cushing's disease were included in the study. In addition, 23 patients with a Rathke's cleft cyst (RCC) diagnosed on an MRI with normal pituitary hormone levels were included as a control, to prevent non-blinded positive results. Postcontrast T1 3D fast spin echo (FSE) images were acquired after DCE images in 3T MRI and image subtraction of pre- and postcontrast T1 3D FSE images were performed. Inter-observer agreement, interpretation time, multiobserver receiver operating characteristic (ROC), and net benefit analyses were performed to compare 2D DCE and T1 3D subtraction techniques. RESULTS: Inter-observer agreement for a visual scale of contrast enhancement was poor in DCE (κ = 0.57) and good in T1 3D subtraction images (κ = 0.75). The time taken for determining contrast-enhancement in pituitary lesions was significantly shorter in the T1 3D subtraction images compared to the DCE sequence (P < 0.05). ROC values demonstrated increased reader confidence range with T1 3D subtraction images (95% confidence interval [CI]: 0.94–1.00) compared with DCE (95% CI: 0.70–0.92) (P < 0.01). The net benefit effect of T1 3D subtraction images over DCE was 0.34 (95% CI: 0.12–0.56). For Cushing's disease, both reviewers misclassified one case as a nonenhancing lesion on the DCE images, while no cases were misclassified on T1 3D subtraction images. CONCLUSION: The T1 3D subtraction technique shows superior performance for determining the presence of enhancement on pituitary lesions compared with conventional DCE techniques, which may aid in diagnosing Cushing's disease.

An activating mutation in the CRHR1 gene is rarely associated with pituitary-dependent hyperadrenocorticism in poodles

OBJECTIVES: Pituitary-dependent hyperadrenocorticism is the most common cause of naturally occurring hypercortisolism in dogs. CRHR1 expression in human and dog corticotrophinomas suggested that this gene affects pituitary tumorigenesis. The present study aimed to investigate mutations in the CRHR1 coding region in poodles with pituitary-dependent hyperadrenocorticism. METHODS: Fifty poodles with pituitary-dependent hyperadrenocorticism and 50 healthy poodles were studied. Genomic DNA was amplified by PCR and analyzed by Sanger sequencing. RESULTS: The novel CRHR1 p.V97M mutation was identified in one dog. This valine residue, located in the amino-terminal extracellular domain, exhibits high affinity for its corticotropin-releasing hormone (CRH) ligand. Bioinformatic analysis revealed structural rearrangements in the mutant protein, with a 17% increase in the surface binding affinity between CRHR1 and CRH. In vitro functional studies showed that mutant CRHR1 induced higher ACTH secretion than the wild type after stimulation with human CRH. CONCLUSION: These results suggest that germline activating mutations in CRHR1 may be a rare cause of pituitary hyperadrenocorticism in poodles.

Recent Progress in the Medical Therapy of Pituitary Tumors

Management of pituitary tumors is multidisciplinary, with medical therapy playing an increasingly important role. With the exception of prolactin-secreting tumors, surgery is still considered the first-line treatment for the majority of pituitary adenomas. However, medical/pharmacological therapy plays an important role in controlling hormone-producing pituitary adenomas, especially for patients with acromegaly and Cushing disease (CD). In the case of non-functioning pituitary adenomas (NFAs), pharmacological therapy plays a minor role, the main objective of which is to reduce tumor growth, but this role requires further studies. For pituitary carcinomas and atypical adenomas, medical therapy, including chemotherapy, acts as an adjuvant to surgery and radiation therapy, which is often required to control these aggressive tumors. In the last decade, knowledge about the pathophysiological mechanisms of various pituitary adenomas has increased, thus novel medical therapies that target specific pathways implicated in tumor synthesis and hormonal over secretion are now available. Advancement in patient selection and determination of prognostic factors has also helped to individualize therapy for patients with pituitary tumors. Improvements in biochemical and “tumor mass” disease control can positively affect patient quality of life, comorbidities and overall survival. In this review, the medical armamentarium for treating CD, acromegaly, prolactinomas, NFA, and carcinomas/aggressive atypical adenomas will be presented. Pharmacological therapies, including doses, mode of administration, efficacy, adverse effects, and use in special circumstances are provided. Medical therapies currently under clinical investigation are also briefly discussed.

