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Background: Cushing’s disease (CD) poses significant challenges in its treatment due to the lack of reliable biomarkers for predicting tumor localization or postoperative clinical outcomes. Sphingosine-1-phosphate (S1P) has been shown to increase cortisol biosynthesis and is regulated by adrenocorticotropic hormone (ACTH). Methods: We employed bilateral inferior petrosal sinus sampling (BIPSS), which is considered the gold standard for diagnosing pituitary sources of CD, to obtain blood samples and explore the clinical predictive value of the S1P concentration ratio in determining tumor laterality and postoperative remission. We evaluated 50 samples from 25 patients who underwent BIPSS to measure S1P levels in the inferior petrosal sinuses bilaterally. Results: Serum S1P levels in patients with CD were significantly higher on the adenoma side of the inferior petrosal sinus than on the nonadenoma side (397.7 ± 15.4 vs. 261.9 ± 14.88; P < 0.05). The accuracy of diagnosing tumor laterality with the interpetrosal S1P and ACTH ratios and the combination of the two was 64%, 56% and 73%, respectively. The receiver operating characteristic curve analysis revealed that the combination of interpetrosal S1P and ACTH ratios, as a predictor of tumor laterality, exhibited a sensitivity of 81.82% and a specificity of 75%, with an area under the curve value of 84.09%. Moreover, we observed that a high interpetrosal S1P ratio was associated with nonremission after surgery. Correlation analyses demonstrated that the interpetrosal S1P ratio was associated with preoperative follicle-stimulating hormone (FSH), luteinizing hormone (LH), and postoperative ACTH 8 am levels (P < 0.05). Conclusion: Our study demonstrated a significant association between the interpetrosal S1P ratio and tumor laterality, as well as postoperative remission in CD, suggesting that the interpetrosal S1P ratio could serve as a valuable biomarker in clinical practice. 1 Introduction Cushing’s disease (CD), also known as adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma, arises from the pituitary corticotroph cells and induces endogenous hypercortisolism by stimulating the adrenal glands to produce excessive amount of cortisol (1). Patients with CD typically exhibit symptoms of hypercortisolism, such as hypertension, diabetes, purplish skin striae, mental disturbances, hyposexuality, hirsutism, menstrual disorders, acne, fatigue, obesity, and osteoporosis (1). The overall mortality of patients with CD is twice that of the general population, and if left untreated, hypercortisolism resulting from CD increases this rate to approximately four times the expected value (2–4). Transsphenoidal surgery continues to be the primary treatment for CD (5). However, previous studies reported variable remission rates, ranging from 45% to 95% (6–8). Long-term follow-up data have revealed recurrence in 3–66% of patients who had initially achieved complete remission (9, 10). The rate of surgical remission in CD can be influenced by various factors, including the size and location of the tumor, expertise of the neurosurgeon, and criteria used for assessing remission (11). Preoperative clinical variables, such as age, gender, disease duration, and severity of clinical signs and symptoms, cannot reliably identify patients at a higher risk of nonremission (12, 13). Therefore, predicting postsurgical remission in CD remains a challenging goal. Accumulating evidence has shown that sphingosine-1-phosphate (S1P), an intracellular pleiotropic bioactive sphingolipid metabolite synthesized by sphingosine kinase 1 (SPHK1), plays a pivotal role in diverse endocrine disorders (14–16). Overexpression of SPHK1 promotes the progression of multiple neuroendocrine tumors (17, 18). ACTH can rapidly activate sphingolipid metabolism, causing an increase in S1P secretion in the adrenal cortex (19). Furthermore, the activation of S1P signaling in H295R cells, a human adrenocortical tumor cell line, has been suggested to induce increased transcription of hormone-sensitive lipase and steroidogenic acute regulatory protein, ultimately elevating cortisol production (20). Recently, surgical removal of ACTH-secreting adenoma has been reported to cause a decline in sphingomyelin levels (21). However, whether they have a similar role in the pituitary gland remains to be investigated. Bilateral inferior petrosal sinus sampling (BIPSS) is a highly effective procedure for diagnosing pituitary sources of ACTH in CD (22, 23). Contemporaneous differences in ACTH concentration during venous sampling between the two sides of the adenoma can predict the location of the adenoma within the pituitary (on the side of the gland with a microadenoma) and may guide surgical treatment in cases with inconclusive magnetic resonance imaging findings. Previous studies demonstrated that an ACTH gradient of ≥1.4 between the inferior petrosal sinuses can indicate microadenoma lateralization in patients with CD (24–26). However, the correct lateralization only occurs in 57–68% of all cases (27–29). Therefore, we analyzed the clinical behavior of a well-characterized cohort of patients with CD who underwent BIPSS before surgery. We measured the difference in the concentration of S1P in bilateral petrosal sinus blood samples and explored the clinical predictive value of the S1P concentration ratio in determining tumor laterality and postoperative remission. 2 Materials and methods 2.1 Patients and study design This study was conducted at a tertiary center, involving a cohort of 25 patients diagnosed with CD who had undergone BIPSS and surgery, with a minimum follow-up duration of 2 years. Comprehensive chart reviews were conducted to collect data on demographics, clinical characteristics, pituitary imaging findings, tumor pathology, and biochemical tests. The criteria used for diagnosing CD encompassed the presence of characteristic signs and symptoms of hypercortisolism, along with biochemical evaluation of two urinary free cortisol measurements exceeding the normal range for the respective assay, serum cortisol level >1.8 μg/dL (50 nmol/L) after an overnight 1-mg dexamethasone suppression test, and two late-night salivary cortisol measurements exceeding the normal range for the respective assay (30). A diagnosis of Cushing’s syndrome was established if the patient had positive test results for at least two of the three aforementioned tests. Adrenal insufficiency was diagnosed if patients exhibited symptoms or signs of adrenal insufficiency or if serum cortisol levels were ≤3 μg/dL, even in the absence of clinical signs or symptoms. Remission was defined as normalization of the levels of 24-h urinary free cortisol, late-night salivary cortisol, and overnight 1-mg dexamethasone suppression test in patients without concurrent central adrenal insufficiency after surgery (31). 2.2 Patients and tissue/serum samples Surgical specimens of CD-affected tissues were collected from Xiangya Hospital, Central South University. Three normal pituitary tissues were obtained from cadaveric organ donors without any history of endocrine disease (Central South University). A total of 25 CD tissue samples were obtained for immunohistochemistry analysis. This study was conducted in compliance with the Helsinki Declaration and was ethically approved by the Xiangya Hospital Ethics Committee, Xiangya Hospital (Changsha, China). Tumor samples and corresponding clinical materials were obtained with written consent from all patients. 2.3 BIPSS After obtaining informed consent, BIPSS was performed using standard techniques described in previous studies (32, 33). Briefly, the patient’s head was immobilized to ensure midline positioning and prevent any potential bias towards asymmetric pituitary drainage by the petrosal sinuses. After placing peripheral catheters and cannulating both inferior petrosal sinuses, blood samples were collected at baseline and at 3, 5, 10, and 15 min following intravenous administration of DDAVP, which stimulates pituitary production of ACTH. Additional samples for experimental purposes were collected immediately following the 15-min sample collection to avoid interference with the patient’s diagnostic study. 2.4 Measurement of baseline plasma S1P concentration Blood samples were obtained from both petrosal sinuses and were centrifuged to remove cellular components. Samples that exhibited hemolysis or coagulation were excluded from the study. Plasma samples were stored at −80°C. The S1P levels in plasma were analyzed using a S1P competitive ELISA kit (Echelon Biosciences, Salt Lake City, UT) according to the manufacturer’s instructions (34). 2.5 Immunofluorescence staining The pituitary tissues were post-fixed and dehydrated with alcohol as follows: 70% for 24 h, 80% for 3 h, 90% for 4 h, 95% for 3 h, and finally in absolute alcohol for 2 h. Tissue slices with a 5-μm thickness were cut using a microtome (Thermo Fisher Scientific), blocked with 3% BSA, and then treated with primary antibodies to SPHK1 (CST, #3297) and ACTH (Proteintech, CL488-66358). Subsequently, the tissue slides were incubated with Alexa Fluor 488-conjugated anti-rabbit (Invitrogen, A21206, 1:200) or Alexa Fluor 555-conjugated anti-rabbit (Invitrogen, A21428, 1:200) secondary antibodies. Specimens were visualized and imaged using a fluorescence microscope. 2.6 Statistical analysis The Mann–Whitney U test was used to assess the clinical–molecular associations in adenoma samples, whereas the chi-square test was used to compare categorical data. The Kruskal–Wallis analysis and ANOVA were conducted for multiple comparisons. Statistical analyses were conducted using SPSS v20 and GraphPad Prism version 7. All results were presented in graphs and tables as median ± interquartile range. The distribution of each parameter was presented as the minimum–maximum range. Parametric or nonparametric statistical tests were applied, as appropriate, after testing for normality. The receiver operating characteristic curve was used to determine the cut-off value for predicting tumor laterality. Pearson correlation analyses was used to examine the correlations between variables. Proportions were expressed as percentages, and significance was defined as P < 0.05. 3 Results 3.1 Clinical characteristics of remission and nonremission in patients with CD This study included 25 patients with CD who underwent BIPSS before surgery (Figure 1). Among them, 12 patients had microadenomas, whereas the remaining 13 had inconclusive magnetic resonance imaging findings; clinicopathological data are summarized in Supplementary Table 1. Table 1 displays the demographics of patients who achieved remission (n = 16) and those who did not (n = 9). No significant differences were observed in terms of sex, age at diagnosis, or radiological variables between patients who achieved and those who did not achieve remission (P > 0.05). Patients who achieved remission exhibited a higher prevalence of emotional lability (P < 0.05). However, no significant differences were observed in other parameters (P > 0.05). Figure 1 Figure 1 Flowchart of the screening process employed to select eligible participants for the study. Table 1 Table 1 Baseline clinical features of patients with pituitary tumors secreting adrenocorticotropin. Several recent studies have established morning cortisol level measured on postoperative day 1 (POD1) as a predictive biomarker for long-term remission of CD (35, 36). For biochemical features, patients who did not achieve remission exhibited higher serum cortisol (19.16 ± 5.55 vs. 5.95 ± 1.42; P = 0.014) and median serum (8 am) ACTH (10.26 ± 8.24 vs. 5.15 ± 3.68; P = 0.042) levels on POD1. No significant differences were observed in the preoperative baseline 4 pm serum cortisol levels, preoperative baseline 0 am serum cortisol levels, preoperative 8 pm ACTH levels, 4 pm ACTH levels, and 0 am ACTH levels (P > 0.05) (Table 2). In addition preoperative FT3, FT4, TSH, GH, FSH, LH, and PRL levels were comparable in patients with and without remission. Table 2 Table 2 Baseline clinical and biochemical features of patients with pituitary tumors secreting adrenocorticotropin. 3.2 Overexpression of SPHK1 and higher concentrations of serum S1P on the tumor side in patients with CD Prior studies have demonstrated that ACTH acutely activates SPHK1 to increase S1P concentrations (19). Upregulation of SPHK1 is associated with poor prognosis in endocrine-related cancer (17, 18, 21). To investigate the role of SPHK1 in CD, we performed a heatmap analysis of key genes involved in phospholipid metabolism and signaling pathways in CD adenomas and surrounding normal tissues using the GEO dataset (GEO208107). This analysis revealed the activation of crucial genes involved in phospholipid metabolism and signaling pathways in ACTH-secreting pituitary adenomas (Supplementary Figure 1). Subsequently, we compared the association between pituitary SPHK1 expression and proopiomelanocortin, corticotropin-releasing hormone, corticotropin releasing hormone receptor 1, and corticotropin releasing hormone receptor 2 in pituitary tumor tissues and identified a positive correlation between SPHK1 and ACTH tumor-related genes in the TNM plot database (Supplementary Figure 2). To investigate the potential role of SPHK1 in CD, we compared the expression values of SPHK1 in the normal pituitary tissues and those obtained from patients with CD in the remission/nonremission groups. Immunofluorescence staining (Figures 2A, B; Supplementary Figure 3) revealed an increased number of double-positive cells for SPHK1 and ACTH in CD-affected pituitary tissues than those in the normal pituitary tissues. Furthermore, the proportion of double-positive cells for SPHK1 and ACTH was significantly higher in the nonremission CD adenomas tissues than that in the remission CD adenomas. Furthermore, we investigated the concentration of S1P in bilateral petrosal sinus blood samples and observed that the concentration was significantly higher on the adenoma side than that on the nonadenoma side (397.7 ± 15.4 vs. 261.9 ± 14.88; P < 0.05, Figure 2C). Thus, these findings suggested a close association between S1P concentration and the development of ACTH-secreting tumor. Figure 2 Figure 2 (A) Representative images of immunofluorescence double staining for SPHK1 (green) and ACTH (pink) in normal pituitary glands and ACTH-secreting pituitary adenomas from the remission and nonremission groups (Normal: n = 3, ACTH pituitary adenoma: remission vs. nonremission: n = 16 vs. 9); scale bars: 100-μm upper and 50-μm lower. (B) Quantitative analysis; white arrows indicate double-positive cells for ACTH and SPHK1. (C) The concentration of S1P in the plasma obtained from the inferior petrosal sinus of the adenoma side and nonadenoma side. ***P < 0.001. Bar represents mean ± SD. 3.3 Combination of interpetrosal S1P and ACTH ratios improved the diagnostic performance for adenoma laterality The pathology of patients with CD was classified based on adenomatous tissue with ACTH-positive immunostaining into adenoma or nonadenoma sides. To evaluate the correlation between the interpetrosal S1P ratio lateralization and tumor location, we compared the accuracy of predicting tumor laterality using the interpetrosal S1P ratio (>1) and interpetrosal ACTH ratio (>1.4) (the interpetrosal ACTH ratio >1.4 is acknowledged for its positive role in predicting tumor laterality), as well as their combination. Our results indicated that using the interpetrosal S1P or ACTH ratios alone yielded accuracies of 64% and 56% respectively. Notably, the combination of both demonstrated a significantly improved accuracy of 73% (Figure 3A). Figure 3 Figure 3 (A) Bar graph illustrating the accuracy of predicting tumor laterality. (B) Receiver operating characteristic (ROC) curve analysis of interpetrosal ACTH ratio to predict tumor location. (C) ROC curve analysis of the interpetrosal S1P ratio to predict tumor location. (D) ROC curve analysis of the combination of the interpetrosal S1P and ACTH ratios to predict tumor location. Thereafter, the receiver operating characteristic analysis was performed to determine the role of predicting tumor laterality. In particular, the interpetrosal ACTH ratio with an AUC of 75.32% (95% CI: 60.06–97.46%, P < 0.05) and the interpetrosal S1P ratio demonstrated a clinically significant diagnostic accuracy for lateralization, with an AUC of 79.17% (95% CI: 44.40–85.84%, P < 0.05). Furthermore, combining the interpetrosal S1P and ACTH ratios generated an receiver operating characteristic curve with an AUC of 84.09% (95% CI: 52.3–96.77%, P < 0.05) for predicting lateralization with tumor location (cutoff value: interpetrosal S1P ratio ≥1.06, interpetrosal ACTH ratio ≥2.8, 81.82% sensitivity, and 75% specificity) (Figures 3B–D). 3.4 Interpetrosal S1P ratio serves as a predictive factor for early remission in CD To investigate whether the interpetrosal S1P ratio is associated with early postoperative remission in CD, we compared the baseline interpetrosal S1P ratio between patients with CD in the remission and nonremission groups. Interestingly, we observed that the nonremission group exhibited higher interpetrosal S1P ratios than those of the remission group (median, 1.28 ± 0.25 vs. 1.10 ± 0.09, P = 0.012) (Figure 4). Figure 4 Figure 4 Left picture: Scatter plot of bilateral S1P concentrations in the remission and nonremission groups; the slope represents the interpetrosal S1P ratio, blue dots represent the remission group, and red dots represent the nonremission group. Right picture: The interpetrosal S1P ratio in the remission and nonremission groups. *P < 0.05. Bar represents mean ± SD. To investigate potential factors affecting the interpetrosal S1P ratio, we compared the correlation between interpetrosal S1P ratio and various clinical indicators. This analysis revealed that the interpetrosal S1P ratio positively correlated with preoperative FSH and LH levels, as well as with postoperative 8 am ACTH levels. No significant difference was observed between the interpetrosal S1P ratio and other indicators (Supplementary Figure 4). 4 Discussion The use of BIPSS involves collection of samples from each inferior petrosal sinus simultaneously, enabling a direct comparison of ACTH concentrations between the left and right petrosal sinuses. BIPSS is used for two purposes: 1) to assist in the differential diagnosis of Cushing’s syndrome; and 2) to determine which side of the pituitary gland contains an adenoma in patients with CD. The interpetrosal ACTH ratio is also useful in determining the location/lateralization of pituitary microadenomas (24, 30, 37), thereby providing guidance to the neurosurgeon during surgery. To our knowledge, this is the first study to demonstrate that serum S1P levels in patients with CD are significantly higher on the adenoma side of the inferior petrosal sinus than on the nonadenoma side. The interpetrosal S1P ratio exhibited a positive significance in predicting tumor laterality, and the predictive performance was improved when S1P was combined with the interpetrosal ACTH ratio. Notably, the interpetrosal S1P ratio exhibited a positive significance in predicting remission after surgery. Furthermore, the interpetrosal S1P ratio demonstrated a positive and significant correlation with preoperative FSH and LH levels, as well as 8 am ACTH levels on POD1. ACTH is recognized for its role in controlling the expression of genes involved in steroid production and cortisol synthesis in the human adrenal cortex through sphingolipid metabolism (19). Specifically, ACTH rapidly stimulates SPHK1 activity, leading to an increased in S1P levels, which in turn, increases the expression of multiple steroidogenic proteins (20). Our study demonstrated that higher S1P concentrations were present on the tumor side than on the nontumor side in patients with CD, indicating that the regulatory relationship between ACTH and S1P also exists in ACTH-secreting pituitary adenomas. Several pieces of evidence have supported the potential relationship between S1P and the occurrence of CD. Interestingly, SPHK1 and S1P are known to be integral to the regulation of epidermal growth factor receptor (EGFR) (38), which is highly expressed in human corticotropinomas, where it triggers proopiomelanocortin (the precursor of ACTH) transcription and ACTH synthesis (39). Blocking EGFR activity with an EGFR inhibitor can attenuate corticotroph tumor cell proliferation (40). Furthermore, SPHK1 and proopiomelanocortin share a common transcriptional coactivator, P300 (41, 42). Notably, S1P also directly binds to and inhibits histone deacetylase 2, thereby regulating histone acetylation and gene expression (43). Notably, histone deacetylase 2 expression is deficient in ACTH-pituitary adenomas in CD, contributing to glucocorticoid insensitivity (44), which is a hallmark of CD and a feature associated with nonremission. These studies further demonstrated an association between high S1P ratio and nonremission of CD. Our study, for the first time, established an association between SPHK1/S1P and ACTH adenoma. Nevertheless, further experimental verification is required to confirm the existence of common pathways linking SPHK1 and ACTH. Thus, these findings indicated that the S1P ratio can, to some extent, reflect the differences in ACTH levels and may serve as a surrogate marker for detecting ACTH-secreting pituitary adenomas. BIPSS is a highly effective procedure for diagnosing pituitary sources of ACTH in CD and remains the gold standard diagnostic method. However, some findings indicated certain limitations associated with the use of the inferior petrosal sinus sampling (IPSS) method in predicting tumor lateralization. The possible causes of error include asymmetrical or underdeveloped petrosal sinus anatomy and placement of the catheter (27). The present study revealed a notable increase in the interpetrosal ACTH ratio among patients with accurate predictions of tumor laterality than among those with inaccurate predictions, although the positive predictive value remained low. These findings suggested that other mechanisms may exist that contribute to false-positive results. The limitations on lateralization highlighted the need for further research to understand the underlying mechanisms contributing to the accuracy of IPSS in predicting tumor lateralization. Further investigation is required to understand these potential mechanisms and improve the accuracy of IPSS in predicting tumor lateralization. We observed that the interpetrosal S1P ratio was slightly more effective than the ACTH ratio in predicting tumor laterality. However, combining both methods significantly improved the diagnostic sensitivity and specificity. These results have important implications for clinical practice as accurate tumor lateralization is essential for the correct management and treatment of pituitary adenomas. Overall, these findings highlighted the importance of using multiple measures in predicting tumor lateralization and suggested that combining measures may be more effective than relying on any single measure alone. Future research should investigate additional measures to improve the accuracy of tumor lateralization and optimize the use of existing measures for making clinical decisions. The initial treatment recommendation for CD is surgery. However, long-term surveillance is necessary because of the high recurrence rate (12). Therefore, identifying patients who are at a greater recurrence risk would be helpful in establishing an effective surveillance strategy. Our study revealed that the expression of SPHK1 in pituitary tissue was higher in postoperative nonremission group than in postoperative remission group. Moreover, patients in the nonremission group exhibited significantly higher interpetrosal S1P ratios than those of patients in the remission group. SPHK1 catalyzes the direct phosphorylation synthesis of S1P, and the S1P ratio can thus reflect the expression level of SPHK1 in ACTH tumors. Since S1P can increase the expression of multiple steroidogenic proteins, including steroidogenic acute regulatory protein, 18-kDa translocator protein, low-density lipoprotein receptor, and scavenger receptor class B type I (20), the interpetrosal S1P ratios may be indicative of disease prognosis. This finding is consistent with previous findings indicating the overexpression of SPHK1 is associated with poor prognosis in various neuroendocrine tumors, as factors associated with tumor proliferation, S1P and SPHK1, may play a key role in the proliferation and survival of ACTH pituitary adenomas. The high proportions of SPHK1/ACTH double-positive cells are likely associated with greater phenotypic severity, and CD tumors with this phenotype may have a poor prognosis. These findings hold clinically significance for predicting early postoperative remission in patients with CD. As aforementioned, the interpetrosal S1P ratios have been suggested as a useful diagnostic tool for determining adenoma lateralization in CD, which can also serve as a prognostic indicator for postoperative remission. Pearson correlation analysis indicated that ACTH 8 am on POD1 and FSH/LH levels were significantly associated with the interpetrosal S1P ratio, suggesting that these pituitary dysfunctions may have a role in the early remission of CD. However, the sample size in this study was relatively small, and further studies with larger sample sizes are needed to confirm these findings. Additionally, other factors affecting surgical outcomes, such as the experience of the surgeon, extent of surgical resection, and use of adjuvant therapy, should be considered when predicting postoperative remission in patients with CD. This study has some limitations. First, the study was retrospective in design, which limited the control of confounding factors. Additionally, because of the limited sample size, we did not specifically investigate cases where the ACTH ratio failed to accurately identify the correct tumor location. Finally, we did not explore the functional evidence of a common pathway between SPHK1 and ACTH. Despite these limitations, the study contributes to our understanding of the potential utility of the interpetrosal S1P ratio as a biomarker for CD and provides a basis for future research in this area. In conclusion, our study demonstrated a significant association between the interpetrosal S1P ratio and tumor laterality, as well as in early remission in CD. These findings suggested that the interpetrosal S1P ratio could serve as a useful biomarker in clinical practice. Moreover, targeting genes and drugs related to SPHK1/S1P could provide novel therapeutic strategies for treating CD. Data availability statement The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author. Ethics statement The studies involving humans were approved by The Xiangya Hospital Ethics Committee, Xiangya Hospital (Changsha, China). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Author contributions HS: conceptualization, methodology, software, visualization, and investigation. CW and BH: software. YX: writing – review & editing. All authors contributed to the article and approved the submitted version. Funding The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article. Acknowledgments The authors gratefully acknowledge contributions from the GEO databases and TNMplot database (https://www.tnmplot.com/). Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Supplementary material The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fendo.2023.1238573/full#supplementary-material References 1. Tritos NA, Miller K. Diagnosis and management of pituitary adenomas: A review. JAMA (2023) 329(16):1386–98. doi: 10.1001/jama.2023.5444 PubMed Abstract | CrossRef Full Text | Google Scholar 2. Ntali G, Hakami O, Wattegama M, Ahmed S, Karavitaki N. Mortality of patients with cushing's disease. Exp Clin Endocrinol Diabetes (2021) 129(3):203–7. doi: 10.1055/a-1197-6380 CrossRef Full Text | Google Scholar 3. Hakami O, Ahmed S, Karavitaki N. Epidemiology and mortality of Cushing's syndrome. Best Pract Res Clin Endocrinol Metab (2021) 35(1):101521. doi: 10.1016/j.beem.2021.101521 PubMed Abstract | CrossRef Full Text | Google Scholar 4. Clayton RN, Raskauskiene D, Reulen RC, Jones PW. Mortality and morbidity in Cushing's disease over 50 years in Stoke-on-Trent, UK: audit and meta-analysis of literature. J Clin Endocrinol Metab (2011) 96(3):632–42. doi: 10.1210/jc.2010-1942 PubMed Abstract | CrossRef Full Text | Google Scholar 5. Jones PS, Swearingen B. Pituitary surgery in Cushing’s disease: first line treatment and role of reoperation. Pituitary (2022) 25:713–717. doi: 10.1007/s11102-022-01254-8 PubMed Abstract | CrossRef Full Text | Google Scholar 6. Juszczak A, Ertorer ME, Grossman AB. The therapy of cushing’s disease in adults and children: an update. Hormone Metab Res (2012) 45:109–117. doi: 10.1055/s-0032-1330009 CrossRef Full Text | Google Scholar 7. Biller BM, Grossman AB, Stewart PM, Melmed S, Bertagna XY, Bertherat J, et al. Treatment of adrenocorticotropin-dependent Cushing's syndrome: a consensus statement. J Clin Endocrinol Metab (2008) 93(7):2454–62. doi: 10.1210/jc.2007-2734 PubMed Abstract | CrossRef Full Text | Google Scholar 8. Chandler WF, Barkan AL, Hollon TC, Sakharova AA, Sack JT, Brahma B, et al. Outcome of transsphenoidal surgery for cushing disease: A single-center experience over 32 years. Neurosurgery (2016) 78(2):216–23. doi: 10.1227/NEU.0000000000001011 PubMed Abstract | CrossRef Full Text | Google Scholar 9. Feng M, Liu Z, Liu X, Bao X, Yao Y, Deng K, et al. Diagnosis and outcomes of 341 patients with cushing's disease following transsphenoid surgery: A single-center experience. World Neurosurg (2018) 109:e75–80. doi: 10.1016/j.wneu.2017.09.105 PubMed Abstract | CrossRef Full Text | Google Scholar 10. Aranda GB, Ensenãat J, Mora M, Puig-Domingo M, Martínez de Osaba MJ, Casals G, et al. Long-term remission and recurrence rate in a cohort of Cushing’s disease: the need for long-term follow-up. Pituitary (2014) 18:142–9. doi: 10.1007/s11102-014-0567-8 CrossRef Full Text | Google Scholar 11. Nieman LK, Biller BM, Findling JW, Murad MH, Newell-Price JD, Savage MO, et al. Treatment of cushing's syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metab (2015) 100(8):2807–31. doi: 10.1210/jc.2015-1818 PubMed Abstract | CrossRef Full Text | Google Scholar 12. Galiana PA, Montañana CF, Suárez PA, Vela JG, Escrivá CM, Lillo VR. Predictors of long-term remission after transsphenoidal surgery in Cushing's disease. Endocrinol y Nutricioín Oírgano La Sociedad Espanãola Endocrinol y Nutricioín (2013) 60:475–82. Google Scholar 13. Ayala AR, Manzano AJ. Detection of recurrent Cushing’s disease: proposal for standardized patient monitoring following transsphenoidal surgery. J Neuro-Oncol (2014) 119:235–242. doi: 10.1007/s11060-014-1508-0 CrossRef Full Text | Google Scholar 14. Liu M, Frej C, Langefeld CD, Divers J, Bowden DW, Carr JJ, et al. Plasma apoM and S1P levels are inversely associated with mortality in African Americans with type 2 diabetes mellitus. J Lipid Res (2019) 60:1425–1431. doi: 10.1194/jlr.P089409 PubMed Abstract | CrossRef Full Text | Google Scholar 15. Anderson AK, Lambert JM, Montefusco DJ, Tran BN, Roddy P, Holland WL, et al. Depletion of adipocyte sphingosine kinase 1 leads to cell hypertrophy, impaired lipolysis, and nonalcoholic fatty liver disease. J Lipid Res (2020) 61:1328–1340. doi: 10.1194/jlr.RA120000875 PubMed Abstract | CrossRef Full Text | Google Scholar 16. Smith C, Williams J, Hall C, Casas J, Caley M, O’Toole E, et al. Ichthyosis linked to sphingosine 1-phosphate lyase insufficiency is due to aberrant sphingolipid and calcium regulation. J Lipid Res (2023) 64(4):100351. doi: 10.1016/j.jlr.2023.100351 PubMed Abstract | CrossRef Full Text | Google Scholar 17. Maczis MA, Maceyka M, Waters MR, Newton J, Singh M, Rigsby MF, et al. Sphingosine kinase 1 activation by estrogen receptor α36 contributes to tamoxifen resistance in breast cancer. J Lipid Res (2018) 59:2297–2307. doi: 10.1194/jlr.M085191 PubMed Abstract | CrossRef Full Text | Google Scholar 18. Hii L-W, Chung FF, Mai CW, Yee ZY, Chan HH, Raja VJ, et al. Sphingosine kinase 1 regulates the survival of breast cancer stem cells and non-stem breast cancer cells by suppression of STAT1. Cells (2020) 9(4):886. doi: 10.3390/cells9040886 PubMed Abstract | CrossRef Full Text | Google Scholar 19. Ozbay T, Merrill AH, Sewer MB. ACTH regulates steroidogenic gene expression and cortisol biosynthesis in the human adrenal cortex via sphingolipid metabolism. Endocrine Res (2004) 30:787–794. doi: 10.1081/ERC-200044040 CrossRef Full Text | Google Scholar 20. Lucki NC, Li D, Sewer MB. Sphingosine-1-phosphate rapidly increases cortisol biosynthesis and the expression of genes involved in cholesterol uptake and transport in H295R adrenocortical cells. Mol Cell Endocrinol (2012) 348:165–75. doi: 10.1016/j.mce.2011.08.003 PubMed Abstract | CrossRef Full Text | Google Scholar 21. Lin K, Cheng W, Shen Q, Wang H, Wang R, Guo S, et al. Lipid profiling reveals lipidomic signatures of weight loss interventions. Nutrients (2023) 15(7):1784. doi: 10.3390/nu15071784 PubMed Abstract | CrossRef Full Text | Google Scholar 22. Detomas M, Ritzel K, Nasi-Kordhishti I, Schernthaner-Reiter MH, Losa M, Tröger V, et al. Bilateral inferior petrosal sinus sampling with human CRH stimulation in ACTH-dependent Cushing's syndrome: results from a retrospective multicenter study. Eur J Endocrinol (2023) 2023:lvad050. doi: 10.1093/ejendo/lvad050 CrossRef Full Text | Google Scholar 23. Zampetti B, Grossrubatscher EM, Dalino Ciaramella P, Boccardi E, Loli P. Bilateral inferior petrosal sinus sampling. Endocrine Connections (2016) 5:R12–R25. doi: 10.1530/EC-16-0029 PubMed Abstract | CrossRef Full Text | Google Scholar 24. Oldfield EH, Doppman JL, Nieman LK, Chrousos GP, Miller DL, Katz D, et al. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome. New Engl J Med (1991) 325(13):897–905. doi: 10.1056/NEJM199109263251301 PubMed Abstract | CrossRef Full Text | Google Scholar 25. Oldfield EH, Chrousos GP, Schulte HM, Schaaf M, Mckeever PE, Krudy AG, et al. Preoperative lateralization of ACTH-secreting pituitary microadenomas by bilateral and simultaneous inferior petrosal venous sinus sampling. New Engl J Med (1985) 312(2):100–3. doi: 10.1056/NEJM198501103120207 PubMed Abstract | CrossRef Full Text | Google Scholar 26. Colao A, Faggiano A, Pivonello R, Pecori Giraldi F, Cavagnini F, Lombardi G. Inferior petrosal sinus sampling in the differential diagnosis of Cushing's syndrome: results of an Italian multicenter study. Eur J Endocrinol (2001) 144(5):499–507. doi: 10.1530/eje.0.1440499 PubMed Abstract | CrossRef Full Text | Google Scholar 27. Lefournier V, Martinie M, Vasdev A, Bessou P, Passagia JG, Labat-Moleur F, et al. Accuracy of bilateral inferior petrosal or cavernous sinuses sampling in predicting the lateralization of Cushing's disease pituitary microadenoma: influence of catheter position and anatomy of venous drainage. J Clin Endocrinol Metab (2003) 88(1):196–203. doi: 10.1210/jc.2002-020374 PubMed Abstract | CrossRef Full Text | Google Scholar 28. Liu C, Lo JC, Dowd CF, Wilson CB, Kunwar SM, Aron DC, et al. Cavernous and inferior petrosal sinus sampling in the evaluation of ACTH-dependent Cushing's syndrome. Clin Endocrinol (2004) 61(4):478–86. doi: 10.1111/j.1365-2265.2004.02115.x CrossRef Full Text | Google Scholar 29. Batista DL, Gennari M, Riar J, Chang R, Keil MF, Oldfield EH, et al. An assessment of petrosal sinus sampling for localization of pituitary microadenomas in children with Cushing disease. J Clin Endocrinol Metab (2006) 91(1):221–4. doi: 10.1210/jc.2005-1096 PubMed Abstract | CrossRef Full Text | Google Scholar 30. Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, et al. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol (2021) 9(12):847–75. doi: 10.1016/S2213-8587(21)00235-7 PubMed Abstract | CrossRef Full Text | Google Scholar 31. Hinojosa-Amaya JoséM, Cuevas-Ramos D. “The definition of remission and recurrence of Cushing's disease.” Best practice & research. Clin Endocrinol Metab (2021) 35(1):101485. doi: 10.1016/j.beem.2021.101485 CrossRef Full Text | Google Scholar 32. Deipolyi AR, Karaosmanoğlu AD, Habito CM, Brannan SM, Wicky ST, Hirsch JA, et al. The role of bilateral inferior petrosal sinus sampling in the diagnostic evaluation of Cushing syndrome. Diagn Interventional Radiol (2012) 18(1):132–8. doi: 10.4261/1305-3825.DIR.4279-11.0 CrossRef Full Text | Google Scholar 33. Deipolyi AR, Bailin A, Hirsch JA, Walker TG, Oklu R. Bilateral inferior petrosal sinus sampling: experience in 327 patients. J neurointerv Surg (2016) 9:196–199. doi: 10.1136/neurintsurg-2015-012164 PubMed Abstract | CrossRef Full Text | Google Scholar 34. Chongsathidkiet P, Jackson C, Koyama S, Loebel F, Cui X, Farber SH, et al. Sequestration of T-cells in bone marrow in the setting of glioblastoma and other intracranial tumors. Nat Med (2018) 24:1459–1468. doi: 10.1038/s41591-018-0135-2 PubMed Abstract | CrossRef Full Text | Google Scholar 35. Catalino MP, Moore DT, Ironside N, Munoz AR, Coley J, Jonas R, et al. Post-operative serum cortisol and cushing disease recurrence in patients with corticotroph adenomas. J Clin Endocrinol Metab (2023) 2023:dgad347. doi: 10.1210/clinem/dgad347 CrossRef Full Text | Google Scholar 36. Wang F, Catalino MP, Bi WL, Dunn IF, Smith TR, Guo Y, et al. Post-operative day one morning cortisol value as a biomarker to predict long-term remission of cushing disease. J Clin Endocrinol Metab (2021) 106(1):e94-e102. doi: 10.1210/clinem/dgaa773 PubMed Abstract | CrossRef Full Text | Google Scholar 37. Newell-Price JD, Bertagna XY, Grossman AB, Nieman LK. Cushing's syndrome. Lancet (2005) 367(9522):1605–17. doi: 10.1383/medc.2005.33.11.11 CrossRef Full Text | Google Scholar 38. Tamashiro PM, Furuya H, Shimizu Y, Kawamori T. Sphingosine kinase 1 mediates head & neck squamous cell carcinoma invasion through sphingosine 1-phosphate receptor 1. Cancer Cell Int (2014) 14(1):76. doi: 10.1186/s12935-014-0076-x PubMed Abstract | CrossRef Full Text | Google Scholar 39. Perez-Rivas LG, Theodoropoulou M, Ferraù F, Nusser C, Kawaguchi K, Stratakis CA, et al. The gene of the ubiquitin-specific protease 8 is frequently mutated in adenomas causing cushing's disease. J Clin Endocrinol Metab (2015) 100(7):E997–1004. doi: 10.1210/jc.2015-1453 PubMed Abstract | CrossRef Full Text | Google Scholar 40. Fukuoka H, Cooper O, Ben-Shlomo A, Mamelak A, Ren SG, Bruyette D, et al. EGFR as a therapeutic target for human, canine, and mouse ACTH-secreting pituitary adenomas. J Clin Invest (2011) 121(12):4712–21. doi: 10.1172/JCI60417 PubMed Abstract | CrossRef Full Text | Google Scholar 41. Postepska-Igielska A, Giwojna A, Gasri-Plotnitsky L, Schmitt N, Dold A, Ginsberg D, et al. LncRNA khps1 regulates expression of the proto-oncogene SPHK1 via triplex-mediated changes in chromatin structure. Mol Cell (2015) 60(4):626–36. doi: 10.1016/j.molcel.2015.10.001 PubMed Abstract | CrossRef Full Text | Google Scholar 42. Smith RG, Betancourt L, Sun Y. Molecular endocrinology and physiology of the aging central nervous system. Endocrine Rev (2005) 26(2):203–50. doi: 10.1210/er.2002-0017 CrossRef Full Text | Google Scholar 43. Hait NC, Allegood J, Maceyka M, Strub GM, Harikumar KB, Singh SK, et al. Regulation of histone acetylation in the nucleus by sphingosine-1-phosphate. Science (2009) 325:1254–7. doi: 10.1126/science.1176709 PubMed Abstract | CrossRef Full Text | Google Scholar 44. Bilodeau S, Vallette-Kasic S, Gauthier Y, Figarella-Branger D, Brue T, Berthelet F, et al. Role of Brg1 and HDAC2 in GR trans-repression of the pituitary POMC gene and misexpression in Cushing disease. Genes Dev (2006) 20:2871–86. doi: 10.1101/gad.1444606 PubMed Abstract | CrossRef Full Text | Google Scholar Keywords: ipss, sphingosine-1-phosphate, Cushing’s disease, remission, tumor laterality Citation: Sun H, Wu C, Hu B and Xiao Y (2023) Interpetrosal sphingosine-1-phosphate ratio predicting Cushing’s disease tumor laterality and remission after surgery. Front. Endocrinol. 14:1238573. doi: 10.3389/fendo.2023.1238573 Received: 12 June 2023; Accepted: 17 October 2023; Published: 31 October 2023. Edited by: Anton Luger, Medical University of Vienna, Austria Reviewed by: Guangwei Wang, Hunan University of Medicine, China Marie Helene Schernthaner-Reiter, Medical University of Vienna, Austria Copyright © 2023 Sun, Wu, Hu and Xiao. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Yuan Xiao, xiaoyuan2021@csu.edu.cn Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. From https://www.frontiersin.org/articles/10.3389/fendo.2023.1238573/full

Abstract Background This single-center retrospective cohort study aimed to describe the findings and validity of Bilateral inferior petrosal sinus sampling (BIPSS) in the differential diagnosis of patients with ACTH-dependent Cushing’s syndrome (CS). Methods Eleven patients underwent BIPSS due to equivocal biochemical tests and imaging results. Blood samples were taken from the right inferior petrosal sinus (IPS), left IPS, and a peripheral vein before and after stimulation with desmopressin (DDAVP). ACTH and prolactin levels were measured. The diagnosis was based on the ACTH ratio between the IPS and the peripheral vein. Also, lateralization of pituitary adenoma in patients with Cushing’s disease (CD) was predicted. No significant complications were observed with BIPSS. Results Based on the pathology report, eight patients had CD, and three had ectopic ACTH syndrome (EAS). Unstimulated BIPSS resulted in a sensitivity of 87.5%, specificity of 100%, PPV of 100%, NPV of 75%, and accuracy of 91%. Stimulated BIPSS resulted in a sensitivity of 100%, specificity of 100%, PPV of 100%, NPV of 100%, and accuracy of 100%. However, pituitary magnetic resonance imaging (MRI) had a lower diagnostic accuracy (sensitivity:62.5%, specificity:33%, PPV:71%, NPV:25%, accuracy:54%). BIPSS accurately demonstrated pituitary adenoma lateralization in 75% of patients with CD. Conclusions This study suggests that BIPSS may be a reliable and low-complication technique in evaluating patients with ACTH-dependent CS who had inconclusive imaging and biochemical test results. The diagnostic accuracy is improved by DDAVP stimulation. Pituitary adenoma lateralization can be predicted with the aid of BIPSS. Peer Review reports Introduction All disorders with manifestations associated with glucocorticoid excess are called Cushing’s syndrome. Exogenous corticosteroids cause most CS cases, and endogenous CS cases are rare [1, 2]. The diagnosis of Cushing’s syndrome may be complicated, particularly in cases with ambiguous clinical findings, atypical presentations, and cyclic hypercortisolemia [3,4,5]. The initial laboratory tests for diagnosis of CS include 24-hour urinary free cortisol (UFC), late-night salivary cortisol, and low-dose dexamethasone suppression test (DST). These tests only represent hypercortisolemia [1, 2]. Once CS is diagnosed, further evaluations are needed to identify the etiology. The first step is to measure the plasma ACTH level. A low plasma ACTH level indicates ACTH-independent CS and a high level suggests ACTH-dependent CS. Normal ACTH can also occur in ACTH-dependent CS. Almost all cases of ACTH-dependent are due to pituitary adenoma (Cushing’s disease) or EAS [1, 2, 6]. Some ectopic sources include neuroendocrine tumors, bronchial carcinoma, and pancreatic carcinoma [7, 8]. Because of the high mortality in tumors associated with EAS, it is essential to differentiate CD from EAS. To distinguish CD from EAS, a high-dose dexamethasone suppression test (HDDST), corticotropin-releasing hormone (CRH), or DDAVP stimulation tests, or pituitary MRI is recommended [1, 2, 6, 9,10,11,12]. MRI can be equivocal in half of the patients, and only relatively large lesions (> 6 mm) detected on MRI reliably confirm the diagnosis of CD with biochemical confirmation and expected clinical symptoms [9]. Considering the relatively low sensitivity and specificity of non-invasive tests [13, 14] and the high complications of the surgery, it seems reasonable to use a test with high sensitivity and specificity and few complications before resection. BIPSS with CRH or DDAVP stimulation can be helpful for further evaluation [1, 2, 10, 15, 16]. The BIPSS procedure is the same in both stimulation methods. Due to its lower cost, availability, and comparable diagnostic accuracy, using DDAVP instead of CRH for BIPSS is an alternative [17, 18]. BIPSS has been reported to have high sensitivity and specificity and is a safe procedure when performed by experienced interventional radiologists [15, 16, 19, 20]. This case series describes the experience with BIPSS and examines the validity of BIPSS for differentiating CD from EAS in patients with ACTH-dependent CS who had ambiguous or equivocal results in non-invasive tests. Materials and methods Patients This retrospective cohort study included 11 patients with ACTH-dependent CS who underwent BIPSS between 2018 and 2020 in a tertiary care hospital. Data collection Well-trained nurses conducted anthropometric measurements, including height and weight. Standing height was measured with a portable stadiometer (rounded to the nearest 0.1 cm). Using a calibrated balance beam scale, this study measured weight in the upright position (rounded to the nearest 0.1 kg). Body mass index (BMI) was calculated by dividing weight (kg) by height squared (m2). Well-trained examiners measured blood pressure (systolic and diastolic) at the left arm in the sitting position after 5 min of rest using a calibrated mercury sphygmomanometer. The blood sample was taken, and fasting blood sugar (FBS), hemoglobin (Hb), potassium (K), and creatinine (Cr) were measured. All research was performed in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants or their legal guardians. Biochemical tests and imaging Patients with signs and symptoms of CS underwent screening evaluations, and confirmatory tests were performed using serum cortisol and 24-hour UFC. After confirmation of CS, ACTH was measured using an immunoradiometric assay to categorize patients into ACTH-dependent or independent groups. ACTH test was performed with SIEMENS IMMULITE 2000 device with an analytical sensitivity of 5 pg/ml (1.1 pmol/l) and CV ∼7.5%. HDDST was conducted by administering 2 mg dexamethasone every 6 h for 48 h to all patients, and then serum cortisol and 24-hour UFC were rechecked. A pituitary MRI was performed with sagittal and coronal T1- and T2-weighted images before and after the gadolinium injection. BIPSS procedure After biochemical tests and imaging, an experienced interventional radiologist performed bilateral and simultaneous catheterization of the inferior petrosal sinuses. Venography was obtained to evaluate venous anatomy and catheter placement. The retrograde flow of contrast dye into the contralateral cavernous sinuses was used as a marker of adequate sampling. After the correct placement of catheters, blood samples were obtained from each of three ports (peripheral (P), left inferior petrosal sinus (IPS), and right IPS) at -15, -10, -5, and 0 min. The current study used DDAVP for stimulation. After peripheral injection of 10 micrograms of DDAVP, blood samples from these three sites were obtained at + 3, +5, + 10, and + 15 min. Three samples from these sites were also obtained to measure prolactin. Upon collection, BIPSS samples were placed in an ice-water bath. At the end of the procedure, samples were taken to the laboratory, where the plasma was separated and used for immediate measurement of ACTH. Specimens were refrigerated, centrifuged, frozen, and assayed within 24 h. After the samples were obtained, both femoral sheaths were removed, and manual compression was used to obtain hemostasis before transferring patients to the recovery room. The whole procedure took 1–2 h. Patients underwent strict bed rest for 4 h before discharge on the same day. All BIPSS were performed without significant complications, and only hematoma at the catheterization site was observed in some patients. BIPSS interpretation The ratio of IPS ACTH to peripheral ACTH level (IPS/P ACTH) for each side was calculated. Baseline sampling at minute 0 with IPS/P ≥ 2 or stimulated sampling at minute 3 with 1PS/P ≥ 3 is confirmatory for CD [1, 8]. Also, the IPS/P ratio was checked for prolactin level after DDAVP stimulation (stimulated IPS/P prolactin). A stimulated IPS/P prolactin ≥ 1.8 indicates successful catheterization, meaning the catheter is correctly placed in the IPS [21]. For further evaluation, the current study normalized the ACTH to the prolactin level by dividing stimulated IPS/P ACTH into stimulated IPS/P prolactin for each side. A normalized ACTH/prolactin IPS/P ratio ≥ 1.3 supports a pituitary ACTH source (Cushing’s disease), and a normalized ratio ≤ 0.7 an ectopic source (EAS) [22]. The values between 0.7 and 1.3 are equivocal. The inter-sinus ratio was defined as the ratio of the IPS/P ACTH level of one side with the higher level divided by the IPS/P ACTH level of the other side with the lower level, either before or after stimulation. An inter-sinus ratio ≥ 1.4 indicates lateralization to the side with a higher IPS/P ACTH level [23]. Statistical analysis This analysis used SPSS software version 18 (SPSS, Inc.) to perform analyses. Data were expressed as numbers and percentages. Continuous variables were presented as means (± SD). This study reported the median or range when the data did not follow a normal distribution. The Shapiro-Wilk test was used to test for normality. The nonparametric Mann-Whitney U Test was utilized to compare variables. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the tests were calculated based on standard statistical equations. Results Baseline characteristics and clinical manifestations This retrospective research studied 11 patients with ACTH-dependent CS, including eight females (72.7%) and three (27.3%) males. The median (Q1-Q3) age was 32.0 (22–45) years. The median (Q1-Q3) of BMI, systolic blood pressure (SBP), diastolic blood pressure (DBP), FBS, Hb, K, and Cr were 29.2 (24.8–33.3), 130.0 (125–140), 80.0 (80–95), 98.0 (88–103), 13.5 (12.4–13.9), 4.2 (3.9–4.5), and 1.0 (0.9–1.1), respectively. The demographic characteristics of patients are presented in Table 1. The Hb levels were not different in women and men (median 13.35 vs. 13.70, p-value = 0.776). In addition, no statistical difference between patients with a final diagnosis of CD and EAS was detected for Hb levels (Total: median 13.60 vs. 13.2, p-value > 0.05) (Women: median 13.5 vs. 13.2, p-value > 0.05) (Men: median 13.7 vs. 13.25, p-value > 0.05). Table 1 Demographic characteristics of the studied patients Full size table 90% of patients had at least one skin manifestation, such as striae, easy bruising, acne, hyperpigmentation, hirsutism, hair loss, edema, and hypertrichosis. Other symptoms were hypertension (HTN) (81%), reproductive dysfunction (81%), including infertility, oligomenorrhea, loss of libido, weight gain (72%), proximal muscle weakness (45%), and headache (27%) (Table 2). Table 2 Clinical manifestations of the studied patients Full size table Results of biochemical tests Biochemical tests results, including basal serum cortisol (median:26 mcg/dl, range:15-54.5 mcg/dl), basal 24-hour UFC (median:670 mcg/dl, range:422–1545 mcg/dl), ACTH (median:58.8 pg/ml, range:25–155 pg/ml), serum cortisol after HDDST (median:14.2 mcg/dl, range:2.63-36.0 mcg/dl), 24-hour UFC after HDDST (median:292 mcg/dl, range:29.5–581 mcg/dl) are presented in Table 3. According to the basal serum cortisol results, eight patients (Cases 1, 3, 5, 7, 8, 9, 10, and 11) had basal serum cortisol levels > 22 mcg/dl, which indicates hypercortisolemia. Other patients (Cases 2, 4, and 6) had basal serum cortisol in the normal range (5–25 mcg/dl) and were considered as false negative results of this test. Table 3 The results of biochemical tests in the studied patients Full size table All patients had elevated basal 24-hour UFC levels (422–1545 mcg/dl), indicative of hypercortisolemia (Table 3). There were six patients with elevated peripheral ACTH levels (> 58 pg/ml) (cases 5, 6, 8, 9, 10, and 11). Other patients had ACTH within the normal range (6–58 pg/ml) (cases 1, 2, 3, 4, 7) (Table 3). None of the patients showed suppression after 1 mg DST. After HDDST, cases 2, 3, 8, and 10 had more than 50% suppression of serum cortisol. In the other six patients, serum cortisol was not suppressed or suppressed by less than 50%. In one patient, serum cortisol levels were not measured (case 1) because the sample was not stored under standard test conditions. Also, eight patients had more than 50% 24-hour UFC suppression after HDDST (cases 1, 2, 3, 4, 6, 7, 9, and 10). In two patients, 24-hour UFC was suppressed less than 50% (cases 5 and 11), and in one patient (case 8), the 24-hour UFC sample was not tested due to the non-standard condition of the sample. BIPSS results BIPSS results before and after stimulation are shown in Table 4. The baseline value (sampling at minute 0) of IPS/P ACTH ≥ 2 confirms CD. According to this ratio, cases 1,3,4,5,6,7, and 8 were diagnosed as CD. The unilateral source for CD was confirmed in cases 1, 3, 7, and 8. BIPPS didn’t demonstrate lateralization in cases 4, 5, and 6. Table 4 Baseline and stimulated IPS/P ratio for ACTH and Prolactin in the studied patients Full size table The highest IPS/P ACTH ratio was 3 min after the DDAVP injection. A sampling at minute 3 with stimulated IPS/P ACTH ≥ 3 confirms CD. This ratio confirmed CD in cases 1–8 and showed a unilateral source for CD in cases 1, 2, 3, and 7. The ratio didn’t demonstrate lateralization in cases 4, 5, 6, and 8. The stimulated IPS/P prolactin was ≥ 1.8 in all cases. The variability in the IPS/P ACTH ratio in patients with CD is shown in Fig. 1. The peak of this ratio was 3 min after the DDAVP injection. In patients with EAS, there were no changes before or after the DDAVP stimulation. Fig. 1 Comparison of mean values of IPS/P ACTH in CD (Lt.) and EAS (Rt.). IPS; inferior petrosal sinus; P: peripheral; ACTH: adrenocorticotropic hormone; CD: Cushing’s disease; EAS: ectopic ACTH syndrome; Lt: left; Rt: right Full size image According to the Prolactin-normalized ACTH IPS/P ratios, eight patients (cases 1–8) were diagnosed as CD and three as EAS (cases 9–11). In cases 1, 2, 3, 7, and 8, unilateral sources of CD were confirmed, but in cases 4,5 and 6, bilateral sources were detected (Table 4). According to the inter-sinus ratio, BIPSS could lateralize the source of ACTH in all patients with CD. The inter-sinus ratio in patients with EAS could not lateralize any pituitary source for ACTH (Table 4). In five patients with CD and one with EAS, the highest peripheral ACTH level was observed 15 min after stimulation. Two patients with CD and one with EAS had the highest peripheral ACTH level 10 min after stimulation. Only one patient with CD and one with EAS had the highest peripheral ACTH level 5 min after stimulation. No patient had maximum peripheral ACTH levels in the first post-stimulation sample (minute 3). The larger numerator or smaller denominator produces a higher value in a ratio. In the samples obtained immediately after stimulation, the highest concentration of ACTH was in the IPS, and the lowest was in the peripheral blood. Therefore, as mentioned, the highest post-stimulation value of the IPS/P ACTH ratio was obtained at minute 3. MRI results MRI results showed pituitary adenoma in five patients, enhancement in one patient, pituitary mass and lesion in two patients, empty sella in two patients, and possible pituitary adenoma and adrenal mass in one patient (Table 5). Table 5 Final diagnosis, lateralization, MRI results, and management Full size table Immunohistochemistry (IHC) results According to the pathology report, eight patients were confirmed as CD (Table 5). The other two patients were EAS (one carcinoid tumor of the lung and one pheochromocytoma). One patient had no documented pathologic source of hypercortisolemia because the patient did not consent to surgery, and the diagnosis of EAS was made based on the results of biochemical tests. BIPSS vs. MRI results MRI results showed pituitary adenoma in five patients with CD. MRI and BIPSS showed the adenoma on a similar side in two of them. In the other three patients, MRI showed bilateral adenoma, but BIPSS lateralized the adenoma to one side. One of the other three patients had only left-sided enhancement but no overt adenoma on MRI, whereas BIPSS lateralized the adenoma to the right side. One patient had a low-signal pituitary mass on the right side on MRI, and BIPSS also lateralized to the right. Another patient with a history of transsphenoidal surgery (TSS), diagnosed as recurrent CD, had a partially empty sella. MRI was equivocal, but BIPSS lateralized to the left side. Among patients with EAS, one with an equivocal BIPSS result had an empty sella on MRI. Two other patients had pituitary lesions on MRI, but BIPSS results were equivocal. Comparison between BIPSS, MRI, and surgery Among patients with CD, the final diagnosis based on surgery in three patients was consistent with MRI and BIPSS results and lateralized the adenoma on the same side. In one patient, the surgery result was similar to the MRI findings and showed bilateral adenoma, but BIPSS showed adenoma on the left side. In the patient with equivocal MRI findings and a history of TSS, IHC could not identify ACTH +, although BIPSS lateralized to the left side. In three other patients, surgery results were concordant with BIPSS and lateralized the adenoma on the same side, although MRI showed discordant results. Validity of BIPSS Baseline IPS/P ACTH resulted in a sensitivity of 87.5%, specificity of 100%, PPV of 100%, NPV of 75%, and accuracy of 91%. Stimulation with DDAVP improved validity. Both stimulated IPS/P ACTH and normalized ACTH/prolactin IPS/P ratio resulted in a sensitivity of 100%, specificity of 100%, PPV of 100%, NPV of 100%, and accuracy of 100%. BIPSS, either unstimulated or stimulated, had higher validity than MRI, with a sensitivity of 62.5%, specificity of 33%, PPV of 71%, NPV of 25%, and accuracy of 54%. BIPSS accurately predicted pituitary adenoma lateralization in 75% of patients with CD. Discussion In this study, BIPSS before stimulation showed a sensitivity of 87.5% and a specificity of 100%. However, BIPSS after stimulation showed a sensitivity of 100% and specificity of 100%. It has been demonstrated that the sensitivity of BIPSS can vary from 88 to 100%, and its specificity from 67 to 100% in the diagnosis of CD [24]. Previous studies have reported sensitivity and specificity of more than 80% and 90% for BIPSS, and the combination of BIPSS with stimulation by CRH or DDAVP improves the sensitivity and specificity to more than 95 and 100%, respectively [15, 19, 25]. Chen et al. suggested the optimal IPS:P cutoff value of 1.4 before and 2.8 after stimulation [20]. Considering these cutoffs, the only patient in this study who was negative for CD before stimulation becomes positive, and the sensitivity before stimulation increases from 87.5 to 100%. The diagnostic accuracy after stimulation remains unchanged. Results of the current study showed that BIPSS is highly valued in final diagnosis, even without stimulation. In this investigation, the utilization of Prolactin-normalized ACTH IPS/P ratios exhibited a sensitivity and specificity of 100% for the CD diagnosis. This finding aligns with research conducted by Detomas et al., which reported a sensitivity of 96% and specificity of 100% for the normalized ACTH: Prolactin IPS/P ratio [26]. It seems that concurrently assessing prolactin levels may potentially enhance the diagnostic accuracy of BIPSS. However, the current literature is inconsistent. Some studies do not support the use of prolactin to diagnose CD [27]. In all patients, the IPS/P ACTH ratio at minute 15 did not show a considerable difference from this ratio at minute 0. Previous studies have shown that sampling at minute 15 is not helpful for diagnosis [1, 15, 20, 28]. Unlike the IPS/P ACTH ratio, six patients had the highest peripheral ACTH level at minute 15 after stimulation, but no patient had it at minute 3 after stimulation. However, more studies are needed to obtain more precise results, and this study’s sample size was limited. BIPSS accurately lateralized the adenoma in six patients with CD, but MRI was able to lateralize the adenoma in two patients correctly. BIPSS had higher validity than MRI in differentiating CD from EAS, both with and without stimulation. The current literature is controversial. Colao et al. reported that adenoma could be accurately localized in 65% of patients using IPSS [23]. However, Lefournier et al. showed that the diagnostic accuracy of IPSS in identifying the side of the pituitary adenoma was 57% [28]. Wind et al. showed that the PPV for IPSS to identify the tumor side correctly was 69%. Additionally, MRI was more accurate than IPSS in tumor lateralization [29]. Earlier studies have shown that MRI may show a pituitary lesion, and BIPSS indicates a pituitary adenoma. However, the lesion observed on the MRI is not related to the pituitary adenoma [1, 15, 19, 25, 28]. Also, MRI may show pituitary lesions, while BIPSS indicates EAS. In the current study, the concordance of IHC results with BIPSS and MRI findings was inconclusive, possibly due to the limited number of patients. However, there is disagreement about the role of pathological study in diagnosis [19, 28]. Eight patients had elevated basal serum cortisol levels in this study (Sensitivity:73%). Instead, all patients had hypercortisolemia according to basal 24-hour UFC results, and no false-negative results were observed (Sensitivity:100%). This study’s findings were consistent with previous studies regarding low sensitivity for basal serum cortisol and high sensitivity for 24-hour UFC as screening tests for hypercortisolemia [6, 30, 31]. After HDDST, basal serum cortisol suppression was observed in three patients with CD (cases 2, 3, and 😎 but not in the others with CD. Also, serum cortisol levels were suppressed after HDDST in a patient with EAS who had a lung carcinoid tumor. Arnaldi et al. showed that some carcinoid tumors might be sensitive to HDDST, and suppression of serum cortisol may be observed after this test [1, 32]. After HDDST, six patients with CD had suppressed 24-hour UFC, but one did not show more than 50% suppression. Two patients with EAS had more than 50% 24-hour UFC suppression. According to the final pathology report, the sensitivity of serum and urine cortisol level tests after HDDST was 43% and 86%, and the specificity was 67% and 33%, respectively. PPV in both was 75%, NPV was 33% and 50%, and accuracy was 50% and 70%, respectively, which shows that these preliminary tests cannot be a good guide for the final diagnosis and subsequent treatment planning. Previous studies showed that more than one biochemical test could improve the accuracy for differentiating between CD and EAS [1, 5, 6, 9, 31]. The current study confirms the importance of using more than one biochemical test for diagnosing hypercortisolemia and diagnosing CD from EAS. Detomas et al. reported that Hb levels were high in females with CS while they were low in males with CS. Furthermore, there were lower levels of Hb in EAS than in CD in females [33]. In the current study, the Hb levels were not different in women and men. Furthermore, no statistical difference was observed for Hb levels between patients with a final diagnosis of CD and EAS. Hb levels did not contribute to diagnosing ACTH-dependent CS in this analysis. There were some limitations in this study. First, the sample size was relatively small. Second, it was a retrospective study. Further studies could investigate the BIPSS in a larger sample size and determine the validity of this method in patients with CS. Conclusions The current study suggests that BIPSS can be a reliable and low-complication method in evaluating patients with ACTH-dependent CS who had equivocal results in imaging and biochemical tests, even before stimulation. Stimulation with DDAVP increases diagnostic accuracy. BIPSS can be used to predict the lateralization of the pituitary adenoma. Data Availability All data generated or analyzed during this study are included in this published article. Abbreviations BIPSS: Bilateral inferior petrosal sinus sampling ACTH: Adrenocorticotropic hormone CS: Cushing’s syndrome IPS: Inferior petrosal sinus DDAVP: Desmopressin CD: Cushing’s disease EAS: Ectopic ACTH syndrome MRI: Magnetic resonance imaging UFC: Urinary free cortisol DST: Dexamethasone suppression test HDDST: High-dose dexamethasone suppression test CRH: Corticotropin-releasing hormone BMI: Body mass index FBS: Fasting blood glucose Hb: Hemoglobin Cr: Creatinine PPV: Positive predictive value NPV: Negative predictive value SBP: Systolic blood pressure DBP: Diastolic blood pressure K: Potassium HTN: Hypertension IHC: Immunohistochemistry TSS: Transsphenoidal surgery References Arnaldi G, Angeli A, Atkinson A, Bertagna X, Cavagnini F, Chrousos G, et al. Diagnosis and Complications of Cushing’s syndrome: a consensus statement. J Clin Endocrinol Metabolism. 2003;88(12):5593–602. Article CAS Google Scholar Sharma ST, Nieman LK, Feelders RA. Cushing’s syndrome: epidemiology and developments in Disease management. Clin Epidemiol. 2015;7:281. PubMed PubMed Central Google Scholar Boscaro M, Barzon L, Sonino N. The diagnosis of Cushing’s syndrome: atypical presentations and laboratory shortcomings. Arch Intern Med. 2000;160(20):3045–53. Article CAS PubMed Google Scholar Atkinson AB, Kennedy AL, Carson DJ, Hadden DR, Weaver JA, Sheridan B. Five cases of cyclical Cushing’s syndrome. Br Med J (Clin Res Ed). 1985;291(6507):1453–7. Article CAS PubMed Google Scholar Velez DA, Mayberg MR, Ludlam WH. Cyclic Cushing syndrome: definitions and treatment implications. NeuroSurg Focus. 2007;23(3):1–3. Article Google Scholar Nieman LK, Biller BM, Findling JW, Newell-Price J, Savage MO, Stewart PM, et al. The diagnosis of Cushing’s syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metabolism. 2008;93(5):1526–40. Article CAS Google Scholar Isidori AM, Kaltsas GA, Pozza C, Frajese V, Newell-Price J, Reznek RH, et al. The ectopic adrenocorticotropin syndrome: clinical features, diagnosis, management, and long-term follow-up. J Clin Endocrinol Metabolism. 2006;91(2):371–7. Article CAS Google Scholar Lad SP, Patil CG, Laws ER, Katznelson L. The role of inferior petrosal sinus sampling in the diagnostic localization of Cushing’s Disease. NeuroSurg Focus. 2007;23(3):1–6. Article Google Scholar Gross BA, Mindea SA, Pick AJ, Chandler JP, Batjer HH. Diagnostic approach to Cushing Disease. NeuroSurg Focus. 2007;23(3):1–7. Google Scholar Tomycz ND, Horowitz MB. Inferior petrosal sinus sampling in the diagnosis of sellar neuropathology. Neurosurg Clin North Am. 2009;20(3):361–7. Article Google Scholar Ceccato F, Barbot M, Mondin A, Boscaro M, Fleseriu M, Scaroni C. Dynamic testing for Differential diagnosis of ACTH-Dependent Cushing Syndrome: a systematic review and Meta-analysis. J Clin Endocrinol Metabolism. 2022;108(5):e178–e88. Article Google Scholar Detomas M, Ritzel K, Nasi-Kordhishti I, Wolfsberger S, Quinkler M, Losa M et al. Outcome of CRH stimulation test and overnight 8 mg dexamethasone suppression test in 469 patients with ACTH-dependent Cushing’s syndrome. Front Endocrinol. 2022;13. Ezzat S, Asa SL, Couldwell WT, Barr CE, Dodge WE, Vance ML, et al. The prevalence of pituitary adenomas: a systematic review. Cancer: Interdisciplinary International Journal of the American Cancer Society. 2004;101(3):613–9. Article Google Scholar Javorsky BR, Findling JW. Inferior petrosal sampling for the differential diagnosis of ACTH-dependent Cushing’s syndrome. Cushing’s Syndrome: Springer; 2010. pp. 105–19. Google Scholar Deipolyi A, Bailin A, Hirsch JA, Walker TG, Oklu R. Bilateral inferior petrosal sinus sampling: experience in 327 patients. J NeuroInterventional Surg. 2017;9(2):196–9. Article Google Scholar Valizadeh M, Ahmadi AR, Ebadinejad A, Rahmani F, Abiri B. Diagnostic accuracy of bilateral inferior petrosal sinus sampling using desmopressin or corticotropic-releasing hormone in ACTH-dependent Cushing’s syndrome: a systematic review and meta-analysis. Reviews in Endocrine and Metabolic Disorders. 2022:1–12. Pinelli S, Barbot M, Scaroni C, Ceccato F. Second-line tests in the diagnosis of adrenocorticotropic hormone-dependent hypercortisolism. Ann Lab Med. 2021;41(6):521–31. Article PubMed PubMed Central Google Scholar Zampetti B, Grossrubatscher E, Dalino Ciaramella P, Boccardi E, Loli P. Bilateral inferior petrosal sinus sampling. Endocr Connect. 2016;5(4):R12–25. Article CAS PubMed PubMed Central Google Scholar Wang H, Ba Y, Xing Q, Cai R-C. Differential diagnostic value of bilateral inferior petrosal sinus sampling (BIPSS) in ACTH-dependent Cushing syndrome: a systematic review and Meta-analysis. BMC Endocr Disorders. 2020;20(1):1–11. Article Google Scholar Chen S, Chen K, Wang S, Zhu H, Lu L, Zhang X, et al. The optimal cut-off of BIPSS in differential diagnosis of ACTH-dependent Cushing’s syndrome: is stimulation necessary? J Clin Endocrinol Metabolism. 2020;105(4):e1673–e85. Article Google Scholar Qiao X, Ye H, Zhang X, Zhao W, Zhang S, Lu B, et al. The value of prolactin in inferior petrosal sinus sampling with desmopressin stimulation in Cushing’s Disease. Endocrine. 2015;48(2):644–52. Article CAS PubMed Google Scholar Sharma ST, Nieman LK. Is prolactin measurement of value during inferior petrosal sinus sampling in patients with adrenocorticotropic hormone-dependent Cushing’s syndrome? J Endocrinol Investig. 2013;36(11):1112–6. CAS Google Scholar Colao A, Faggiano A, Pivonello R, Giraldi FP, Cavagnini F, Lombardi G. Inferior petrosal sinus sampling in the differential diagnosis of Cushing’s syndrome: results of an Italian multicenter study. Eur J Endocrinol. 2001;144(5):499–507. Article CAS PubMed Google Scholar Perlman JE, Johnston PC, Hui F, Mulligan G, Weil RJ, Recinos PF, et al. Pitfalls in performing and interpreting inferior petrosal sinus sampling: personal experience and literature review. J Clin Endocrinol Metabolism. 2021;106(5):e1953–e67. Article Google Scholar Castinetti F, Morange I, Dufour H, Jaquet P, Conte-Devolx B, Girard N, et al. Desmopressin test during petrosal sinus sampling: a valuable tool to discriminate pituitary or ectopic ACTH-dependent Cushing’s syndrome. Eur J Endocrinol. 2007;157(3):271–7. Article CAS PubMed Google Scholar Detomas M, Ritzel K, Nasi-Kordhishti I, Schernthaner-Reiter MH, Losa M, Tröger V, et al. Bilateral inferior petrosal sinus sampling with human CRH stimulation in ACTH-dependent Cushing’s syndrome: results from a retrospective multicenter study. Eur J Endocrinol. 2023;188(5):448–56. Article Google Scholar De Sousa SMC, McCormack AI, McGrath S, Torpy DJ. Prolactin correction for adequacy of petrosal sinus cannulation may diminish diagnostic accuracy in Cushing’s Disease. Clin Endocrinol (Oxf). 2017;87(5):515–22. Article PubMed Google Scholar Lefournier V, Martinie M, Vasdev A, Bessou P, Passagia J-G, Labat-Moleur Fo, et al. Accuracy of bilateral inferior petrosal or cavernous sinuses sampling in predicting the lateralization of Cushing’s Disease pituitary microadenoma: influence of catheter position and anatomy of venous drainage. J Clin Endocrinol Metabolism. 2003;88(1):196–203. Article CAS Google Scholar Wind JJ, Lonser RR, Nieman LK, DeVroom HL, Chang R, Oldfield EH. The lateralization accuracy of inferior petrosal sinus sampling in 501 patients with Cushing’s Disease. J Clin Endocrinol Metab. 2013;98(6):2285–93. Article CAS PubMed PubMed Central Google Scholar Elamin MB, Murad MH, Mullan R, Erickson D, Harris K, Nadeem S, et al. Accuracy of diagnostic tests for Cushing’s syndrome: a systematic review and metaanalyses. J Clin Endocrinol Metabolism. 2008;93(5):1553–62. Article CAS Google Scholar Pecori Giraldi F, Ambrogio AG, De Martin M, Fatti LM, Scacchi M, Cavagnini F. Specificity of first-line tests for the diagnosis of Cushing’s syndrome: assessment in a large series. J Clin Endocrinol Metabolism. 2007;92(11):4123–9. Article Google Scholar Terzolo M, Pia A, Reimondo G. Subclinical cushing’s syndrome: definition and management. Clin Endocrinol. 2012;76(1):12–8. Article CAS Google Scholar Detomas M, Deutschbein T, Tamburello M, Chifu I, Kimpel O, Sbiera S et al. Erythropoiesis in Cushing syndrome: sex-related and subtype-specific differences. Results from a monocentric study. J Endocrinol Investig. 2023. Download references Acknowledgements The authors wish to thank the patients for their participation and kind cooperation. Funding The authors did not receive support from any organization for the submitted work. Author information Authors and Affiliations Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran Mohammadali Tavakoli Ardakani, Soghra Rabizadeh, Amirhossein Yadegar, Fatemeh Mohammadi, Sahar Karimpour Reyhan, Reihane Qahremani, Alireza Esteghamati & Manouchehr Nakhjavani Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran Hossein Ghanaati Contributions MN and MTA and SR: Conception and design of the study. AY and FM and HG: Acquisition of data. MTA and AY and SR: Analysis and interpretation of data. FM and RQ and SK: Drafting the article. MN and AE and AY: Critical revision of the article. All authors read and approved the final manuscript. Corresponding author Correspondence to Manouchehr Nakhjavani. Ethics declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. Informed consent was obtained from all participants or their legal guardians. Approval was granted by the Research Ethics Committee of Tehran University of Medical Sciences (Approval number: IR.TUMS.MEDICINE.REC.1398.707). Consent for publication In order to publish this study, written informed consent was obtained from each participant. A copy of the written consent form is available for review by the journal editor. Competing interests The authors declare no competing interests. Additional information Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Reprints and Permissions Cite this article Ardakani, M.T., Rabizadeh, S., Yadegar, A. et al. Bilateral inferior petrosal sinus sampling: validity, diagnostic accuracy in lateralization of pituitary microadenoma, and treatment in eleven patients with Cushing’s syndrome – a single-center retrospective cohort study. BMC Endocr Disord 23, 232 (2023). https://doi.org/10.1186/s12902-023-01495-z Download citation Received05 July 2023 Accepted19 October 2023 Published23 October 2023 DOIhttps://doi.org/10.1186/s12902-023-01495-z Share this article Anyone you share the following link with will be able to read this content: Get shareable link Provided by the Springer Nature SharedIt content-sharing initiative Keywords BIPSS Bilateral inferior petrosal sinus sampling Cushing’s Disease Cushing’s syndrome EAS From https://bmcendocrdisord.biomedcentral.com/articles/10.1186/s12902-023-01495-z