A rare case of multiple pituitary adenomas in an adolescent Cushing disease presenting as a vertebral compression fracture

Cushing disease in children and adolescents, especially with multiple pituitary adenomas (MPAs), is very rare. We report 17-year-old boy with MPAs. He presented with a vertebral compression fracture, weight gain, short stature, headache, and hypertension. On magnetic resonance imaging (MRI), only a left pituitary microadenoma was found. After surgery, transient clinical improvement was observed but headache and hypertension were observed again after 3 months later. Follow-up MRI showed a newly developed right pituitary microadenoma 6 months after the surgery. The need for careful clinical and radiographic follow-up should be emphasized in the search for potential MPAs in patients with persistent Cushing disease.

Characteristics of brain functional alterations and task functional magnetic resonance imaging in patients with Cushing's disease / 解放军医学杂志

Objective To analyze the relationship between the brain functional alterations of patients with Cushing's disease (CD) and patients' mental symptom by applying the Evaluating Emotional Scales and task functional magnetic resonance imaging (Task fMRI).Methods Task fMRI was performed on 8 patients with diagnosed CD admitted in the Department of Endocrinology of Chinese PLA General Hospital from Nov. 2015 to Nov. 2016 and 21 healthy people with matched age, gender and education level as control. Meanwhile, Self-Rating Depression Scale (SDS), Self-Rating Anxiety Scale (SAS), Positive and Negative Affective Scale (PANAS) and Cushing Quality of Life Scale (Cushing QOL) were obtained to assess the brain functions.Results Significant depression and anxiety were observed in patients with CD, and their positive affective score was substantially lower while the negative affective score was relatively higher compared with that in the controls. Task fMRI revealed that, when watching the positive pictures, the activation degree of left cerebellum and right postcentral gyrus weakened in CD patients than in the controls, and the positive correlations existed between the activation degree of left cerebellum and the 16 o'clock adrenocorticotrophic hormone (ACTH) level, and between the activation degree of right postcentral gyrus and the urinary free cortisol (UFC) level in CD patients. In contrast, when watching the negative pictures, the activation degree of left cerebellum, bilateral parahippocampal gyrus and left inferior frontal gyrus was weakened in CD patients than in the controls, and the activation degree of left cerebellum was negatively correlated to the 0 o'clock cortisol level and SAS score, but is positively correlated to the UFC level. When watching the neutral pictures, the activation degree of left cerebellum and left parahippocampal gyrus was weakened in CD patients than in the controls.Conclusions CD patients may have impaired brain function with depression and anxiety mental symptoms. By Task fMRI, it can be found that the weakened activation degree of left inferior frontal gyrus, right postcentral gyrus, bilateral parahippocampal gyrus and left cerebellum may be related to CD patients' mental symptoms.

Long-term Results after CT-Guided Percutaneous Ethanol Ablation for the Treatment of Hyperfunctioning Adrenal Disorders

OBJECTIVES: To evaluate the safety and long-term efficacy of computed tomography-guided percutaneous ethanol ablation for benign primary and secondary hyperfunctioning adrenal disorders. METHOD: We retrospectively evaluated the long-term results of nine patients treated with computed tomography-guided percutaneous ethanol ablation: eight subjects who presented with primary adrenal disorders, such as pheochromocytoma, primary macronodular adrenal hyperplasia and aldosterone-producing adenoma, and one subject with Cushing disease refractory to conventional treatment. Eleven sessions were performed for the nine patients. The patient data were reviewed for the clinical outcome and procedure-related complications over ten years. RESULTS: Patients with aldosterone-producing adenoma had clinical improvement: symptoms recurred in one case 96 months after ethanol ablation, and the other patient was still in remission 110 months later. All patients with pheochromocytoma had clinical improvement but were eventually submitted to surgery for complete remission. No significant clinical improvement was seen in patients with hypercortisolism due to primary macronodular adrenal hyperplasia or Cushing disease. Major complications were seen in five of the eleven procedures and included cardiovascular instability and myocardial infarction. Minor complications attributed to sedation were seen in two patients. CONCLUSION: Computed tomography-guided ethanol ablation does not appear to be suitable for the long-term treatment of hyperfunctioning adrenal disorders and is not without risks.

Cushing’s Disease and High Dose Cabergoline Monotherapy: Rapid and Sustained Clinical and Biochemical Improvement, with Reversal of Diabetes, Hypertension and Infertility.