Medically reviewed by Daniel More, MD You may notice that your face appears puffy or more round on certain days. This can happen as your weight and hormones fluctuate or when you experience allergies or a temporary illness. However, if the puffiness persists or if your facial swelling is severe, this may be a sign of moon face—a condition that causes your face to become rounder due to fluid buildup. Symptoms Moon face causes swelling in your face as a result of excess fluid buildup. You may notice extra puffiness in your cheeks, forehead, and chin. When your facial features enlarge, it creates a round shape that mimics the look of the moon—hence the name, "moon face." It’s important to pay attention to the way your face feels. Sometimes, moon face is mild and not easily noticeable. But other times, moon face can be painful or affect your breathing. Keep track of any pain and swelling you're experiencing. Before seeing a healthcare provider, it can also help to document the following: What pain you're feeling Where the pain is located When your swelling began What improves and worsens your pain and swelling Any other symptoms that accompany puffiness These notes can help your healthcare provider understand the severity of your symptoms and recommend appropriate treatment options. Causes A variety of factors can cause moon face—ranging from mild everyday reactions to more serious conditions. Infections Underlying infections and medical conditions can cause facial swelling and increase your risk of moon face. These include: Conjunctivitis, or “pink eye” Infection in your salivary glands (the glands that produce saliva) Sinusitis, or swelling of your sinuses Styes that cause swelling around your eye Tooth abscesses, or infections in your teeth that cause a pocket of pus Cellulitis, a type of bacterial skin infection Cushing's Syndrome Among the most common causes of moon face is Cushing's syndrome—a condition that occurs when your body makes too much cortisol, which is commonly referred to as the "stress hormone." One of the most common symptoms of Cushing's syndrome is moon face, but you might also experience darkening of the skin, weight gain, and muscle weakness. Corticosteroids If your body doesn’t produce enough cortisol, your healthcare provider may prescribe corticosteroids. These anti-inflammatory drugs can also help treat several conditions such as arthritis, severe allergies, multiple sclerosis, lupus, certain kinds of cancer, and other conditions related to your lungs, skin, eyes, blood, kidneys, thyroid, stomach, or intestines. One of the most common corticosteroids is Deltasone (prednisone). Excess amounts or long-term use of corticosteroids can cause moon face to occur. Medical Side Effects Besides corticosteroids, other types of medication and medical treatment can also cause moon face. Specifically, you may develop moon face as a reaction to a blood transfusion or a range of medications, such as Bayer (aspirin) and certain types of antibiotics. You can also experience moon face after head, nose, or jaw surgery. Weight Changes Both severe malnutrition (not eating enough to get the nutrients you need) and obesity may lead to moon face. Some people with malnutrition develop kwashiorkor—a condition that can lead to swelling of your arms, legs, and face. This can happen because not eating enough food or drinking enough water can cause low levels of fluid and force your body to retain excess salt, which can cause swelling. People with obesity may also be more likely to develop moon face. It's estimated that approximately three out of every four people with Cushing's syndrome experience obesity. When Cushing's syndrome causes excess weight on your body, you may also be at an increased risk of developing fat deposits in your face. Other Causes Other common causes of moon face include: Allergic reactions Burns or injuries to the face Angioedema—a condition that causes swelling under the skin due to an issue with your immune system functioning Myxedema, which is a severe form of hypothyroidism—a condition that occurs when your thyroid gland doesn't make enough thyroid hormone and causes symptoms like skin changes and weight gain Superior vena cava (SVC) syndrome—a condition that causes facial and neck swelling because your SVC (a type of vein in your body) becomes compressed and isn't able to drain or pump blood back to the heart How to Get Rid of Moon Face Because moon face is a symptom of other underlying health conditions, it’s best to consult a healthcare provider to understand what's causing your facial swelling and learn about treatment options. For example, if your moon face is the result of an injury, you might try using ice to reduce the swelling. In addition, propping your head up with extra pillows while you sleep may help improve fluid drainage and reduce swelling. But, if a condition like Cushing's syndrome is causing moon face, medication or surgery may help improve facial swelling. How to Prevent Moon Face There isn't one surefire way to prevent moon face—mostly because a variety of factors can cause symptoms to develop. If you are at risk or concerned about a particular cause of facial swelling, speak with your healthcare provider about your options. If you’re prescribed a corticosteroid, there are particular steps you can take to reduce your chances of developing moon face. When taking a prescribed corticosteroid like prednisone, pay close attention to your symptoms and let your healthcare provider know early if you are developing any symptoms of Cushing's syndrome, including moon face. The earlier they are able to recommend alternative treatment, the better your chances of preventing long-term swelling. When to Contact a Healthcare Provider It’s important to seek care from your provider if you have specific symptoms associated with moon face, including: Swelling that comes on suddenly, causes pain, or is severe Long-lasting swelling Signs of infection, including fever, redness, or tenderness What To Expect at Your Appointment If you seek medical care for moon face, your healthcare provider will likely begin your appointment by taking your medical history and performing a physical exam. They may also ask about: How long your face has been swollen and when it began Things that improve or worsen your symptoms What allergies you have Which medications you take Any recent facial injury, medical test, or surgery Additional symptoms you're experiencing Once they gather this information, your provider can order the necessary testing, understand the underlying cause of your symptoms, and offer treatment options for moon face. A Quick Review Moon face is a condition that occurs when fluid builds up under your skin and causes facial swelling. Several factors can cause moon face, like reactions to medication or surgery, allergies, infections, weight changes, and underlying health conditions. If you have symptoms of moon face or notice your face getting puffy without a clear reason, talk to your provider. They can help you pinpoint the underlying cause and recommend treatment. Adapted from https://www.yahoo.com/lifestyle/moon-face-180000163.html

We have an opportunity for you to take part in a Cushing’s Disease, Type 2 Diabetes Study (M3_8994) for patients. Our project number for this study is M3_8994. Project Details: Web-assisted telephone interview (you must be by a computer with high-speed internet access while on the phone during the time of the interview) Interview is 60-minutes long 120 Dollar Reward Things to Note: We recommend using the web browsers Google Chrome or FireFox Study is open to patients Please do not share study links One participant per household only Want to share this opportunity? Let us know and we can provide a new link Please use a laptop/computer ONLY. No smartphones or tablets - Preliminary questions are mobile friendly! Save this email to reference if you have any questions about the study! If you have any problems, email tana.karamustafic@rarepatientvoice.com and reference the project number. If you are interested in this study, please click the link below to answer a few questions to see if you qualify. Study link: Start Here OR if the study hyperlink is not clickable above, please copy/paste this URL below. https://panel.rarepatientvoice.com/newdesign/site/rarepatientvoice/surveystart.php?surveyID=s4gl5f3v5tr8&panelMemberID=trfnbc7mvduh1gseff1h&invite=email Thanks as always for your participation! Please be aware that by entering this information you are not guaranteed that you will be selected to participate. As always, we do not share any of your contact information without your permission. We have recently updated our Privacy Policy. Please make sure you have read through it and agree to the terms and conditions before taking studies. Please contact us at research@rarepatientvoice.com if you have any questions.

Objective: This study evaluated short- and long-term efficacy and safety of the second-generation somatostatin receptor ligand pasireotide alone or in combination with dopamine agonist cabergoline in patients with Cushing’s disease (CD). Study design: This is an open-label, multicenter, non-comparative, Phase II study comprising 35-week core phase and an optional extension phase. All patients started with pasireotide, and cabergoline was added if cortisol remained elevated. Eligible patients had active CD, with or without prior surgery, were pasireotide naïve at screening or had discontinued pasireotide for reasons other than safety. Primary endpoint was proportion of patients with a mean urinary free cortisol (mUFC) level not exceeding the upper limit of normal (ULN) at week 35 with missing data imputed using last available post-baseline assessments. Results: Of 68 patients enrolled, 26 (38.2%) received pasireotide monotherapy and 42 (61.8%) received pasireotide plus cabergoline during the core phase. Thirty-four patients (50.0%; 95% CI 37.6–62.4) achieved the primary endpoint, of whom 17 (50.0%) received pasireotide monotherapy and 17 (50.0%) received combination therapy. Proportion of patients with mUFC control remained stable during the extension phase up to week 99. Treatment with either mono or combination therapy provided sustained improvements in clinical symptoms of hypercortisolism up to week 99. Hyperglycemia and nausea (51.5% each), diarrhea (44.1%) and cholelithiasis (33.8%) were the most frequent adverse events. Conclusion: Addition of cabergoline in patients with persistently elevated mUFC on maximum tolerated doses of pasireotide is an effective and well-tolerated long-term strategy for enhancing control of hypercortisolism in some CD patients. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT01915303, identifier NCT01915303. 1 Introduction Cushing’s disease (CD) is a rare condition arising from chronic overproduction of cortisol, secondary to an adrenocorticotropic hormone (ACTH)-secreting pituitary tumor (1). Untreated hypercortisolism results in substantial multisystem morbidity, impaired quality of life (QoL) and premature mortality (1–4). Pasireotide is a second-generation, multireceptor-targeted somatostatin receptor ligand (SRLs), with affinity for 4 of the 5 known somatostatin receptor subtypes (SSTRs) (5) and is approved for the treatment of patients with CD for whom surgery has failed or is not an option (6). Phase III trials of pasireotide monotherapy have shown sustained biochemical and clinical benefits up to 5 years (6–9). These benefits are also reflected in real-world evidence (10). Cabergoline, a potent dopamine agonist with high affinity for dopamine type 2 receptors (D2), is commonly used off-label for the treatment of CD (2). Small, retrospective, non-randomized studies have demonstrated long-term urinary free cortisol (UFC) control (24−;60 months) in 23−;40% of patients with CD, especially those with mild hypercortisolism (11–13). A meta-analysis of individual patient data from six observational studies (n=124) reported normalization of mean UFC (mUFC) levels in 34% of patients (14, 15). However, a short prospective study on cabergoline monotherapy showed a limited value in controlling UFC, possibly linked to short duration (16). As most corticotropinomas co­express SSTR5 and D2, combining pasireotide and cabergoline in a stepwise approach could potentially improve efficacy with achieving more rapid biochemical control (17), a premise supported by results from an 80-day pilot study of 17 patients with CD treated with cabergoline- pasireotide combination, and low-dose ketoconazole (in case of lack of complete control with the two-drug combination) (18). The current study aims to report the efficacy and safety of prolonged treatment with pasireotide alone or in combination with cabergoline from the largest prospective, multicentre study to date of a pituitary-targeting combination treatment regimen in patients with CD (NCT01915303). 2 Materials and methods 2.1 Patients Adults (≥18 years) with a confirmed diagnosis of CD or de novo CD, if they were not candidates for surgery or refused surgery were enrolled. Cushing’s disease was defined by a mean 24-hour (24h) UFC level greater than the upper limit of normal (ULN, 137.95 nmol/24h), calculated from three 24h samples collected within 2 weeks; a morning plasma ACTH level within or above the normal range; and a confirmed pituitary source of Cushing’s syndrome, determined by MRI confirmation of pituitary adenoma >6mm or inferior petrosal sinus sampling (IPSS) gradient >3 after CRH stimulation (or >2 if IPSS without CRH stimulation) for those patients with a tumor ≤6mm. For patients who had prior pituitary surgery, histopathology confirming an ACTH staining adenoma was considered confirmatory of CD. Key exclusion criteria included optic chiasm compression requiring surgery, poorly controlled diabetes (glycated hemoglobin [HbA1c] >8%) and having risk factors for torsades de pointes (for further details, see the Supplementary Appendix). 2.2 Study design This was a single-arm, open-label, multicenter, non-comparative, Phase II study. After 4 weeks of screening, patients were treated in a stepwise approach during the core phase. Patients received subcutaneous pasireotide 0.6 mg twice daily (bid) for 8 weeks. Patients with a mUFC level exceeding ULN after 8 weeks received pasireotide 0.9 mg bid for another 8 weeks. If mUFC level remained elevated with pasireotide 0.9 mg bid, oral cabergoline 0.5 mg once daily (qd) was added for 8 weeks and could be increased to 1.0 mg qd for another 8 weeks (Supplementary Figure S1). After 35 weeks of treatment in the core phase, patients could enter the extension phase of the trial. Addition or titration of cabergoline during the extension phase was at the discretion of investigators. Collection of extension data commenced from week 43, and patients continued their current study treatment up to study end (4 September 2019; date of last patient visit), week 257. Data beyond week 99 are not reported here because of small patient numbers. 2.3 End points and assessments The primary endpoint of the study was the proportion of patients with mUFC ≤ULN at week 35. Secondary endpoints (reported at 4-week intervals up to week 35 and 8-week intervals from week 43 to the date of the last patient visit) included changes from baseline in mUFC, plasma ACTH, serum cortisol, total cholesterol, and clinical signs (systolic/diastolic blood pressure, body mass index (BMI), weight, waist circumference, facial rubor, hirsutism, striae, supraclavicular and dorsal fat pads) and symptoms (CushingQoL). Treatment escape was defined as an increase in one UFC above the normal range during follow-up of complete responders (14). Cushing Quality of Life Questionnaire (CushingQoL) (19) scores were reported up to week 35 only. Details on the safety assessments are provided in the Supplementary Appendix. 2.4 Statistical analyses No formal hypothesis testing was performed because of the exploratory design of the study. Efficacy analyses were conducted on full analysis set, i.e., all patients to whom study treatment was assigned. Safety analyses were conducted on all patients who received ≥1 dose of pasireotide per day during the study. For patients with missing mUFC value at week 35, including those who discontinued, the last available assessment was carried forward. Details on the post hoc analyses and sample size estimation is provided in the Supplementary Appendix. Enrolled patients, who were observed for failed inclusion or exclusion criteria during the monitoring visits, were classified under protocol deviation. However, patients with no safety concerns were allowed to continue in the study and included in the full analysis set as intention to treat – assessing the study outcome, while some patients were excluded from the per protocol analysis. 3 Results 3.1 Study population A total of 68 patients were enrolled in the study. At baseline, 66 (97.1%) patients were pasireotide naïve, while 2 (2.9%) were treated with pasireotide previously with 4 weeks of washout period prior to screening (Table 1). Of 68 patients received treatment during the core phase, 26 (38.2%) received pasireotide monotherapy and 42 (61.8%) received combination therapy. Fifty-two (76.5%) patients completed the 35-week core phase while 16 (23.5%) discontinued (Figure 1). All 68 patients were included in the full analysis set based on the intention to treat (ITT) principle. One of the protocol deviations observed during the study, was inclusion of 3 patients with normal mUFC value at screening visit (baseline) and assigning a treatment. The deviation category for the 3 patients was ‘failed inclusion criteria’ with screening mUFC value ≤ULN (137.95 nmol/24h) or mUFC calculated using ❤️ UFC values or 2 out of 3 UFC values ≤ULN. One of these patients (baseline mUFC 37.37 nmol/24h ≤ULN) was discontinued from the study at Week 2 and due to lack of post-baseline mUFC assessment, was classified ‘non-responder’ at Week 35 assessment. The 2nd patient’s baseline mUFC value of 135.20 nmol/24h was close to ULN (137.95 nmol/24h) and was rescreened. Based on the rescreened mUFC value 306.5 nmol/24h, this patient was included in study, and the mUFC at Week 35 was 192.30 nmol/24h (non-responder at Week 35 assessment). For all study assessments, the scheduled screening visit’s first mUFC value (≤ULN) was used as baseline value. The 3rd patient (baseline mUFC value 131.77 nmol/24h) was discontinued from the study at Week 26 and was also observed for non-compliant schedule visit and medication dosages. The mUFC value recorded at Week 26 (88.95 nmol/24h) was ≤ULN and this last observation was carried forward to Week 35. Hence, the patient was classified ‘responder’, leaving one patient included in the study as responder as a protocol deviation. Table 1 Table 1 Patient demographics and baseline characteristics. Figure 1 Figure 1 Patient disposition. *If the study drugs were locally available at the end of the core phase, patients could switch over to the commercial supply and exit the extension phase. Only in countries where the drug was not locally available were patients given the option to enter the extension phase. Percentage for patients not entering the extension phase was calculated from the total number of patients enrolled in the study. Twenty-nine (42.6%) patients continued treatment in the extension phase; 10 (34.5%) received pasireotide monotherapy and 19 (65.5%) received combination therapy. Twelve (41.4%) patients completed the extension phase, while 17 (58.6%) discontinued treatment before study end, most commonly for unsatisfactory therapeutic effect (n=8). The most common reason for discontinuation was adverse events (AEs): 5 (17.2%) patients with pasireotide monotherapy and 2 (5.1%) patients with combination therapy. 3.2 Efficacy: biochemical response Overall, 34/68 (50.0%; 95% CI 37.6–62.4) patients achieved the primary endpoint, of whom 17 (50.0%) were receiving pasireotide monotherapy and 17 (50.0%) were receiving combination therapy. Patients with mild hypercortisolism (mUFC 1.0–<2.0 x ULN) at baseline were more likely to respond to both pasireotide monotherapy and combination therapy (n=15; 22.1%, Figure 2). Seven of 17 patients in the pasireotide monotherapy group met the primary endpoint based on their last available assessment prior to week 35. Even if the 3 patients who had mUFC ≤ULN at baseline were excluded from the primary analysis, 33/65 (50.7%; 95% CI 38.1–63.4) patients would have achieved the primary endpoint. The results are similar to the original analysis (34/68 (50.0%; 95% CI 37.6–62.4) based on the full analysis set. Figure 2 Figure 2 Patients achieving mUFC ≤ULN at week 35. †At baseline there were 23 patients with mild, 30 with moderate and 12 with severe hypercortisolism. mUFC, mean urine free cortisol; ULN, upper limit of normal. For the overall study population (n=68), mUFC rapidly decreased from 501.6 nmol/24h (3.6 x ULN; SD: 488.66 nmol/24h) to 242.1 nmol/24h (1.8 x ULN; SD: 203.47 nmol/24h) at week 4 and mUFC remained below baseline levels up to week 35 (184.8 nmol/24h; 1.3 x ULN; SD:140.13 nmol/24h). For patients who received pasireotide monotherapy (n=26), mUFC( ± SD) decreased from baseline (442.1± 557.13 nmol/24h [n=26]; 3.2 x ULN) to week 35 (136.6 ± 127.77 nmol/24h [n=14]; 1 x ULN) and at the end of the study (111.2 ± 40.39 nmol/24h [n=5]; 0.8 x ULN) using the last-observation-carried-forward (LOCF). For those who did not normalize on pasireotide monotherapy (n=42), mUFC ( ± SD) decreased from baseline, i.e., last observation before starting cabergoline (280.20 ± 129.03 nmol/24h [n=40]; 2.0 x ULN) to week 35 (206.6 ± 141.96 nmol/24h [n=31]; 1.5 x ULN) and at the end of the study (219.60 ± 83.78 nmol/24h [n=7]; 1.6 x ULN) using the LOCF. During the core phase, mean serum cortisol decreased from 738.6 nmol/L (1.3 x ULN) at baseline to 538.2 nmol/L (0.95 x ULN) and ACTH levels from 16.3 pmol/L (2.7 x ULN) to 11.0 pmol/L (1.8 x ULN) at week 35. During the extension phase, 25 patients had a mUFC assessment; of whom 12 (48%) had a mUFC ≤ULN at the end of the extension phase. During the extension phase, mUFC levels decreased slightly and fluctuated above and below the ULN up to the week 139 (Figure 3A), while mean serum cortisol remained below ULN (404 nmol/L; Figure 3B) and ACTH levels fluctuated from 8.2 pmol/L to 11.5 pmol/L) and remained above the ULN value (Figure 3C). Figure 3 Figure 3 Mean actual change over time in (A) mUFC (B) serum cortisol, and (C) ACTH. ACTH, adrenocorticotropic hormone; mUFC, mean urine free cortisol; ULN, upper limit of normal . Twenty-one of 38 (55%) patients achieved control with combination therapy at some point during the core or extension study, of whom 13 (62%) experienced escape (at least one UFC >ULN after previous control). The time to achieve control after starting cabergoline ranged from 14−;343 days. Notably, one patient received pasireotide 0.6 mg bid initially, dose increased to 0.9 mg bid at Week 17, followed by addition of cabergoline 0.5 mg od at Week 31. The patient achieved biochemical control (mUFC value of 120.15 nmol/24h) on the same day of the start of combination therapy. Clinically it is highly unlikely that biochemical control was achieved with single dose of cabergoline administration. Therefore, it could be considered that normalization was achieved while receiving pasireotide monotherapy. Also, the physician might have prescribed combination therapy before receiving the mUFC value of the (urinary) sample delivered on the morning of combination therapy initiation (while the patient was still on monotherapy). The patient continued combination therapy and maintained biochemical control up to Week 35 and beyond. Furthermore, at Week 59 the cabergoline dose was increased to 1.0 mg/day due to mUFC >ULN at previous visit (Week 51). The patient remained on pasireotide 0.9 mg bid/cabergoline 1.0 mg od combination therapy until the study end. The median time to escape after achieving control with the addition of cabergoline was 58 days (range 28−;344). 10/13patients regained biochemical control with combination therapy. No patients on pasireotide alone experienced escape, probably due to the short observation time. 3.3 Clinical signs and symptoms of CD Relative to baseline, pasireotide monotherapy was accompanied by reductions in median blood pressure, weight, BMI, waist circumference, and total cholesterol. Overall improvement in clinical measures persisted over time (Supplementary Table S1). Clinical improvements were also seen following the addition of cabergoline, particularly for hirsutism (Supplementary Figures S2, S3). Mean( ± SD) standardized CushingQoL score was 41.6(± 20.2) at baseline and increased to 47.6(± 20.8) at week 35 (Supplementary Table S2), indicating improvements in patients’ QoL (19). 3.4 Safety and tolerability Median duration of exposure to pasireotide was 35.0 weeks (range 0−;268), with a median dose of 1.53 mg/day (range 0.29−;1.80). Median duration of exposure to cabergoline was 16.9 weeks (range 1−;215), with a median dose of 0.50 mg/day (range 0.44−;0.97). All patients (N=68) reported at least one AE and 28/68 (41.2%) patients had a grade 3/4 AE (Table 2). The most common AEs (≥30%) were hyperglycemia and nausea (51.5% each), diarrhea (44.1%) and cholelithiasis (33.8%). Treatment-related AEs (TRAEs) were reported in 66/68 (97.1%) patients; the most frequent TRAEs (≥30%) were hyperglycemia and nausea (47.1% each), diarrhea (39.7%), and cholelithiasis (32.4%). Fourteen (20.6%) patients had ≥1 AE leading to discontinuation. Table 2 Table 2 Summary of adverse events (≥10%), overall and by treatment regimen. The most common AEs leading to discontinuation were increased gamma-glutamyl transferase (GGT) and hyperglycemia (two patients each, 2.9%). Twenty-three (33.8%) patients had ≥1 AE leading to dose adjustment or interruption. Details on special safety assessments such as hyperglycemia-related AEs, blood glucose, HbA1c, IGF-1 as well as hematological and biochemical abnormalities are presented in the Supplementary Appendix. Three (4.4%) patients died during the study, two (2.9%) during the core phase and one (1.5%) during the extension. All deaths were considered unrelated to study medication. The causes during the core phase were multi-organ dysfunction syndrome for one patient aged 79 years and unknown for the other aged 34 years. Uncontrolled hypertension was reported as the cause of death for the patient aged 47 during the extension phase. 4 Discussion The severe morbidity and increased mortality with uncontrolled CD highlight the importance of identifying an effective medical strategy. This study explored the potential of a synergistic benefit of the addition of cabergoline to pasireotide treatment in patients with CD. Complete normalization of cortisol production is required to reverse the risks of morbidity and mortality in patients with CD (1). Two small studies showed clinical improvement of normalized UFC when cabergoline and ketoconazole were combined (20, 21). Benefit has also been reported with triple therapy with pasireotide, cabergoline and ketoconazole (18) and triple therapy with ketoconazole, metyrapone and mitotane in severe CD (22). In the current study, 50% of patients achieved the primary endpoint of mUFC ≤ULN at week 35 and a similar proportion (48%) sustained biochemical control throughout the extension phase. Notably, combination treatment doubled the number of patients who attained mUFC ≤ULN from the core phase to the end of the extension phase. In particular, mUFC was rapidly reduced with treatment, i.e., in most patients within 2 months, while measures of patient-reported outcomes also improved including QoL. Twenty-three patients (33.8%) who completed the core phase did not enter the extension phase. This was because only patients from countries where a commercial supply was unavailable were given the option to enter the extension phase. This study confirms previous reports that patients with mild hypercortisolism at baseline were more likely to achieve mUFC control with pasireotide monotherapy than patients with moderate or severe hypercortisolism (6, 23). In addition, patients with moderate hypercortisolism at baseline were more likely to achieve mUFC control with the addition of cabergoline. This supports that a combination therapy can be effective for patients with a wider range of disease severity. Accordingly, in vitro data may indeed indicate synergism between SSTR and D2 that might increase therapeutic efficacy (24, 25). Improvements in clinical signs and symptoms with pasireotide monotherapy were consistent with published data (6, 10). In the core phase, an improvement of blood pressure and BMI was observed with pasireotide monotherapy and, to a lesser extent, with combination therapy which may related to the difference in duration of biochemical remission. The overall safety profile was consistent with that expected for pasireotide, with most AEs being mild/moderate (26, 27). There were no new safety signals identified with the addition of cabergoline. Common AEs including nausea, headache, dizziness, and fatigue are suggestive of steroid withdrawal symptoms associated with the decrease in UFC, although direct drug effects cannot fully be excluded. Adrenal insufficiency was not reported as side effect. Rates of hyperglycemia-related AEs (68%) were consistent with those in previous reports of pasireotide monotherapy (6, 10). FPG increased with pasireotide monotherapy during the first 8 weeks of treatment and stabilized for the remainder of the study, including following the addition of cabergoline. These data highlight the vital role of blood glucose monitoring in these patients. Both pasireotide and cabergoline are pituitary-targeted agents that act directly on the source of the disease via inhibition of ACTH release by the corticotroph tumor, which may be an advantage over steroid synthesis inhibitors. This study further confirms previous data reporting the benefits of pasireotide in combination with cabergoline in patients with CD (18). While not entirely elucidated, down-regulation of dopamine D2 receptors (D2R) expression, and post-receptor desensitization and/or tumor regrowth of corticotroph tumor cell were suggested as possible mechanisms for treatment escape (15). Moreover, different dopamine receptor patterns and/or D2R isoforms also influence the response and eventually the treatment escape. Treatment escape has been observed in some studies after long-term (7−;12 months) treatment with cabergoline (13), however it is possible that use of concomitant SRLs could potentially reduce the rate of escape. In this study, a total of 13 patients experienced treatment escape. However, 10 of these patients regained biochemical control. For 7 of these 10 patients, there was up titration of doses to a maximum of 1.8 mg/day of pasireotide and 1 mg/day of cabergolineAlthough pasireotide and cabergoline have shown long-term reduction in IGF-1 levels in patients with acromegaly (28, 29), there is little evidence for this effect in patients with CD (4, 30). One study (n=17) found significant decreases in IGF-1 after 28 days’ treatment with pasireotide that was independent of UFC reduction. One-third of patients had low IGF-1 (30). Our study showed that almost half of patients (47.6%) had IGF-1 levels either above ULN or below LLN prior to the addition of cabergoline, and IGF-1 levels decreased relative to the baseline, with majority of values within the normal range during the core and extension phases up to week 99. Baseline levels of IGF-1 may already be low because of the suppressive effect of excess cortisol on the somatotropic axis (31). Although clinicians have several therapeutic options at their disposal to treat hypercortisolemia associated with CD, the optimal treatment approach should be based on the individual clinical situation and the benefit–risk considerations for each patient. In this study, 13 patients had history of pituitary radiation, with a duration of at least 2.6 years (median 3.3 years) between the last radiation treatment and the observed response date. However, only 7/13 patients achieved the therapeutic target. Although there was a gap of > 2 years, we cannot exclude the role of radiation in normalizing UFC. Contrastingly, 6/13 patients treated with radiation did not achieve mUFC ≤ULN (responders) at Week 35. The impact of the adjuvant radiation therapy remains unclear. The strengths of this study are that this is the largest and longest prospective study with pituitary-directed pharmacotherapy, to date, evaluating the addition of cabergoline to pasireotide in patients with CD, and this stepwise approach reflects real-world clinical practice (18). The study is limited by the open-label design and the fact that it was not a head-to-head comparative study of pasireotide only versus pasireotide plus cabergoline. This may be of importance in interpreting patient-reported outcomes. Several patients continued treatment for almost 2 years; however, interpretation of long-term data should be made with caution because of the small patient numbers. Notably, the last available assessment was carried forward for patients with missing mUFC value at week 35 including those who discontinued and were considered for response analysis. It should also be noted that the definition of loss of response, also known as escape, used in this study (at least one UFC value >ULN after previously achieving UFC ≤ULN) may overestimate the rate of apparent escape as UFC values may have fluctuated about the ULN range or been marginally elevated. The definition of treatment escape differs across studies, and we have used a very stringent one in this study, requiring only a single high UFC to meet the classification as escape. Thus, it is likely that some loss of biochemical control interpreted as escape is actually fluctuation of cortisol around the upper limit of normal range. Other limitations include protocol deviations in including 3 patients with normal UFC at baseline (one patient was uncontrolled at rescreen, and one was discontinued at 2 weeks - both classified as non-responders), lack of data on impact of radiation therapy without study drug in patients who gained biochemical control with adjuvant radiation therapy, lack of pituitary magnetic resonance imaging to detect pituitary tumor changes, lack of data about effective cabergoline dose and absence of cardiac valve assessment for mild to moderate severity in the medium term. Both pasireotide and cabergoline can induce tumor shrinkage in CD (6, 9, 32–35) and it would be interesting to examine the combined effect on tumor size. This study used the subcutaneous formulation of pasireotide, whereas the most common usage currently is the long-acting formulation. Efficacy of long-acting pasireotide (36) seems higher compared to the subcutaneous formulation (7) and the effect of combination of long-acting pasireotide with cabergoline should be evaluated in future studies. No formal assessments were made for impulsive control disorders, which have been associated with dopamine agonists, including cabergoline (32, 33, 37, 38). The reason that several different terms were used for hyperglycemia-related AEs is that they were reported as per discretion of each investigator. No additional psychiatric AEs were reported, although they were not exhaustively searched. 5 Conclusions This is the first study demonstrating that pituitary-targeted combination treatment with pasireotide and cabergoline doubled the number of patients who attained mUFC ≤ULN. Both short- and long-term safety profile are consistent with known data for pasireotide and cabergoline. The low rate of discontinuation due to AEs suggests that pasireotide alone or as combination treatment is generally well-tolerated if appropriately monitored, even with prolonged treatment. The addition of cabergoline to pasireotide treatment in patients with persistently elevated mUFC could be an effective long-term strategy for enhancing the control of CD in a subset of patients, with close monitoring for possible escape. Data availability statement The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author. Ethics statement The studies involving humans were approved by Hospital Britanico, Buenos Aires, Argentina; Ethische commissie University Hospitals Leuven, Leuven, Belgium; Universitair Ziekenhuis Gent, Gent, Belgium; Comite de Etica em Pesquisa Hospital Moinhos de Vento, Porto Alegre-RS, Brazil; Comitê de Ética em Pesquisa do Hospital de Clı́nicas, Universidade Federal do Paraná, Curitiba-PR, Brazil; Comissão de Ética para Análise de Projetos de Pesquisa, São Paulo - SP, Brazil; Ethics Committee for clinical trials, Sofia, Bulgaria; Comité Corporativo de Ética en Investigación, Bogotá DC, Colombia; Comite De Protection Des Personnes, Groupe Hospitalier Pellegrin - Bat, Bordeaux Cedex, France; Friedrich-Alexander Universitat Erlangen-Nurnberg, Medizinische Fakultat, Erlangen, Germany;National Ethics Committee, Cholargos, Athens, Greece; Ethics Committee for Clinical Pharmacology (ECCP), Budapest, Hungary; Institute Ethics Committee, New Delhi, India; Institutional Review Board (IRB) Ethics Committee Silver, Christian Medical College, Vellore, Tamil Nadu, India; Institute Ethics Committee, PGIMER, Chandigarh, India; Comitato Etico Dell’irccs Istituto Auxologico Italiano Di Milano, Milano, Italy; Comitato Etico Universita’ Federico Ii Di Napoli, Napoli, Italy; Jawatankuasa Etika & Penyelidikan Perubatan (Medical Research and Ethics Committee), d/a Institut Pengurusan Keshatan Jalan Rumah Sakit, Kuala Lumpur, Malaysia; Institutd Nacional De Neurologia Y Neurocirugia, Mexico City, Mexico; Clinica Bajio (CLINBA), Guanajuato, Mexico; Medische Ethische Toetsings Commissie, Rotterdam; Netherlands; CEIm Provincial de Málaga, Málaga, Spain; Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey; WIRB, Puyallup, WA, USA; Research Integrity Office, Oregon Health & Science University Portland, OR USA. The studies were conducted in accordance with local legislations and institutional requirements. The participants provided their written informed consent to participate in this study. Author contributions All authors directly participated in the planning, execution, or analysis, and have had full control of complete primary data, and hold responsibility for data integrity and accuracy. All authors contributed to the article and approved the submitted version. Acknowledgments We thank Julie Brown, Mudskipper Business Ltd, and Manojkumar Patel and Sashi Kiran Goteti, Novartis Healthcare Private Limited, for medical editorial assistance with this manuscript. We would also like to thank all investigators, sub-investigators, study nurses and coordinators, and patients who have made this study possible. Conflict of interest HP and RM were Novartis employees and owned Novartis stocks. AMP was employed by Novartis and Recordati. AC is a Novartis employee and owns Novartis stocks. RF received research grants from Strongbridge and Corcept, consulting fee from Recordati, honoraria and financial support for meetings and/or travel from HRA Pharma and Recordati, and attended advisory boards for Recordati. MF has received research support to Oregon Health & Science University as a principal investigator from Recordati and Xeris Strongbridge and has performed occasional scientific consultancy for Recordati, HRA Pharma, Sparrow, and Xeris Strongbridge. PK attended advisory boards for Recordati. MB’s institution received consulting fee and attended advisory boards from Recordati. DG-D received research grants from Recordati Rare Disease and Bayer, consulting fee from Abbott-Lafrancol, Biotoscana, PTC lab, Glaxo/Helou, Recordati Rare Disease, and Bayer, honoraria from Valentech Pharma, Sanofi, and Bayer, travel grants from Recordati Rare Disease, advocacy groups and other leadership roles from Asociación Colombiana de Endocrinologia and Asociación Colombiana de Osteoporosis y Metabolismo, and other financial and non-financial interests include Asociacion Colombiana de Endocrinologia y Metabolismo, Hospital Universitario Fundación Santa Fé de Bogota, and Asociación Colombiana de Osteoporosis y Metabolismo. CB received research grants from Novartis and Recordati, and consulting and speaker fee from Novartis. BB served as the principal investigator for grants to Massachusetts General Hospital from Cortendo/Strongbridge Xeris, Millendo, and Novartis and has occasionally consulted for Cortendo/Strongbridge Xeris, HRA Pharma, Novartis Recordati, and Sparrow. RP and his institution received research grants and honoraria from Pfizer, Ipsen, Novartis, Merck Serono, IBSA Farmaceutici, Corcept, Shire, HRA Pharma, ICON, Covance, Neuroendocrine CAH, Camurus, Recordati, Janssen Cilag, and CMED Clinical Services, received consulting fee from Recordati Rare Disease, Organon Italia, Siunergos Pharma, Corcept, S&R Farmaceutici S.p.A., DAMOR Farmaceutici, and Pfizer, attended advisory boards from Crinetics Pharmaceuticals, Recordati Rare Disease, Pfizer, and HRA Pharma. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors declare that this study received funding from Novartis Pharma AG. Novartis was involved in the study design, analysis, interpretation of data, and providing financial support for medical editorial assistance of this article. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Supplementary material The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fendo.2023.1165681/full#supplementary-material References 1. Lacroix A, Feelders RA, Stratakis CA, Nieman LK. Cushing’s syndrome. Lancet (2015) 386(9996):913–27. doi: 10.1016/s0140-6736(14)61375-1 PubMed Abstract | CrossRef Full Text | Google Scholar 2. Feelders RA, Newell-Price J, Pivonello R, Nieman LK, Hofland LJ, Lacroix A. Advances in the medical treatment of Cushing’s syndrome. Lancet Diabetes Endocrinol (2019) 7(4):300–12. doi: 10.1016/s2213-8587(18)30155-4 PubMed Abstract | CrossRef Full Text | Google Scholar 3. Newell-Price J. Mortality in cushing disease. Nat Rev Endocrinol (2016) 12(9):502–3. doi: 10.1038/nrendo.2016.118 PubMed Abstract | CrossRef Full Text | Google Scholar 4. Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, et al. Consensus on diagnosis and management of Cushing’s disease: a guideline update. Lancet Diabetes Endocrinol (2021) 9(12):847–75. doi: 10.1016/s2213-8587(21)00235-7 PubMed Abstract | CrossRef Full Text | Google Scholar 5. Schmid HA. Pasireotide (SOM230): Development, mechanism of action and potential applications. Mol Cell Endocrinol (2008) 286(1):69–74. doi: 10.1016/j.mce.2007.09.006 PubMed Abstract | CrossRef Full Text | Google Scholar 6. Colao A, Petersenn S, Newell-Price J, Findling JW, Gu F, Maldonado M, et al. A 12-month Phase 3 study of pasireotide in Cushing’s disease. N Engl J Med (2012) 366(10):914–24. doi: 10.1056/NEJMoa1105743 PubMed Abstract | CrossRef Full Text | Google Scholar 7. Lacroix A, Gu F, Gallardo W, Pivonello R, Yu Y, Witek P, et al. Efficacy and safety of once-monthly pasireotide in Cushing’s disease: a 12 month clinical trial. Lancet Diabetes Endocrinol (2018) 6(1):17–26. doi: 10.1016/s2213-8587(17)30326-1 PubMed Abstract | CrossRef Full Text | Google Scholar 8. Fleseriu M, Petersenn S, Biller BMK, Kadioglu P, De Block C, T’Sjoen G, et al. Long-term efficacy and safety of once-monthly pasireotide in Cushing’s disease: A Phase III extension study. Clin Endocrinol (2019) 91(6):776–85. doi: 10.1111/cen.14081 CrossRef Full Text | Google Scholar 9. Petersenn S, Salgado LR, Schopohl J, Portocarrero-Ortiz L, Arnaldi G, Lacroix A, et al. Long-term treatment of Cushing’s disease with pasireotide: 5-year results from an open-label extension study of a Phase III trial. Endocrine (2017) 57(1):156–65. doi: 10.1007/s12020-017-1316-3 PubMed Abstract | CrossRef Full Text | Google Scholar 10. Fleseriu M, Iweha C, Salgado L, Mazzuco TL, Campigotto F, Maamari R, et al. Safety and efficacy of subcutaneous pasireotide in patients with Cushing’s disease: results from an open-label, multicenter, single-arm, multinational, expanded-access study. Original Res Front Endocrinol (Lausanne) (2019) 10:436. doi: 10.3389/fendo.2019.00436 CrossRef Full Text | Google Scholar 11. Pivonello R, De Martino MC, Cappabianca P, De Leo M, Faggiano A, Lombardi G, et al. The medical treatment of Cushing’s disease: effectiveness of chronic treatment with the dopamine agonist cabergoline in patients unsuccessfully treated by surgery. J Clin Endocrinol Metab (2009) 94(1):223–30. doi: 10.1210/jc.2008-1533 PubMed Abstract | CrossRef Full Text | Google Scholar 12. Godbout A, Manavela M, Danilowicz K, Beauregard H, Bruno OD, Lacroix A. Cabergoline monotherapy in the long-term treatment of Cushing’s disease. Eur J Endocrinol (2010) 163(5):709–16. doi: 10.1530/eje-10-0382 PubMed Abstract | CrossRef Full Text | Google Scholar 13. Ferriere A, Cortet C, Chanson P, Delemer B, Caron P, Chabre O, et al. Cabergoline for Cushing’s disease: a large retrospective multicenter study. Eur J Endocrinol (2017) 176(3):305–14. doi: 10.1530/eje-16-0662 PubMed Abstract | CrossRef Full Text | Google Scholar 14. Palui R, Sahoo J, Kamalanathan S, Kar SS, Selvarajan S, Durgia H. Effect of cabergoline monotherapy in Cushing’s disease: an individual participant data meta-analysis. J Endocrinol Invest (2018) 41(12):1445–55. doi: 10.1007/s40618-018-0936-7 PubMed Abstract | CrossRef Full Text | Google Scholar 15. Palui R, Sahoo J, Kamalanathan S, Kar SS, Selvarajan S, Durgia H. Correction to: Palui R, Sahoo J, Kamalanathan S, Kar SS, Selvarajan S, Durgia H. Effect of cabergoline monotherapy in Cushing’ disease: an individual participant data meta-analysis. J Endocrinol Invest. 2018; 41(12):1445-1455. Doi: 10.1007/s40618-018-0936-7. J Endocrinol Invest (2022) 45(4):899–900. doi: 10.1007/s40618-021-01723-0 PubMed Abstract | CrossRef Full Text | Google Scholar 16. Burman P, Edén-Engström B, Ekman B, Karlsson FA, Schwarcz E, Wahlberg J. Limited value of cabergoline in Cushing’s disease: a prospective study of a 6-week treatment in 20 patients. Eur J Endocrinol (2016) 174(1):17–24. doi: 10.1530/eje-15-0807 PubMed Abstract | CrossRef Full Text | Google Scholar 17. Colao A, Filippella M, Pivonello R, Di Somma C, Faggiano A, Lombardi G. Combined therapy of somatostatin analogues and dopamine agonists in the treatment of pituitary tumours. Eur J Endocrinol (2007) 156:S57–63. doi: 10.1530/eje.1.02348 PubMed Abstract | CrossRef Full Text | Google Scholar 18. Feelders RA, de Bruin C, Pereira AM, Romijn JA, Netea-Maier RT, Hermus AR, et al. Pasireotide alone or with cabergoline and ketoconazole in Cushing’s disease. N Engl J Med (2010) 362(19):1846–8. doi: 10.1056/NEJMc1000094 PubMed Abstract | CrossRef Full Text | Google Scholar 19. Webb SM, Badia X, Barahona MJ, Colao A, Strasburger CJ, Tabarin A, et al. Evaluation of health-related quality of life in patients with Cushing’s syndrome with a new questionnaire. Eur J Endocrinol (2008) 158(5):623–30. doi: 10.1530/eje-07-0762 PubMed Abstract | CrossRef Full Text | Google Scholar 20. Barbot M, Albiger N, Ceccato F, Zilio M, Frigo AC, Denaro L, et al. Combination therapy for Cushing’s disease: effectiveness of two schedules of treatment: should we start with cabergoline or ketoconazole? . Pituitary (2014) 17(2):109–17. doi: 10.1007/s11102-013-0475-3 PubMed Abstract | CrossRef Full Text | Google Scholar 21. Vilar L, Naves LA, Azevedo MF, Arruda MJ, Arahata CM, Moura E, et al. Effectiveness of cabergoline in monotherapy and combined with ketoconazole in the management of Cushing's disease. Pituitary (2010) 13(2):123–9. doi: 10.1007/s11102-009-0209-8 PubMed Abstract | CrossRef Full Text | Google Scholar 22. Kamenický P, Droumaguet C, Salenave S, Blanchard A, Jublanc C, Gautier JF, et al. Mitotane, metyrapone, and ketoconazole combination therapy as an alternative to rescue adrenalectomy for severe ACTH-dependent Cushing's syndrome. J Clin Endocrinol Metab. (2011) 96(9):2796–804. doi: 10.1210/jc.2011-0536 PubMed Abstract | CrossRef Full Text | Google Scholar 23. Boscaro M, Ludlam WH, Atkinson B, Glusman JE, Petersenn S, Reincke M, et al. Treatment of pituitary-dependent Cushing’s disease with the multireceptor ligand somatostatin analog pasireotide (SOM230): a multicenter, Phase II trial. J Clin Endocrinol Metab (2009) 94(1):115–22. doi: 10.1210/jc.2008-1008 PubMed Abstract | CrossRef Full Text | Google Scholar 24. Rocheville M, Lange DC, Kumar U, Patel SC, Patel RC, Patel YC. Receptors for dopamine and somatostatin: formation of hetero-oligomers with enhanced functional activity. Science (2000) 288(5463):154–7. doi: 10.1126/science.288.5463.154 PubMed Abstract | CrossRef Full Text | Google Scholar 25. Baragli A, Alturaihi H, Watt HL, Abdallah A, Kumar U. Heterooligomerization of human dopamine receptor 2 and somatostatin receptor 2 Co-immunoprecipitation and fluorescence resonance energy transfer analysis. Cell Signal (2007) 19(11):2304–16. doi: 10.1016/j.cellsig.2007.07.007 PubMed Abstract | CrossRef Full Text | Google Scholar 26. Pivonello R, Ferrigno R, De Martino MC, Simeoli C, Di Paola N, Pivonello C, et al. Medical treatment of Cushing's disease: an overview of the current and recent clinical trials. Front Endocrinol (Lausanne) (2020) 11:648. doi: 10.3389/fendo.2020.00648 CrossRef Full Text | Google Scholar 27. 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(5):321–39. doi: 10.1080/17446651.2020.1802243 PubMed Abstract | CrossRef Full Text | Google Scholar 28. Colao A, Bronstein MD, Brue T, De Marinis L, Fleseriu M, Guitelman M, et al. Pasireotide for acromegaly: long-term outcomes from an extension to the Phase III PAOLA study. Eur J Endocrinol (2020) 182(6):583. doi: 10.1530/EJE-19-0762 PubMed Abstract | CrossRef Full Text | Google Scholar 29. Marazuela M, Ramos-Leví A, Sampedro-Núñez M, Bernabeu I. Cabergoline treatment in acromegaly: pros. Endocrine (2014) 46(2):215–9. doi: 10.1007/s12020-014-0206-1 PubMed Abstract | CrossRef Full Text | Google Scholar 30. Varewijck AJ, Feelders RA, de Bruin C, Pereira AM, Netea-Maier RT, Zelissen PMJ, et al. P3-535, Pasireotide treatment in cushing disease: effects on the IGF-I system. Endocr Rev (2011) 32(Suppl 1):1–3095. doi: 10.1210/endo-meetings.2011.PART4.P5.P3-535 CrossRef Full Text | Google Scholar 31. Mazziotti G, Giustina A. Glucocorticoids and the regulation of growth hormone secretion. Nat Rev Endocrinol (2013) 9(5):265–76. doi: 10.1038/nrendo.2013.5 PubMed Abstract | CrossRef Full Text | Google Scholar 32. Batista RL, Musolino NRC, Cescato VAS, da Silva GO, Medeiros RSS, Herkenhoff CGB, et al. Cabergoline in the management of residual nonfunctioning pituitary adenoma: a single-center, open-label, 2-year randomized clinical trial. Am J Clin Oncol (2019) 42(2):221–7. doi: 10.1097/coc.0000000000000505 PubMed Abstract | CrossRef Full Text | Google Scholar 33. Lacroix A, Gu F, Schopohl J, Kandra A, Pedroncelli AM, Jin L, et al. Pasireotide treatment significantly reduces tumor volume in patients with Cushing’s disease: results from a Phase 3 study. Pituitary (2020) 23(3):203–11. doi: 10.1007/s11102-019-01021-2 PubMed Abstract | CrossRef Full Text | Google Scholar 34. Simeoli C, Auriemma RS, Tortora F, De Leo M, Iacuaniello D, Cozzolino A, et al. The treatment with pasireotide in Cushing’s disease: effects of long-term treatment on tumor mass in the experience of a single center. Endocrine (2015) 50(3):725–40. doi: 10.1007/s12020-015-0557-2 PubMed Abstract | CrossRef Full Text | Google Scholar 35. Manavela MP, Danilowicz K, Bruno OD. Macrocorticotropinoma shrinkage and control of hypercortisolism under long-term cabergoline therapy: case report. Pituitary (2012) 15:33–6. doi: 10.1007/s11102-011-0309-0 PubMed Abstract | CrossRef Full Text | Google Scholar 36. Lacroix A, Bronstein MD, Schopohl J, Delibasi T, Salvatori R, Li Y, et al. Long-acting pasireotide improves clinical signs and quality of life in Cushing’s disease: results from a phase III study. J Endocrinol Invest. (2020) 43(11):1613–22. doi: 10.1007/s40618-020-01246-0 PubMed Abstract | CrossRef Full Text | Google Scholar 37. Hinojosa-Amaya JM, Johnson N, González-Torres C, Varlamov EV, Yedinak CG, McCartney S, et al. Depression and impulsivity self-assessment tools to identify dopamine agonist side effects in patients with pituitary adenomas. Front Endocrinol (Lausanne) (2020) 11:579606. doi: 10.3389/fendo.2020.579606 PubMed Abstract | CrossRef Full Text | Google Scholar 38. Grall-Bronnec M, Victorri-Vigneau C, Donnio Y, Leboucher J, Rousselet M, Thiabaud E, et al. Dopamine agonists and impulse control disorders: a complex association. Drug Saf. (2018) 41(1):19–75. doi: 10.1007/s40264-017-0590-6 PubMed Abstract | CrossRef Full Text | Google Scholar Keywords: somatostatin, pasireotide, cabergoline, Cushing’s disease, hypercortisolism Citation: Feelders RA, Fleseriu M, Kadioglu P, Bex M, González-Devia D, Boguszewski CL, Yavuz DG, Patino H, Pedroncelli AM, Maamari R, Chattopadhyay A, Biller BMK and Pivonello R (2023) Long-term efficacy and safety of subcutaneous pasireotide alone or in combination with cabergoline in Cushing’s disease. Front. Endocrinol. 14:1165681. doi: 10.3389/fendo.2023.1165681 Received: 14 February 2023; Accepted: 11 August 2023; Published: 09 October 2023. Edited by: Renato Cozzi, Endocrinology Unit Ospedale Niguarda, Italy Reviewed by: Przemyslaw Witek, Warsaw Medical University, Poland Athanasios Fountas, General Hospital of Athens G. Genimatas, Greece Copyright © 2023 Feelders, Fleseriu, Kadioglu, Bex, González-Devia, Boguszewski, Yavuz, Patino, Pedroncelli, Maamari, Chattopadhyay, Biller and Pivonello. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Richard A. Feelders, r.feelders@erasmusmc.nl †Present addresses: Alberto M. Pedroncelli, Chief Medical Office, Camurus AB, Lund, SwedenRicardo Maamari, Global Medical Affairs, Mayne Pharma, Raleigh, NC, United States ‡These authors have contributed equally to this work Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Abstract Mifepristone and misoprostol are globally used medications that have become disparaged through the stigmatization of reproductive healthcare. Patients are hindered from receiving prompt treatment in clinical scenarios where misoprostol and mifepristone are the drugs of choice. It is no exaggeration to emphasize that in cases where reproductive healthcare is concerned. The aim of this paper is to discuss the different indications of mifepristone and to delineate where the discrepancy in accessibility arises. For this systematic review, we included publications citing clinical trials involving the use and efficacy of mifepristone published in English within the date range of 2000 to 2023. Five databases were searched to identify relevant sources. These databases are Google Scholar, MEDLINE with full text through EBSCO, and three National Center for Biotechnology Information (NCBI) databases (NCBI Bookshelf, PubMed, and PubMed Central). Twenty-three records were ultimately included in this review. Mifepristone has been shown to have therapeutic effects in the treatment of psychiatric disorders, such as major depressive disorder and psychotic depression. There was a significant decrease in depression and psychiatric rating symptoms for patients taking mifepristone versus placebo with no adverse events. Mifepristone has also been shown to improve treatment course in patients with Cushing’s disease (CD) who failed or are unable to undergo surgical treatment. In addition, mifepristone has been shown to be a successful treatment option for adenomyosis and leiomyomas. Patients had a statistically significant decrease in uterine volumes following mifepristone treatment, which aided in the alleviation of other symptoms, such as blood loss and pelvic discomfort. Mifepristone is a synthetic steroid that has immense potential to provide symptomatic relief in patients suffering from a wide array of complicated diseases. Historically, mifepristone has been proven to have an incredible safety profile. While further research is certainly needed, the politicization of its medical use for only one of its many indications has unfortunately led to the willful ignorance of its potential despite its evidence-based safety profile and efficacy. Introduction & Background Mifepristone is a synthetic steroid derived from norethindrone and therefore has antagonistic activity against progesterone and glucocorticoid receptors. Misoprostol is a synthetic prostaglandin E1 analog that works through the direct stimulation of prostaglandin E1 receptors. Recently, these medications have become disparaged due to their associations with the controversial medical procedure known as abortion. Abortions, however, have been so common that one out of four women will have had an abortion by the time they reach the age of 45 [1]. It is estimated that 3.7 million women have used mifepristone and misoprostol for medication abortions since they were first approved by the Food and Drug Administration (FDA) in 2000 [1]. Mifepristone followed by misoprostol is up to 14 times safer than carrying the patient’s pregnancy to term [1]. Aside from abortion, mifepristone is used for both gynecologic and obstetric conditions. Obstetric conditions include induction of labor, postpartum hemorrhage, intrauterine fetal demise, ectopic pregnancies, and miscarriages [2]. Gynecological conditions that can be treated with mifepristone include abnormal uterine bleeding, post-coital contraception, and treatment of gynecological cancers [3]. Due to the stigmatized nature of abortion, however, patients are hindered from receiving prompt treatment in clinical scenarios where mifepristone is the drug of choice. It is no exaggeration to emphasize that in cases where reproductive healthcare is concerned, every second counts [3]. Legislation that varies across states further impacts patients who risk their lives and health as they attempt to navigate their care plan across borders. Travel costs, time-off, childcare, transportation, and living accommodations are just a few more of the factors patients must take into consideration when they are forced to seek life-saving care outside of their homes [3]. Mifepristone is a medication that has multiple therapeutic applications, such as treating leiomyomas, psychotic depression, and post-traumatic stress disorder (PTSD). However, its use is restricted in many countries because of its abortifacient effect. This is a logical fallacy that deprives patients of a beneficial and safe treatment option. This systematic review aims to explore the evidence-based uses of mifepristone and how it can improve patients' health outcomes. The clinical indications that will be discussed are adenomyosis, leiomyomas, psychotic depression, PTSD, and Cushing's disease (CD). Review Methods Eligibility Criteria For this systematic review, we included publications of clinical trials and systematic reviews citing clinical trials relating to the clinical use of mifepristone and published in English within the date range of 2000 to 2023. Info Sources Five databases were searched to identify relevant sources. These databases include Google Scholar, MEDLINE with full text through EBSCO, and three National Center for Biotechnology Information (NCBI) databases (NCBI Bookshelf, PubMed, and PubMed Central). Search Strategy For each database, we inputted “clinical use of mifepristone” as our search term. The populated results were then narrowed down to those published in the English language and within the date range of 2000 to 2023 using automated search tools. Selection Process The titles and abstracts of the remaining records were then screened, and those deemed relevant to clinical uses of mifepristone and its efficacy were included for comprehensive review. This initial record search in three of the four databases (Google Scholar, MEDLINE, and PubMed) was completed by three separate reviewers. The initial record search in the remaining two databases (NCBI Bookshelf and PubMed Central) was completed by another individual reviewer. Data Collection Process After the initial record search, 60 records were deemed relevant to the study topic and compiled for a more comprehensive review. Two records were found to be duplicates and removed. Each of the four reviewers read the remaining 58 records and voted on the eligibility of the publication for inclusion in our review. Older publications that were expanded upon in more recent study trials were excluded to reduce redundancy. In addition, for records with similar study protocols, only the more recently published record was included. Ten records were excluded from the review due to ineligible study design. For those records that were not unanimously accepted (at least one reviewer voted for exclusion), the record was excluded. To ensure that the data utilized in this review were backed by sufficient evidence, the reviewers organized the remaining records into groups based on the disease mifepristone was being studied to treat. After further discussion, it was decided to exclude the records in the groups that lacked at least three separate clinical trials on the use of mifepristone in the treatment of the disease. Thirty articles were excluded. Seven of the 18 remaining records were systematic reviews, and citation searching of the records found four additional records that met the eligibility criteria. The remaining 23 records were included for further review. Data Items Of the remaining 23 records deemed acceptable for inclusion, only studies with statistically significant findings regarding the clinical use of mifepristone were included for detailed analysis. One record was excluded due to early termination of the trial. Our records include two open-label studies, four retrospective studies, seven reviews (systematic, meta-analysis), one wet lab (human specimen was used), five long-term safety extension articles, and seven randomized control experimental trials. Study Risk-of-Bias Assessment We assessed the risk of bias (RoB) in the studies included in the review using the revised Cochrane RoB tool for randomized trials (RoB 2). The five domains assessed were (1) RoB arising from the randomization process, (2) RoB due to deviations from the intended interventions (effect of assignment to intervention and effect of adhering to intervention), (3) missing outcome data, (4) RoB in the measurement of the outcome, and (5) RoB in the selection of the reported result. Each randomized control trial included in this review was assessed for RoB by two authors working independently using the RoB 2. For those studies in which the assessing authors came to different conclusions, the remaining two authors completed independent RoB 2 assessments of the study in question, and the majority of findings was accepted. Utilizing the methodology for assigning the overall RoB for each study as outlined by the RoB 2 tool, each study was designated as having “low risk of bias” or “high risk of bias.” After an initial assessment, both authors deemed the nine randomized control studies had a low RoB. Effect Measures Analysis of the studies included a focus on statistically significant findings that varied between control and intervention groups as defined by a p-value less than 0.5. As each study had its own parameters and primary and secondary endpoints, we focused our analysis on the safety and clinical efficacy of mifepristone as measured and reported by the authors of the studies included. Synthesis Methods As previously mentioned, as the studies included in this review vary widely in their study population and intervention design, our analysis focused on qualitative synthesis of study outcomes. These outcomes were categorized as the clinical efficacy and safety of mifepristone for CD, psychiatric disorders, and select gynecological diseases (adenomyosis and leiomyomas). Certainty Assessment To assess the certainty of the body of evidence regarding the studies included in our review, two reviewers applied the five Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) considerations (study limitations, inconsistency of results, indirectness of evidence, imprecision, and publication bias) to each study. Accordingly, the included studies were categorized as having high, moderate, low, or very low certainty of evidence based on the GRADE criteria. After the assessment, both reviewers deemed that all records had high certainty of evidence. Figure 1: PRISMA 2020 flow diagram for new systematic reviews that included searches of databases, registers, and other sources *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Results Psychiatric Implications Based on the analyses, numerous trials demonstrated the profound therapeutic effect that mifepristone can have on psychiatric disorders. In a double-blind study following 19 patients with bipolar disorder, researchers studied neurocognitive function and mood in patients treated with mifepristone vs. the placebo [4]. Significant improvements in verbal fluency and spatial working memory were seen in the group treated with mifepristone. The Hamilton Depression Rating Scale (HDRS) and Montgomery-Asberg Depression Rating Scale (MADRS) scores also improved from baseline (i.e., lower scores) measurements in these patients. It is worth noting that these improvements were seen in as little as two weeks, which is quicker than what is normally seen with typical therapeutic agents for bipolar disorder (lithium/valproic acid) [4]. The most extensive research demonstrated the benefits of using mifepristone with major or psychotic depression [5]. It is important to note that approximately 20% of patients living with major depression experience psychotic symptoms [6]. A randomized, double-blind study looked at 30 participants with psychotic major depression (PMD) and treated them with mifepristone 600 mg or a placebo for eight days. Using the HDRS and Brief Psychiatric Rating Scale (BPRS) to quantify baseline levels of symptoms, results from eight days later showed that mifepristone was significantly more effective in reducing psychotic symptoms compared to the placebo group [6]. By day 8, nearly half of the participants attained a 50% reduction in the BPRS compared to the placebo group (p<0.046) in addition to lower HDRS scores (although this was not found to be significant). Moreover, when researchers looked further into the use of mifepristone in psychotic depression disorders, they discovered a correlation between higher plasma levels of mifepristone and a reduction in psychotic symptoms [7]. More specifically, the strongest reduction in psychosis symptoms was found to be associated with doses of 1200 mg/day of mifepristone, which resulted in a statistically significant reduction in psychotic symptoms (p<0.0004) [7]. The drug was also well tolerated and demonstrated a large safety margin in contrast to the numerous common adverse effects that patients experience when placed on standard treatment options (i.e., antipsychotics). In another double-blind, placebo-controlled study that took place over four days, five participants diagnosed with psychotic major depression were administered 600 mg of mifepristone [5]. The HDRS and BPRS scores were used, and the results showed that all five participants' depression ratings decreased - a nearly statistically significant finding (p<.07) [5]. Likewise, four out of the five BPRS scores declined, approximating to a 32.5% decline, which is comparable to the 40% decline seen with traditional antipsychotic treatments that span six to eight weeks. Once again, no adverse effects were reported. The use of mifepristone has been explored in many cognitive disorders, including Alzheimer's disease. One study found that patients with mild to moderate Alzheimer’s disease displayed improvement on the Alzheimer’s disease assessment cognitive subtest - by 2.67 as opposed to the 1.67 decline in patients treated with a placebo [5]. Although not statistically significant, this finding encourages further studies to continue exploring the psychiatric and neurologic use of mifepristone. Cushing’s Disease Multiple trials have been conducted regarding the use and efficacy of mifepristone in the treatment of CD. Although surgical intervention to remove the source of excess cortisol production is the current mainstay of treatment, clinical trials have focused on the treatment with mifepristone for medical therapy, especially in patients who have failed surgical intervention or for those who are not good candidates for surgery. Accordingly, a retrospective study of 20 patients with hypercortisolism (12 with adrenocortical carcinoma, three with ectopic adrenocorticotropic hormone (ACTH) secretion, four with CD, and one with bilateral adrenal hyperplasia) found clinically significant improvement in excess cortisol-induced symptoms in 15 out of 20 patients [4]. Patient responses to mifepristone treatment were monitored by clinical signs of hypercortisolism (signs of hypercortisolism, blood pressure measurements, and signs of adrenal insufficiency) and serum potassium and glucose. The study found that 15 out of 20 patients showed significant clinical improvement in excess cortisol-induced symptoms. Psychiatric symptoms and blood glucose levels also improved in the patients [4]. Of note, 11 out of 20 trial participants exhibited moderate to severe hypokalemia as a side effect, although only one patient had to leave the study early due to severe adverse effects [4]. In another well-known study, 50 patients were assessed at baseline and during intervention (total of six times) for 24 weeks, referred to as the SEISMIC study [8]. Changes in oral glucose tolerance tests over time were used to assess the mifepristone effect in type 2 diabetes millets (T2DM)/impaired glucose tolerance patients. Changes in diastolic blood pressure (BP) over time were used to measure the effect of mifepristone in hypertensive cardiogenic shock (CS) patients [8]. Results found a statistically significant improvement in symptoms in both groups: diabetic patients had improvement in response to oral glucose test, decreased A1C, and decreased fasting glucose, and hypertensive patients had decreased diastolic BP or reduction in antihypertensive medications [8]. In addition, the waist circumference and hemoglobin A1C (HbA1C) also improved, and study findings concluded that mifepristone use has an acceptable risk-benefit ratio for six months of treatment [8]. Several extension studies were later performed utilizing the data found during the SEISMIC study [9]. One such study assessing weight loss in patients who participated in the SEISMIC study also found statistically significant improvement in patients with CD. After one-week mifepristone period (patients who chose to participate in this follow-up study had to be assessed to ensure it was safe for them to enroll in this study), 30 patients were enrolled and started on once daily mifepristone at the dose they were taking when the SEISMIC study concluded [9]. The patient's weight was assessed at baseline and week 24 of the SEISMIC study, and for this study, the follow-up weight was taken at months 6, 12, 18, and 24 and a final visit. Data were assessed for 29 of the participants and statistically significant decreases in weight were found for all participants from baseline to end of the SEISMIC study, and the maintenance of weight loss was statistically significant in all participants at their final visit to this study as well [9]. Another SEISMIC extension study focused on monitoring the effects of mifepristone treatment in CD on ACTH levels and pituitary MRI findings [10]. Serum ACTH, urinary, and salivary cortisol levels were monitored during the SEISMIC study (baseline, day 14, and weeks 6, 10, 16, and 24) and once after a six-week mifepristone-free "washout" period. ACTH levels were then monitored one month later and then routinely every three months during the intervention period, which varied per participant [10]. Serum cortisol measures were assessed during the SEISMIC study at the intervals mentioned previously and then every six months during the extension study. Pituitary MRI studies were taken prior to mifepristone administration during the SEISMIC study and at weeks 10 and 24 [10]. Repeat imaging was then taken every six months during the extension study. On average, ACTH levels increased greater than twofold (2.76 ± 1.65-fold over baseline; p<0.0001 vs. baseline) in patients during the SEISMIC and extension study periods and decreased to near baseline levels after six weeks of mifepristone discontinuation [10]. Serum cortisol levels in both the initial intervention and extension period increased as well, although a higher mean cortisol level was seen during the extension study intervention (SEISMIC: 1.97 ± 1.02-fold increase; p<0.0001 vs. baseline; extension study: 2.85 ± 1.05-fold increase; p<0.0001 vs. baseline) [10]. In comparing the baseline and post-intervention MRI images, 30 out of 36 patients showed no progression in pituitary tumor size with mifepristone intervention, two patients showed regression of tumor size, and three patients showed evidence of tumor progression. One patient was found to have a tumor post-intervention despite a negative initial MRI at baseline [10]. A retrospective analysis of data collected during the SEISMIC study utilized oral glucose tolerance test data to assess the mifepristone treatment effect on the total body insulin sensitivity, beta cell function, weight, waist circumference, and additional parameters [11]. The analysis found improved total body insulin sensitivity in all participants, with the greatest improvement occurring from baseline to week 6. The weight and waist circumference both decreased by week 24 [11]. An additional important six-month study was done on 46 patients with refractory CS and either DM2, impaired glucose tolerance, or diagnosis of HTN in which mifepristone treatment was administered daily [12]. Patients were examined by three separate reviewers using global clinical response assessments (-1 = worsening, 0 = no change, 1 = improving) measured by eight clinical categories: glucose control, lipids, blood pressure, body composition, clinical appearance, strength, psychiatric/cognitive symptoms, and quality of life at weeks 6, 10, 16, and 24. A positive correlation with increasing GCR scores was found by week 24, with 88% of participants showing statistically significant improvement (p<0.001) [12]. Adenomyosis/Leiomyoma Adenomyosis and leiomyomas are common gynecological conditions that affect large portions of the female population. Multiple trials have proven mifepristone’s success in treating endometriosis and various forms of cancer. Current data shows that mifepristone is well tolerated and has mild side effects in certain long-term clinical settings. In one trial following mifepristone and its effects on adenomyosis, 20 patients were treated with 5 mg oral mifepristone/day for three months [13]. After the three-month trial, patients demonstrated a statistically significant (p<0.001) reduction in uterine volume as was measured through transvaginal ultrasound. These patients were also found to have significantly decreased CA-125 markers (a marker of adenomyosis and an increase in uterine size) and significantly increased hemoglobin concentration The patient’s endometrial tissue was then obtained from each patient during their hysterectomy [13]. The endometrial tissue samples were treated with varying concentrations of mifepristone for 48 hours. They found that mifepristone significantly decreased the viability of endometrial epithelial and stromal cells in adenomyosis and can induce their apoptosis as well [13]. This concentration-dependent inhibitory effect was most significantly seen with concentrations of mifepristone above 50 μmol/L at 48 hours. The same study showed that mifepristone demonstrated another dose-dependent relationship in the inhibition of the migration of ectopic endometrial and stromal cells. This finding is significant as the migratory nature of the patient’s endometrial and stromal cells is the pathogenesis behind adenomyosis [13]. Another study looked at the effect of mifepristone in combination with high-intensity focused ultrasound (HIFU) and levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis [13]. Out of 123 patients, 34 patients were treated with HIFU alone, 29 patients were treated with HIFU combined with mifepristone, 10 patients with HIFU combined with LNG-IUS, and 50 patients with HIFU combined with mifepristone and LNG-IUS [13]. In the group treated with HIFU combined with mifepristone and LNG-IUS, the uterine volume was significantly reduced after treatment at 3, 6, 12, and 24 months compared to the previous treatment (p<0.05). Dysmenorrhea was measured using a visual analog score (VAS). In the combination group of mifepristone, HIFU, and LNG-IUS, VAS scores decreased from 80.82 ± 12.49 to 29.58 ± 9.29 at 24 months [13]. This was significantly lower than the three other treatment groups (p<0.05). The combination group of mifepristone, HIFU, and LNG-IUS also demonstrated statistically significant decreases in the menstrual volume and CA-125 serum markers [13]. Hemoglobin levels were not statistically different among the four treatment groups, but it is postulated that this could have been due to the fact that the patients who were anemic had been treated with different medications to improve their Hb aside from the trial medications [13]. Uterine leiomyomas are another gynecological condition that has been found to improve with the use of mifepristone as well. Insulin-like growth factor 1 (IGF-1) has been found to be overexpressed in leiomyomas [14]. This study showed that mifepristone inhibited the gene expression of IGF-1, and the reduction in symptoms correlated with a decrease in IGF-1 expression although the mechanism is not fully understood [14]. A meta-analysis studied the effects of mifepristone on uterine and leiomyoma volumes of 780 women from 11 randomized controlled trials. Mifepristone at doses from 2.5, 5, and 10 mg was found to effectively reduce uterine and leiomyoma volumes and alleviate leiomyoma symptoms at six months [6]. Pelvic pain, pelvic pressure, and dysmenorrhea were found to be alleviated after three months of treatment. Mifepristone also decreased the mean loss of blood during menstruation and a statistically significant increase in hemoglobin. No significant difference was found among varying dosages of 2.5, 5, and 10 mg other than increased frequency of hot flashes in patients of the 10 mg group. Another review investigated six clinical trials involving 166 women and the effects of 5-50 mg mifepristone for three to six months on leiomyomas [3]. The review demonstrated that daily treatment with all doses of mifepristone resulted in reductions in pelvic pain, pelvic pressure, dysmenorrhea, and uterine and leiomyoma volume size by 26-74%. Even doses of 2.5 mg of mifepristone resulted in significant improvement in the quality of life scores although there was little reduction in leiomyoma size at this dose [3]. This review also reported the rapid correction of uterine bleeding, amenorrhea, and increases in hemoglobin levels following treatment with 50 mg of mifepristone on alternating days. Even vaginal mifepristone has demonstrated efficacious results in the improvement of leiomyomas. In one such trial, the effects of daily 10 mg vaginal mifepristone were studied in 33 women from the ages of 30-53 [15]. Vaginal mifepristone significantly reduced leiomyoma volume and reduced the effects of symptoms on the patient’s quality of life as measured by the Uterine-Fibroid Symptoms Quality of Life questionnaire (UFS-QoL). It is important to note that the only significant side effect found in this review of trials was hot flashes at doses of mifepristone at 10 mg or more. Mifepristone was otherwise generally well tolerated with minimal if any adverse effects [15]. Discussion Adenomyosis is a gynecologic condition that is characterized by the growth of endometrial cells into the myometrium, resulting in a globally enlarged uterus and an associated increase in CA-125 [16]. This marker is classically known to be an ovarian tumor marker; however, in this class, it reflects the increase in uterine glandular size. Although it is often labeled as a “benign” disease, it affects around 20% of reproductive-aged women. This condition can lead to dysmenorrhea, infertility, and menorrhagia in addition to detrimental effects on a patient’s mental health [16]. Despite 20% of affected patients