Aims: To assess the effects of high dose long term cabergoline monotherapy in a patient with Cushing's disease refusing any form of surgical intervention. Presentation of the Case: A 32-year-old Omani female with hypertension, diabetes mellitus and secondary infertility of 10 years and amenorrhoea of 2 years duration, was referred with recurrent thigh abscesses. She was on 100 units of mixed insulin in two divided doses, metformin 1 gm bd, lisinopril 20 mg od, amlodipine 10 mg od and indapamide 1.5 mg od ."She had all the features of Cushing’s syndrome, with a blood pressure (BP) of 180/110 mmHg, plethoric facies, central obesity and striae". Investigations revealed diabetes, HBA1c 10.7% and ACTH-dependant Cushing’s syndrome, "cortisol 720 nmol/L (normal <624) and ACTH 14.9 pmol/L. (normal 1.6-13.8)". The pituitary MRI and computerised tomographic ( CT) scans from neck to pelvis “ were normal” A neuroendocrine tumour (NET) was deemed unlikely as serum cortisol levels did not “suppress during by a 72 hours trial” of octreotide 100 mcg 8 hourly and her serum chromogranin- A level (CgA) was normal. A diagnosis of Cushing’s disease was made. She refused inferior petrosal sinus sampling (IPSS) and any form of surgery. A trial of cabergoline was agreed upon. Her response was dramatic: On 1 mg daily initially, the serum cortisol was normal after one week, and by 4 months her blood sugar and blood pressure were normal off all other medications. The HBA1c had fallen from 10.7% to 5.4%. Shortly afterwards she became pregnant and on a reduced dose of cabergoline (1.5 mg/week), she delivered a healthy full term baby, echocardiography was normal in both mother and baby. She has now been in complete remission for more than 4 years on cabergoline 0.5 mg 3 times a week without any side effects. Conclusion: This case provides an example of successful acute and sustained primary “monotherpy” with initially high dose cabergoline in Cushing’s disease. The additional positive metabolic effects and the lack of significant side effects makes high dose cabergoline monotherapy an attractive first or second line treatment for patients with Cushing's disease.

Clinical Guidelines for the Diagnosis and Treatment of Cushing's Disease in Korea

Cushing's disease (CD) is a rare disorder characterized by the overproduction of adrenocorticotropic hormone due to a pituitary adenoma that ultimately stimulates excessive cortisol secretion from the adrenal glands. Prior to the detection of pituitary adenomas, various clinical signs of CD such as central obesity, moon face, hirsutism, and facial plethora are usually already present. Uncontrolled hypercortisolism is associated with metabolic, cardiovascular, and psychological disorders that result in increased mortality. Hence, the early detection and treatment of CD are not only important but mandatory. Because its clinical manifestations vary from patient to patient and are common in other obesity-related conditions, the precise diagnosis of CD can be problematic. Thus, the present set of guidelines was compiled by Korean experts in this field to assist clinicians with the screening, diagnoses, and treatment of patients with CD using currently available tests and treatment modalities.

Limited Diagnostic Utility of Plasma Adrenocorticotropic Hormone for Differentiation between Adrenal Cushing Syndrome and Cushing Disease

BACKGROUND: Measurement of the plasma adrenocorticotropic hormone (ACTH) level has been recommended as the first diagnostic test for differentiating between ACTH-independent Cushing syndrome (CS) and ACTH-dependent CS. When plasma ACTH values are inconclusive, a differential diagnosis of CS can be made based upon measurement of the serum dehydroepiandrosterone sulfate (DHEA-S) level and results of the high-dose dexamethasone suppression test (HDST). The aim of this study was to assess the utility of plasma ACTH to differentiate adrenal CS from Cushing' disease (CD) and compare it with that of the HDST results and serum DHEA-S level. METHODS: We performed a retrospective, multicenter study from January 2000 to May 2012 involving 92 patients with endogenous CS. The levels of plasma ACTH, serum cortisol, 24-hour urine free cortisol (UFC) after the HDST, and serum DHEA-S were measured. RESULTS: Fifty-seven patients had adrenal CS and 35 patients had CD. The area under the curve of plasma ACTH, serum DHEA-S, percentage suppression of serum cortisol, and UFC after HDST were 0.954, 0.841, 0.950, and 0.997, respectively (all P<0.001). The cut-off values for plasma ACTH, percentage suppression of serum cortisol, and UFC after HDST were 5.3 pmol/L, 33.3%, and 61.6%, respectively. The sensitivity and specificity of plasma ACTH measurement were 84.2% and 94.3%, those of serum cortisol were 95.8% and 90.6%, and those of UFC after the HDST were 97.9% and 96.7%, respectively. CONCLUSION: Significant overlap in plasma ACTH levels was seen between patients with adrenal CS and those with CD. The HDST may be useful in differentiating between these forms of the disease, especially when the plasma ACTH level alone is not conclusive.