being under the age of 40, the gold standard of treatment is a hysterectomy. Hysterectomies may often not be wanted by patients as it is an invasive surgery that comes with several potential complications of its own. It is important to note that due to the large percentage of patients with adenomyosis who are of reproductive age, hysterectomies may not be an appropriate standard method of treatment. To rob patients of their fertility without attempting medication therapy with mifepristone first is an act of injustice. Surgery alone comes with many complications and the possibility of recurrence. The ability of physicians to manage their patient’s pain and symptoms should be guided medically before surgical sterilization is considered. Many of these patients are forced to seek alternative non-invasive treatments instead of medication therapies to preserve their fertility. HIFU and LNG-IUS are noninvasive therapies for adenomyosis that can be used in patients who refuse hysterectomies or for those who are not good candidates [16]. The pitfalls of these procedures include the fact that 20% of patients on HIFU alone end up relapsing, and LNG-IUS cannot be used in patients with a uterine size that is >12 weeks gestation or a uterine cavity depth that is >9 cm. Because adenomyosis is an estrogen-dependent disease, gonadotropin-releasing hormone agonists (GnRH-a) are also often used in combination with HIFU and LNG-US. Through the inhibition of the secretion of estrogen, GnRH-as facilitate reduced pelvic pain, reduced bleeding, and reduced uterine cavity size [16]. Reduction in cavity size is significant as this alone can lead to improved pain and reduced bleeding and allows patients to qualify for LNG-US where their previous uterine cavity size would have prevented their candidacy. Its current limitations include price (>$200/month), induction of premenopausal syndrome, and high rates of relapse following drug cessation [16]. Mifepristone offers a cheaper alternative (<$4/month) with significantly improved outcomes in reduced uterine cavity size, decreased dysmenorrhea pain scale score, and lower menstruation volume scores [16]. Mifepristone is also able to provide such results without the bone loss that is commonly associated with GnRH-analogs [3]. This is because mifepristone allows for serum estradiol to remain within the patient’s physiologic follicular phase range [3]. In addition, mifepristone is able to significantly reduce serum levels of CA-125 and improve hemoglobin levels in patients with menorrhagia. These reductions in CA-125 demonstrate marked reductions in the size of glands of the uterus of these patients. Through the reduction of cavity size, mifepristone can not only offer therapeutic relief but also allow patients to qualify for noninvasive LNG-US procedures, which can offer further therapeutic benefits. Patients should have the option to explore all potential medical therapies before opting for surgical correction. Leiomyomas, or uterine fibroids, are another commonly encountered gynecologic condition and represent the most common benign tumors found in the female population. These benign smooth muscle tumors are estrogen-sensitive and can rarely develop into malignant leiomyosarcomas. Nearly 20-50% of patients with these fibroids experience symptoms, such as abnormal uterine bleeding (AUB), infertility, pelvic pain, and miscarriages [17]. Currently, the only treatment for this common condition is surgery. Two medications that are commonly used for preoperative reductions in leiomyoma size are mifepristone and enantone. Enantone is a gonadotropin-releasing hormone analog that has shown significant improvement in leiomyoma shrinkage, correction of anemia, and correction of AUB [17]. Through its MOA, however, enantone can lead to harmful adverse effects, such as menopausal symptoms and bone mineral loss. Using hormone supplementation to negate these side effects leads to reduced effectiveness of enantone in fibroid size reduction. Several studies have shown that progesterone plays a large role in the proliferation of leiomyoma growth [17]. Mifepristone, therefore, offers an effective alternate solution by producing the same results without enantone’s adverse effects. When comparing enantone to mifepristone, the two medications both resulted in statistically significant reductions in fibroid size, reduction in dysmenorrhea, reduction in non-menstrual abdominal pain, and increased Hgb/Hct/and RBC count despite differences in dosage [17]. However, mifepristone was able to maintain the patients’ premenopausal levels of estrogen, whereas patients on enantone were found to have estrogen levels of menopausal patients. Furthermore, patients who were treated with enantone also reported more adverse events compared to those in the mifepristone group [17]. Vaginal use of mifepristone has also been shown to significantly reduce leiomyoma size and improve symptoms of anemia while lowering systemic bioavailability of mifepristone [15]. Through its concentrated distribution to uterine tissue, vaginal mifepristone can lead to increased improvement in its clinical outcomes. Vaginal mifepristone showed statistically significant improvements in leiomyoma volume change, USF-QoL, and decreased bleeding intensity at the end of the three-month trial and three months after treatment [15]. For these reasons, mifepristone can be used effectively for conservative therapy in patients suffering from leiomyomas and should be considered a viable option for patients not wishing to undergo surgery. CD refers to hypercortisolism that is caused by pituitary adenomas, adrenal neoplasias, or paraneoplastic ACTH secretion. Hypercortisolism in these patients leads to the development of skin changes, HTN, obesity, insulin resistance, dyslipidemia, anovulation, skeletal disorders, and neuropsychiatric disorders [18]. Patients suffering from these conditions endure a severely decreased quality of life and increased morbidity and mortality. The syndromic nature of this disease prompts delayed diagnosis and further increases the mortality and morbidity of this population [18]. CS therefore necessitates effective and rapid treatment options to diminish harm and clinical burden. The current first-line treatment for CD is pituitary surgery despite its nearly ⅓ relapse rate within 10 years postoperatively [18]. In these patients and patients with recurrent CD, further treatment options are necessitated. These options include adrenal surgery, pituitary radiotherapy, or medication therapy. Radiotherapy further delays symptomatic relief as it usually takes years before excess cortisol levels are managed. It also carries the risk of the patient developing hypopituitarism due to subsequent pituitary damage [18]. While surgery of the adrenal glands can quickly achieve control of excess cortisol, it also carries a risk of permanent adrenal insufficiency. Medication therapy can be used preoperatively, postoperatively, and as adjunctive therapy to radiotherapy. These drug classes include somatostatin analogs, dopamine agonists, and adrenal steroidogenesis inhibitors [18]. The most commonly used medication is the adrenal steroidogenesis inhibitor ketoconazole. While it has been proven to be effective and rapid in its success, doses may need to be frequently increased due to the cortisol blockade that occurs in CD patients [8]. In fact, due to the hormonal imbalances in CD patients, many medications often have to be dose adjusted to achieve therapeutic effect. It is also important to note that many of the medications that are used are not easily tolerated when doses are increased or adjusted frequently. The use of mifepristone has demonstrated statistically significant results in weight reduction, insulin resistance, depression, HTN, and quality of life in CD patients [10]. Furthermore, mifepristone can also be used effectively in patients experiencing cortisol-induced psychosis during acute exacerbations of hypercortisolism. While not included in the classes of more commonly used drugs for CD, mifepristone has been approved by the FDA for the treatment of CD when associated with disorders of glucose metabolism. This is undoubtedly due to the stigmatization of mifepristone and the subsequent reluctance of clinicians to incorporate it into their treatment plans. Neuropsychiatric disorders have been investigated for their associations with dysregulations of the hypothalamic-pituitary-adrenal axis (HPA) and increases in cortisol levels. Studies have shown that patients suffering from depression, schizophrenia, and psychotic depression have elevated levels of cortisol and increased activity of their HPA [19]. The role of cortisol in psychiatric disorders is evidenced by the adverse psychiatric effects that patients can develop in response to exogenous glucocorticoid use through subsequent increases in cortisol. These include delirium, depression, mania, or psychosis. When functioning normally, HPA activity and cortisol secretion are maintained through sensitive negative feedback systems involving glucocorticoid receptors (GCRs) and mineralocorticoid receptors (MCR) [19]. At low doses, cortisol preferentially binds to MCR. As cortisol levels rise, it begins to bind to GCR and thereby initiates the negative feedback loop. Antipsychotics that are typically used work by reducing cortisol levels. Mifepristone, when dosed at >200 mg/day, selectively binds only to GCR and has no effect on MCR [19]. Through its sole inhibition of GCR, it ensures that normal cortisol homeostasis is maintained while ensuring that excess high levels of cortisol are blocked. This was evidenced by the statistically significant correlation between rising plasma concentrations of mifepristone and improvement of psychotic symptoms [20]. The hippocampus is a region of the temporal lobe that is most notably recognized for its role in learning and memory. Further studies have shown correlations between hippocampal atrophy and patients with severe depression, PTSD, and schizophrenia. It is postulated that this hippocampal atrophy leads to persistently high levels of cortisol, worsening these patient’s psychiatric symptoms. Administration of mifepristone to patients with combat-related PTSD demonstrated significant benefits in quality of life and psychiatric improvement. Psychotic major depression is another psychiatric condition that affects around 20% of patients with major depression [7]. When mifepristone was used to treat psychotic depression, patients were able to achieve rapid antipsychotic effects that lasted for weeks after the medication therapy ended. It should be noted that patients suffering from PMD generally have increased cortisol levels even with standard antidepressant therapy alone [7]. Some patients are even unresponsive to electroconvulsive therapy. The ability of patients suffering from psychotic depression to achieve rapid relief is imperative as these patients are more susceptible to suicidal ideation, especially during an episode of psychosis [7]. Bipolar disorder is another mood disorder that has been found to be associated with high levels of cortisol, dysfunction of the HPA axis, and GR dysfunction. Several neuroendocrine studies demonstrated that around 43% of bipolar patients with depression were also dexamethasone-suppression-test (DST) nonsuppressors [7]. Further studies found that bipolar patients suffering through relapse and recovery had abnormal dexamethasone/corticotropin-releasing hormone (dex/CRH) test results [21]. These abnormal (dex/CRH) findings were also seen in healthy patients who had certain genetic predispositions for mood disorders [21]. Regarding these HPA dysfunctions, GR has been implicated in being an important modulator of neurocognitive function and mood. This can be evidenced through research findings that report increased GR number and GR binding in brain tissue following the administration of antidepressants in depressed patients [21]. Mifepristone’s unique advantage is that its selective role as a GR antagonist was also found to increase both MR and GR binding in the frontal cortex. In fact, data from Young et al. [21] reveals significant improvement in frontal cortex functioning following clinical mifepristone trials. These results were seen through improvements in spatial working memory function and reductions in the HDRS17 and MADRS. They also demonstrated significant improvement in verbal fluency from baseline. These improvements in neurocognitive functioning were measured when the subjects’ mood was similar to their baseline or did not vary when compared to the placebo group [21]. This key finding suggests that improvements in neurocognitive functioning were not solely related to improvements in mood or depression. Mifepristone achieves these improvements in neurocognitive function through its selective activity towards GR within the frontal cortex. Furthermore, patients are also able to achieve symptomatic improvement two weeks after the initiation of treatment [21]. The rapid nature of mifepristone adds further clinical benefit as classic bipolar treatments take longer to achieve therapy and the fact that treatment plans for patients with bipolar disorder are tricky to individualize. Other commonly known psychiatric disorders are treated with antipsychotics. While these medications often come with a large array of adverse effects, weight gain, metabolic derangements, and glucose intolerance have been a few of the more frequently reported negative effects. While the exact cause of the weight gain is unknown, mifepristone was shown to significantly reduce weight gain in patients when taken alongside risperidone or olanzapine [21]. As discussed previously, mifepristone also has the ability to significantly improve insulin resistance, thereby further improving the AE patients may experience on antipsychotics. Therefore, through mifepristone’s selective activity as a GCR antagonist, it has immense potential as a psychiatric therapeutic agent. Conclusions Mifepristone is a synthetic steroid that has immense potential to provide symptomatic relief in patients suffering from a wide array of complicated diseases. Prednisone, dexamethasone, and anabolic steroids are also synthetic steroids that are commonly used. Despite being a part of the same class as mifepristone, none of these medications fall under as much legal, political, and social duress as mifepristone. This is in spite of the fact that mifepristone has been proven to have an incredible safety profile since its introduction to the public in the 1980s. In fact, its mortality rate is significantly lower than that of Tylenol, NSAIDs, penicillin, and phosphodiesterase inhibitors. While further research is certainly needed, its involvement in politics has unfortunately led to the willful ignorance of its medical potential despite its evidence-based safety profile and efficacy. References Beaman J, Prifti C, Schwarz EB, Sobota M: Medication to manage abortion and miscarriage. J Gen Intern Med. 2020, 35:2398-405. 10.1007/s11606-020-05836-9 Hagey JM, Givens M, Bryant AG: Clinical update on uses for Mifepristone in obstetrics and gynecology. Obstet Gynecol Surv. 2022, 77:611-23. 10.1097/OGX.0000000000001063 Spitz IM: Mifepristone: where do we come from and where are we going? Clinical development over a quarter of a century. Contraception. 2010, 82:442-52. 10.1016/j.contraception.2009.12.012 Castinetti F, Fassnacht M, Johanssen S, et al.: Merits and pitfalls of mifepristone in Cushing's syndrome. Eur J Endocrinol. 2009, 160:1003-10. 10.1530/EJE-09-0098 Belanoff JK, Flores BH, Kalezhan M, et al.: Rapid reversal of psychotic depression using mifepristone. J Clin Psychopharmacol. 2001, 21:516-21. Eisinger SH, Meldrum S, Fiscella K, et al.: Low-dose mifepristone for uterine leiomyomata. Obstet Gynecol. 2003, 101:243-50. 10.1016/S0029-7844(02)02511-5 Flores BH, Kenna H, Keller J, Solvason HB, Schatzberg AF: Clinical and biological effects of mifepristone treatment for psychotic depression. Neuropsychopharmacology. 2006, 31:628-36. 10.1038/sj.npp.1300884 Fleseriu M, Biller BM, Findling JW, Molitch ME, Schteingart DE, Gross 😄 Mifepristone, a glucocorticoid receptor antagonist, produces clinical and metabolic benefits in patients with Cushing's syndrome. J Clin Endocrinol Metab. 2012, 97:2039-49. 10.1210/jc.2011-3350 Fein HG, Vaughan TB 3rd, Kushner H, Cram D, Nguyen 😧 Sustained weight loss in patients treated with mifepristone for Cushing's syndrome: a follow-up analysis of the SEISMIC study and long-term extension. BMC Endocr Disord. 2015, 15:63. 10.1186/s12902-015-0059-5 Fleseriu M, Findling JW, Koch CA, Schlaffer SM, Buchfelder M, Gross 😄 Changes in plasma ACTH levels and corticotroph tumor size in patients with Cushing's disease during long-term treatment with the glucocorticoid receptor antagonist mifepristone. J Clin Endocrinol Metab. 2014, 99:3718-27. 10.1210/jc.2014-1843 Wallia A, Colleran K, Purnell JQ, Gross C, Molitch ME: Improvement in insulin sensitivity during mifepristone treatment of Cushing syndrome: early and late effects. Diabetes Care. 2013, 36:e147-8. 10.2337/dc13-0246 Katznelson L, Loriaux DL, Feldman D, Braunstein GD, Schteingart DE, Gross 😄 Global clinical response in Cushing's syndrome patients treated with mifepristone. Clin Endocrinol (Oxf). 2014, 80:562-9. 10.1111/cen.12332 Che X, Wang J, He J, et al.: A new trick for an old dog: the application of mifepristone in the treatment of adenomyosis. J Cell Mol Med. 2020, 24:1724-37. 10.1111/jcmm.14866 Shen Q, Zou S, Sheng B, et al.: Mifepristone inhibits IGF-1 signaling pathway in the treatment of uterine leiomyomas. Drug Des Devel Ther. 2019, 14:3161-70. Yerushalmi GM, Gilboa Y, Jakobson-Setton A, Tadir Y, Goldchmit C, Katz D, Seidman DS: Vaginal mifepristone for the treatment of symptomatic uterine leiomyomata: an open-label study. Fertil Steril. 2014, 101:496-500. 10.1016/j.fertnstert.2013.10.015 Zhu H, Ma Q, Dong G, Yang L, Li Y, Song S, Mu Y: Clinical evaluation of high-intensity focused ultrasound ablation combined with mifepristone and levonorgestrel-releasing intrauterine system to treat symptomatic adenomyosis. Int J Hyperthermia. 2023, 40:10.1080/02656736.2022.2161641 Liu C, Lu Q, Qu H, et al.: Different dosages of mifepristone versus enantone to treat uterine fibroids: a multicenter randomized controlled trial. Medicine (Baltimore). 2017, 96:e6124. 10.1097/MD.0000000000006124 Pivonello R, De Leo M, Cozzolino A, Colao A: The treatment of Cushing's disease. Endocr Rev. 2015, 36:385-486. 10.1210/er.2013-1048 Hartmann J, Bajaj T, Klengel C, et al.: Mineralocorticoid receptors dampen glucocorticoid receptor sensitivity to stress via regulation of FKBP5. Cell Rep. 2021, 35:109185. 10.1016/j.celrep.2021.109185 Block TS, Kushner H, Kalin N, Nelson C, Belanoff J, Schatzberg A: Combined analysis of mifepristone for psychotic depression: plasma levels associated with clinical response. Biol Psychiatry. 2018, 84:46-54. 10.1016/j.biopsych.2018.01.008 Young AH, Gallagher P, Watson S, Del-Estal D, Owen BM, Ferrier IN: Improvements in neurocognitive function and mood following adjunctive treatment with mifepristone (RU-486) in bipolar disorder. Neuropsychopharmacology. 2004, 29:1538-45. 10.1038/sj.npp.1300471 From https://www.cureus.com/articles/191397-multiple-clinical-indications-of-mifepristone-a-systematic-review#!/

Abstract Cushing's syndrome is a rare cause of myocardial infarction and heart failure. Herein, we report a female patient who presented acute myocardial infarction and heart failure with reduced ejection fraction. The patient was found to have hypercortisolism secondary to adrenocortical adenoma and responded well to therapy. This case underlines the effects of hypercortisolism on the cardiovascular system. The clinical presentation of this patient is unique because non-atherosclerotic myocardial infarction is rarely reported in Cushing's syndrome patients. Introduction Cushing's syndrome is an endocrine condition associated with excessive secretion of cortisol. Hypertension, vascular atherosclerosis, and chronic cardiac remodelling and dysfunction are commonly recognized cardiovascular complications in Cushing's syndrome patients.1 Herein, we report a rare case of Cushing's syndrome patient with a primary diagnosis of non-atherosclerotic myocardial infarction and heart failure (HF). Case Report A 61-year-old female with a past medical history of chronic obstructive pulmonary disease was admitted with sudden onset chest pain on 6 February 2018. Electrocardiogram showed ST-segment elevation in leads V3–V5. Blood biochemical results of 1 h after the onset of chest pain: cardiac troponin I (cTnI) 0.06 ug/L↑, creatine kinase (CK) 63 U/L, creatine phosphokinase-MB (CK-MB) 22 U/L, aspartate transferase (AST) 19 U/L, and lactic dehydrogenase (LDH) 482 U/L. Myocardial injury markers were markedly elevated at the time point of 18 h after onset: cTnI 13.9 ug/L↑, CK 613 U/L↑, CK-MB 102 U/L↑, AST 112 U/L↑, and LDH 833 U/L↑. Due to the acute ECG changes and elevated myocardial injury markers, the patient was preliminarily diagnosed as ST-segment elevation myocardial infarction (STEMI) and underwent coronary angiography, which showed no stenosis, occlusion or dissection of coronary arteries (Figure 1). Echocardiography showed enlarged left atrial dimension (LAD, 55 mm) and left ventricular end diastolic dimension (LVDd, 57 mm), and reduced ejection fraction (EF, 33%). The patient was treated for STEMI and HF, and was started on aspirin, statin, diuretic of furosemide and spirolactone, metoprolol, and Sacubitril/valsartan (SV, initiated June, 2020). The patient was strictly adherent to the medication prescribed (Table 1). Figure 1 Open in figure viewerPowerPoint Coronary angiogram demonstrating no significant obstruction in coronary artery circulation. Table 1. Echocardiography results 2020-06-22 2020-09-02 2021-03-29 2021-06-02 2021-09-01 2021-10-22 2021-12-21 LAD (mm) 55 55 46 52 47 44 41 LVDd (mm) 57 57 53 55 54 51 55 IVS (mm) 10 10 11 10 10 10 11 LVPW (mm) 11 11 11 10 11 9 10 EF (%) 33 30 31 39 47 49 52.5 EF, ejection fraction; IVS, interventricular septum; LAD, left atrium dimension; LVDd, left ventricular end diastolic dimension; LVPW, left ventricular posterior wall. However, the patient's condition was not improved despite optimized medication. On 26 January 2021, the patient was re-admitted with recurrent chest distress and oedema, with new symptoms of facial plethora, centripetal obesity, and hyperglycaemia (Figure S1). Abdominal CT scan showed a right adrenal adenoma (Figure 2). Cardiac magnetic resonance imaging revealed enlarged LVDd (62 mm), and reduced EF, with delayed myocardial enhancement and evidence of myocardial fibrosis and fatty deposits (Figure 3). Laboratory findings showed hypokalaemia: potassium 3.0 mmol/L, elevated serum cortisol level, low plasma ACTH level, and positive 1-mg overnight dexamethasone suppression test. Based on the above findings, the patient was diagnosed with Cushing's syndrome and started treatment with the glucocorticoid receptor inhibitor mifepristone on 5 February 2021. Figure 2 Open in figure viewerPowerPoint Abdominal CT scan showed adrenal adenoma at the right. Figure 3 Open in figure viewerPowerPoint Cardiac magnetic resonance imaging revealed enlarged LVDd, reduced EF, with delayed myocardial enhancement, evidence of myocardial fibrosis and fatty deposits. With mifepristone added to the previous medical therapy (aspirin, statin, sacubitril/valsartan, metoprolol and diuretic of furosemide and spirolactone, and mifepristone), the patient's condition and cardiac function improved, and echocardiography (21 December 2021) showed increased EF (52.5%). The patient underwent partial adrenalectomy on 22 December 2021. Postoperative pathology confirmed adrenal cortical adenoma. At last follow-up on 29 May 2023, the patient showed marked improvement in face and body shape, with no complaints of chest distress or oedema (Figure S2). Discussion In this case, the patient was first evaluated for STEMI due to her symptoms of chest pain, and the elevated ST-segment on ECG, along with the moderately elevated troponin I and other cardiac enzyme levels. However, coronary atherosclerotic heart disease was ruled out by the normal cardiac catheterization. We presume that a possible reason for acute myocardial infarction (AMI) might be vasospastic angina due to abnormal hormone levels with Cushing's syndrome, leading to increased excessive myocardial metabolic demand and relative myocardial hypoxia, which eventually induced myocardial infarction. Although coronary atherosclerotic heart disease is the main cause of AMI, many non-atherosclerotic processes can lead to an imbalance between decreased coronary blood flow and increased myocardial metabolic demand. To date, non-atherosclerotic myocardial infarction has rarely been reported in Cushing's syndrome patients. Vieira JT et al. reported that a patient with Cushing's disease was considered to have spontaneous coronary artery dissection, which is a rare reason for AMI.2 Cushing's syndrome is associated with an increased risk of cardiac failure,3 with both structural alterations and functional impairment. In our case, the patient's CMR imaging showed typical features of cardiac geometry, function, and fibrosis, in accordance with previous reports.4 The underlying mechanisms may be the enhanced responsiveness to angiotensin II and activation of the mineralocorticoid receptor in direct response to cortisol excess.5 Our patient responded well to the therapy of conventional anti-HF medication of sacubitril/valsartan, metoprolol, and diuretic, once mifepristone was added. This favourable response to the pharmacological regimen supports the benefits of the agents for the normalization of excess cortisol. This case indicates that early diagnosis and effective treatment of Cushing's syndrome may be crucial in preventing irreversible cardiac dysfunction secondary to cardiovascular events and heart failure. Acknowledgements This work was financially supported by the National Natural Science Foundation of China (81900409 and 82172182) and the PLA Youth Training Project for Medical Science (19QNP037). Conflict of interest The authors declares that there is no conflict of interest. From https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14548

Abstract Gastrointestinal perforation is a well-addressed complication of exogenous hypercortisolism; however, patients with endogenous Cushing's syndrome (CS) do not usually experience this condition in clinical practice. The literature on this subject is limited and consists solely of clinical case reports/series with only 23 instances of gastrointestinal perforation occurring in individuals with endogenous Cushing's syndrome. This is mainly attributed to the rarity of Cushing's syndrome itself and the low chance of occurrence of such complications. We report a case of a recently diagnosed adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome in a 30-years-old female who presented initially with a three-month history of progressive weight gain, generalized weakness, acne, menstrual irregularity, and severe hypokalemia, and then developed a gastric ulcer perforation only one month after her ACTH-dependent Cushing's syndrome diagnosis and was managed through emergent surgery. Introduction A disorder of the endocrine system characterized by excessive cortisol production, known as Cushing's syndrome, rarely occurs. The main causes are pituitary tumors, ectopic adrenocorticotropic hormone (ACTH)-secreting tumors, or adrenal tumors that secrete cortisol independently [1]. Patients initially present with a wide range of symptoms, including weight gain, proximal myopathy, skin thinning, and abdominal striae [1]. Additionally, several metabolic disorders, such as diabetes mellitus, hypertension, and dyslipidemia, can occur, especially when the diagnosis is not established at an early stage [2]. There is a possibility of gastrointestinal complications among patients receiving exogenous glucocorticoids. However, there is limited information on gastrointestinal complications associated with endogenous hypercortisolemia [3,4]. Thus far, only 23 instances have been published addressing the co-occurrence of gastrointestinal perforation with endogenous Cushing's syndrome [5-17]. To the best of our knowledge, this is the first case reporting gastric perforation in an ACTH-dependent Cushing's syndrome, while the vast majority reported diverticular, sigmoid, or duodenal perforation with Cushing's syndrome [5-17]. Herein, we describe the medical history, physical examination, and investigatory findings of a 30-year-old female with a recent diagnosis of ACTH-dependent Cushing's syndrome that was complicated by gastric ulcer perforation, necessitating an urgent exploratory laparotomy. The primary motivator of this case report was the rarity of the described condition, the atypical location of the perforation in such patient group, and the relatively young age of the patient. Case Presentation History and examination A 30-year-old female with a history of mental retardation was admitted to our emergency department (ER) with progressive weakness and fatigue. Upon taking the history, she had been having menstrual irregularities, progressive weight gain, and generalized weakness, which was significant enough to limit her physical activity and hinder her movement for the past three months. Initial vital signs showed that the patient had a body temperature of 37°C, a pulse rate of 90 beats per minute, and a blood pressure of 130/80 mmHg. On physical examination, the patient had a moon face with supraclavicular fullness, dorsocervical fat pad, purple abdominal striae, facial signs of hirsutism, and acne all over the face, shoulders, chest, and back. Investigations In the initial laboratory examination, hypokalemia of 2.1 mEq/L, hyperglycemia of 12.1 mmol/L, and metabolic alkalosis were detected (Table 1). The cortisol level after 1 mg dexamethasone suppression test was 2204 nmol/L (normal range 140-690), ACTH 123 pg/mL (normal range 7.2-63.3), DHEA-S 27.85 umol/L (normal range 2.6-13.9), And 24-hour urine cortisol level was 1560 mg/day (normal range 30-350) (Table 1). No suppression was observed in cortisol level with 8 mg dexamethasone suppression test. Parameter Initial presentation Perforation presentation Refrence range Na+ 143 mEq/L 139 mmol/L 135-147 mEq/L Cl- 85 mEq/L 105 mmol/L 98-108 mEq/L K+ 2.1 mEq/L 2.8 mmol/L 3.5-5.0 mEq/L Mg2+ 0.79 mmol/L 0.77 mmol/L 0.85-1.110 mmol/L PO3- 0.88 mmol/L 1.23 mmol/L 0.97-1.46 mmol/L PH 7.54 7.36 7.35-7.45 PCO2 67.5 mmHg 42.7 mmHg 35-45 mmHg PO2 27.7 mmHg 62.2 mmHg 75-100 mmHg HCO3 49.8 mEq/L 23.6 mEq/L 22-26 mEq/L Random blood glucose 12.1 mmol/L 24.1 mmol/L <5.5 mmol/L Hemoglobin 13.5 g/dL 14.9 g/dL 13.7-16.8 g/dL White blood cells 9,720 /uL 11,100 /uL 3,300-8,600 /uL Lymphocyte 0.48% 0.33% - Neutrophil 8.55% 9.66% - Eosinophil 0.0% 0.0% - TSH 0.55 mIU/L Was not ordered 0.4-4.0 mIU/L Cortisol 2204 nmol/L 4842 nmol/L 140-690 nmol/L ACTH 123 pg/mL Was not ordered 7.2-63.3 pg/mL Table 1: Laboratory findings on initial presentation and on perforation day TSH - thyroid stimulating hormone; ACTH - adrenocorticotropic hormone A series of CT scans for the neck, chest, abdomen, and pelvis was performed and failed to localize any tumors acting as an ectopic source. A pituitary MRI was performed, and no adenoma was found. To complete the diagnostic workup, we decided to do an inferior petrosal sinus sampling (IPSS) and PET scan with Gallium 68; however, the patient's family refused and requested discharge and outpatient follow-ups. These results, together with the biochemical and clinical findings, supported the diagnostic hypothesis of ACTH-dependent Cushing's syndrome. Treatment/management When addressing the issue of hypokalemia that the patient presented with initially, it was found to be resistant and difficult to correct. The patient was put on spironolactone 50 mg BID, and potassium chloride 20 mEq q8h, and her potassium level barely reached 3.5 mmol/L after several days. In addition, her magnesium level was corrected with magnesium oxide 800 mg every six hours. Her blood glucose level was controlled with insulin glargine 6 units daily and Novorapid as per the sliding scale. The patient was discharged on spironolactone tablets 50 mg BID (oral), potassium chloride 20 mEq q8h, cholecalciferol, calcium carbonate, insulin glargine 6 units daily, and Novorapid 4 units TID before meals. Follow-up and outcomes Seven days after discharge, she presented to the ER complaining of a new onset of abdominal pain, constipation, and reduced urine output. Her Glasgow Coma Scale (GCS) was 15, her blood pressure measurement was 146/90 mmHg, her pulse rate was 66 beats per minute, her respiratory rate was 21 breaths per minute, and her temperature was 36.7°C. Upon physical examination, the patient had distended non-tender abdomen without any other significant findings. Blood work was done, including renal functions, and all parameters, including potassium, were within normal limits. A chest X-ray was also performed and revealed no evidence of pneumoperitoneum. The patient was clinically stable after managing her abdominal pain with acetaminophen injection and administering fleet enema for constipation. After instructions on when to come again to the ER were given, the patient was discharged home on lactulose and paracetamol, and a close outpatient follow-up appointment was scheduled. Five days after the ER visit, the patient presented again to the ER. She was still complaining of severe non-resolving abdominal pain, constipation, and reduced urine output. Upon physical examination in the ER, the patient was found to have developed a new onset of lower limb edema, abdominal rebound tenderness, and abdominal rigidity and guarding. She was hypotensive with a blood pressure of 91/46 mmHg, pulse rate of 80 beats per minute, respiratory rate of 16 breaths per minute, temperature of 38.2 °C, and SpO2 of 96%. The only significant laboratory finding was her potassium level dropping low to 2.8 mEq/L (Table 1). An X-ray of the chest was requested and showed a large pneumoperitoneum (Figure 1). Figure 1: Posteroanterior chest X-ray at the time of gastric perforation displaying severe air under the diaphragm with bilateral obstruction indicating massive pneumoperitoneum (red arrow) Abdominal CT was also urgently performed and confirmed the presence of gastric perforation likely related to an underlying perforated peptic ulcer with 0.8 cm defect at the distal greater curvature (Figures 2, 3). Figure 2: Coronal-section CT image of abdomen and pelvis at the time of gastric perforation showing features of gastric perforation likely related to the underlying perforated peptic ulcer with 0.8 cm defect at the distal greater curvature Figure 3: Horizontal-section CT image showing features of gastric perforation likely related to the underlying perforated peptic ulcer with 0.8 cm defect at the distal greater curvature The patient underwent an emergent gastric wedge resection for gastric perforation, and the pathology reported evidence of gastric ulcer with no evidence of malignancy. Furthermore, Helicobacter pylori test was performed on the sample, and it came back positive. The patient tolerated the surgery very well, and postoperative recovery was without any complications. Later, the patient was prescribed metyrapone 250 mg Q4h, which was then increased to 500 mg Q4h four days after surgery, and her cortisol level significantly dropped to 634nmol/L. During that time, a gastrin level test was also performed to exclude the presence of gastrinomas, and the level was 45 pg/ml (normal range 13-115). Discussion A small percentage of the population suffers from Cushing's syndrome, which is an endocrine disorder characterized by an endogenous overproduction of glucocorticoids, resulting in hypercortisolemia [1]. It is estimated to affect 0.7 to 2.4 people per million annually [1]. Hypercortisolemia alters psychologic, metabolic, and cardiovascular functions, resulting in increased mortality and morbidity rates, particularly if the diagnosis is delayed and long-term exposure to high cortisol levels occurs [2]. Women are more likely to suffer from this condition than men, and people in their 40s to 60s are most vulnerable to it [1]. Patients initially present with a wide range of symptoms, including weight gain, proximal myopathy, skin thinning, and abdominal striae [1]. Additionally, several metabolic disorders, such as diabetes mellitus, hypertension, and dyslipidemia, can occur [1]. Due to the rarity of this condition, there is often a significant delay in diagnosis and treatment, which could eventually lead to complications from prolonged hypercortisolism. From another standpoint, in a systematic review, the incidence of peptic ulcer perforation ranges from 3.8 to 14 per 100,000 individuals in the general population [18]. In under-developed countries, patients are typically young, tobacco-using males [19]. However, patients in industrialized countries are typically older with multiple co-morbidities and are on long-term non-steroidal anti-inflammatory drugs (NSAIDs) or steroid use [19]. Patients may present with an abrupt onset of abdominal discomfort, abdominal rigidity, and tachycardia in the early stages of a perforated peptic ulcer [19]. Later, abdominal distention, pyrexia, hypotension, fever, and vomiting can occur [19]. Furthermore, when the diagnosis is made early, a perforated ulcer often has a good prognosis. However, the risk of adverse events increases if there is a delay in the diagnosis [20]. Therefore, making an early detection through different imaging modalities is crucial [20]. A history of peptic ulcer disease, NSAIDs, physiological stress, smoking, corticosteroids, and Helicobacter pylori are some of the well-established risk factors for a perforated peptic ulcer [20]. The prevalence of Helicobacter pylori among Saudi patients is high; in one study, the overall prevalence was 46.5% in patients with dyspepsia using gastric biopsy [21]. Several studies have explored the relationship between Helicobacter pylori and gastrointestinal perforation, but the results have been mixed. Some studies have suggested a higher prevalence of Helicobacter pylori infection among individuals with gastrointestinal perforation compared to those without, indicating a potential association. However, other studies have found no significant difference in the prevalence of Helicobacter pylori infection between perforated and non-perforated gastrointestinal ulcer cases [22]. Furthermore, they suggested that the presence of other risk factors like the use of NSAIDs, smoking, and alcohol may interact with Helicobacter pylori infection and contribute to the development of complications such as gastrointestinal perforation [22]. However, in our case, the patient did not have any established risk factors for gastric perforation, such as NSAIDs, smoking, or alcohol. Therefore, considering the low incidence of gastrointestinal perforation and high prevalence of Helicobacter pylori, the conflicting data regarding the association between Helicobacter pylori and gastrointestinal perforation, and the lack of established risk factors for gastrointestinal perforation in our patient, we suggest that prolonged excess glucocorticoids from Cushing's syndrome may have contributed to the gastric perforation either independently or synergistically with Helicobacter pylori since hypercortisolism can lead to a weakened gastrointestinal wall integrity due to decreased collagen turnover and disruption of mucosal protection by prostacyclin [15]. In addition, because of hypercortisolism, perforation may not be contained or healed initially due to the immunosuppressive effects of hypercortisolism, whether endogenous or exogenous [15]. Additionally, high levels of cortisol may delay the diagnosis and treatment since it may mask the symptoms of the perforation [14]. Moreover, our patient was treated for severe hypokalemia with potassium supplementation for an extended period of time. Previous studies have linked potassium chloride supplementation to gastrointestinal ulceration and perforation, making this a possible additive cause of our patient's condition [23,24]. A limited number of studies have addressed gastrointestinal perforations associated with endogenous hypercortisolemia [5-17]. The correlation between Cushing's syndrome and gastrointestinal perforation is highlighted in our study and in the case reports that have been previously published (Table 2). Similar to our case, a female predominance was seen in gastrointestinal perforation among the reported cases of Cushing's syndrome [6,7,12,13,15,16]. Additionally, the average age at which gastrointestinal perforation occurred in patients with endogenous hypercortisolism ranged from 45 to 80, which is a noticeably higher age range than the case we are presenting here (aged 30) [6-10,12]. Furthermore, unlike our case, in which gastrointestinal perforation occurred four months after the onset of Cushing's symptoms, Intestinal perforation occurs approximately 9.8 months after Cushing's symptoms first appear [15]. Furthermore, in our patient, gastric perforation occurred while she was hypercortisolemic and not in a remission state. Hence, in association with Helicobacter pylori infection, severe hypercortisolemia could have been a secondary contributing factor to gastric perforation. The complications of gastric ulceration, specifically with endogenous Cushing's syndrome, have been addressed in two case reports [25,26]. It must be noted, however, that neither case is similar to ours. A case of gastric perforation was reported by Kubicka et al. in a patient who had a confirmed diagnosis of gastrinoma, and the patient was diagnosed with ectopic Cushing's syndrome seven months after gastric perforation [25]. Therefore, since ectopic Cushing's syndrome was diagnosed seven months after the perforation, it is more likely that the gastrinoma contributed to this complication. In contrast, our patient's serum gastrin level was within the normal range, ruling out gastrinoma. Further, Hoshino et al. reported a case of gastrointestinal bleeding in a 39-year-old man with a confirmed diagnosis of Cushing's disease secondary to pituitary adenoma [26]. He was found to have gastric ulceration and bleeding along with Helicobacter pylori infection and elevated cortisol levels [26]. In spite of the patient not developing a gastric perforation, it was suggested by the author that hypercortisolism might be a contributing factor for gastric ulcer complications by slowing down the ulcer healing process [26] Reference Year of publication Age, gender Highest cortisol level plasma cortisol (PC, nmol/L) / UFC (nmol/L) Cause of Cushing's syndrome Time from onset of Cushing's symptoms to perforation (months) Reported site of gastrointestinal perforation Current 2023 30, Female PC 4842 ACTH-dependant 4 Gastric perforation Ishinoda et al. [17] 2023 24, Male PC 1647 Cushing's disease 12 Sigmoid colon perforation Wijewickrama et al. [16] 2021 32, Female PC 1147 Pituitary microadenoma 1 Diverticular perforation Shahidi et al. [15] 2019 72, Female UFC 5296 Pancreatic neuroendocrine tumor 12 Diverticular perforation Shahidi et al. [15] 2019 61, Female PC 1925 Metastatic medullary carcinoma of thyroid 12 Sigmoid colon and diverticular perforation Shahidi et al. [15] 2019 68, Female UFC 410 Cushing's disease 12 Sigmoid colon perforation Shahidi et al. [15] 2019 71, Female UFC 1533 Cushing's disease 4 Diverticular perforation Shahidi et al. [15] 2019 54, Male UFC 374 Cushing's disease 3 Sigmoid colon perforation Shahidi et al. [15] 2019 52, Female UFC 885 Cushing's disease 16 Diverticular perforation Sater et al. [14] 2018 80, Female UFC 5601 Lung carcinoid 36 Diverticular perforation Sater et al. [14] 2018 60, Female UFC 72726 Metastatic islet cell carcinoma 36 Diverticular perforation Sater et al. [14] 2018 31, Male UFC 1297 Cushing's disease 20 Diverticular perforation Sater et al. [14] 2018 52, Female UFC 2371 Lung carcinoid 4 Diverticular perforation Sater et al. [14] 2018 67, Male UFC 3836 Ectopic ACTH 10 Diverticular perforation Sater et al. [14] 2018 51, Male UFC 13552 Metastatic thymic carcinoma 4 Diverticular perforation Kaya et al. [9] 2016 70, Male PC 1432 Small cell lung cancer 1 Diverticular perforation Dacruz et al. [12] 2016 60, Female UFC 4481 Metastatic parotid tumor 5 Sigmoid colon and diverticular perforation Matheny et al. [10] 2016 67, Male UFC 11119 Metastatic medullary carcinoma of thyroid 4 Diverticular perforation Flynn et al. [13] 2016 63, Female UFC 12465 Pheochromocytoma 1 Perforation at the splenic flexure Balestrieri et al. [11] 2016 75, Male PC 2272 Neuroendocrine tumor 1 Intestinal perforation Hara et al, [8] 2013 79, Male PC 1230 Cushing's disease 6 Diverticular perforation De Havenon et al. [7] 2011 71, Female PC 2593 Cushing's disease 9 Diverticular perforation Lutgers et al. [6] 2010 55, Female UFC 10152 Right pheochromocytoma 1 Sigmoid colon and diverticular perforation Drake et al. [5] 1998 35, Male PC 1442 Islet cell tumor 4 Duodenal perforation and rupture of pancreatic pseudocyst Table 2: Current case and previous reported 23 cases of patients with Cushing's syndrome and gastrointestinal perforation UFC - urinary free cortisol; PC - plasma cortisol; ACTH - adrenocorticotropic hormone Conclusions A high blood cortisol level can be associated with various clinical manifestations and diverse sets of complications. This case report sheds light on one of the less common complications of hypercortisolism in patients with Cushing's syndrome, which is gastrointestinal perforation. Our report further supports the published evidence that gastrointestinal perforation is a rare but potentially fatal complication among patients with Cushing's syndrome. Moreover, it highlights the possibility of developing gastric perforations in this patient group, even at younger ages than expected. This should elicit a high clinical suspicion and demand prompt investigation of Cushing's syndrome patients in a hypercortisolism state presenting with modest gastrointestinal symptoms. References Pivonello R, De Martino MC, De Leo M, Lombardi G, Colao A: Cushing's syndrome. Endocrinol Metab Clin North Am. 2008, 37:135-49. 10.1016/j.ecl.2007.10.010 Newell-Price J, Bertagna X, Grossman AB, Nieman LK: Cushing's syndrome. Lancet. 2006, 367:1605-17. 10.1016/S0140-6736(06)68699-6 Goethals L, Nieboer K, De Smet K, De Geeter E, Tabrizi NH, Van Eetvelde E, de Mey J: Cortisone associated diverticular perforation. JBR-BTR. 2011, 94:348-9. 10.5334/jbr-btr.705 Piekarek K, Israelsson LA: Perforated colonic diverticular disease: the importance of NSAIDs, opioids, corticosteroids, and calcium channel blockers. Int J Colorectal Dis. 2008, 23:1193-7. 10.1007/s00384-008-0555-4 Drake WM, Perry LA, Hinds CJ, Lowe DG, Reznek RH, Besser GM: Emergency and prolonged use of intravenous etomidate to control hypercortisolemia in a patient with Cushing's syndrome and peritonitis. J Clin Endocrinol Metab. 1998, 83:3542-4. 10.1210/jcem.83.10.5156 Lutgers HL, Vergragt J, Dong PV, de Vries J, Dullaart RP, van den Berg G, Ligtenberg JJ: Severe hypercortisolism: a medical emergency requiring urgent intervention. Crit Care Med. 2010, 38:1598-601. 10.1097/CCM.0b013e3181e47b7a de Havenon A, Ehrenkranz J: A perforated diverticulum in Cushing's disease. Int J Surg Case Rep. 2011, 2:215-7. 10.1016/j.ijscr.2011.06.009 Hara T, Akutsu H, Yamamoto T, Ishikawa E, Matsuda M, Matsumura A: Cushing's disease presenting with gastrointestinal perforation: a case report. Endocrinol Diabetes Metab Case Rep. 2013, 2013:130064. 10.1530/EDM-13-0064 Kaya T, Karacaer C, Açikgöz SB, Aydemir Y, Tamer A: Severe hypokalaemia, hypertension, and intestinal perforation in ectopic adrenocorticotropic hormone syndrome. J Clin Diagn Res. 2016, 10:OD09-11. 10.7860/JCDR/2016/17198.7127 Matheny LN, Wilson JR, Baum HB: Ectopic ACTH production leading to diagnosis of underlying medullary thyroid carcinoma. J Investig Med High Impact Case Rep. 2016, 4:2324709616643989. 10.1177/2324709616643989 Balestrieri A, Magnani E, Nuzzo F: Unusual Cushing's syndrome and hypercalcitoninaemia due to a small cell prostate carcinoma. Case Rep Endocrinol. 2016, 2016:6308058. 10.1155/2016/6308058 Dacruz T, Kalhan A, Rashid M, Obuobie K: An ectopic ACTH secreting metastatic parotid tumour. Case Rep Endocrinol. 2016, 2016:4852907. 10.1155/2016/4852907 Flynn E, Baqar S, Liu D, et al.: Bowel perforation complicating an ACTH-secreting phaeochromocytoma. Endocrinol Diabetes Metab Case Rep. 2016, 2016:10.1530/EDM-16-0061 Sater ZA, Jha S, McGlotten R, Hartley I, El Lakis M, Araque KA, Nieman LK: Diverticular perforation: A fatal complication to forestall in Cushing syndrome. J Clin Endocrinol Metab. 2018, 103:2811-4. 10.1210/jc.2018-00829 Shahidi M, Phillips RA, Chik CL: Intestinal perforation in ACTH-dependent Cushing's syndrome. Biomed Res Int. 2019, 2019:9721781. 10.1155/2019/9721781 Wijewickrama PS, Ratnasamy V, Somasundaram NP, Sumanatilleke M, Ambawatte SB: A challenging case of Cushing's disease complicated with multiple thrombotic phenomena following trans-sphenoidal surgery; a case report. BMC Endocr Disord. 2021, 21:29. 10.1186/s12902-021-00701-0 Ishinoda Y, Uto A, Meshino H, et al.: Bowel perforation associated with Cushing's disease: a case report with literature review. Endocr J. 2023, 70:933-9. 10.1507/endocrj.EJ23-0110 Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC: Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011, 84:102-13. 10.1159/000323958 Chung KT, Shelat VG: Perforated peptic ulcer - an update. World J Gastrointest Surg. 2017, 9:1-12. 10.4240/wjgs.v9.i1.1 Weledji EP: An overview of gastroduodenal perforation. Front Surg. 2020, 7:573901. 10.3389/fsurg.2020.573901 Akeel M, Elmakki E, Shehata A, Elhafey A, Aboshouk T, Ageely H, Mahfouz MS: Prevalence and factors associated with H. pylori infection in Saudi patients with dyspepsia. Electron Physician. 2018, 10:7279-86. 10.19082/7279 Thirupathaiah K, Jayapal L, Amaranathan A, Vijayakumar C, Goneppanavar M, Nelamangala Ramakrishnaiah VP: The association between Helicobacter pylori and perforated gastroduodenal ulcer. Cureus. 2020, 12:e7406. 10.7759/cureus.7406 Farquharson-Roberts MA, Giddings AE, Nunn AJ: Perforation of small bowel due to slow release potassium chloride (slow-K). Br Med J. 1975, 3:206. 10.1136/bmj.3.5977.206 Payan H, Blaustein A: Potassium chloride and small bowel perforation. Gastroenterology. 1965, 48:877-8. 10.1016/S0016-5085(65)80073-7 Kubicka E, Zawadzka K, Syrycka J, Kałużny M, Pawluś A, Bolanowski M: A case of gastrinoma associated with ectopic Cushing syndrome. Pol Arch Intern Med. 2020, 130:328-9. 10.20452/pamw.15201 Hoshino C, Satoh N, Narita M, Kikuchi A, Inoue M: Another 'Cushing ulcer'. BMJ Case Rep. 2011, 2011:10.1136/bcr.02.2011.3888 From https://www.cureus.com/articles/196132-adrenocorticotropic-hormone-dependent-cushings-syndrome-complicated-with-gastric-ulcer-perforation-in-a-30-year-old-saudi-female-a-case-report-and-a-review-of-the-literature#!/

Abstract Objective Since Cushing's disease (CD) is less common in the paediatric age group than in adults, data on this subject are relatively limited in children. Herein, we aim to share the clinical, diagnostic and therapeutic features of paediatric CD cases. Design National, multicenter and retrospective study. Patients All centres were asked to complete a form including questions regarding initial complaints, physical examination findings, diagnostic tests, treatment modalities and follow-up data of the children with CD between December 2015 and March 2017. Measurements Diagnostic tests of CD and tumour size. Results Thirty-four patients (M:F = 16:18) from 15 tertiary centres were enrolled. The most frequent complaint and physical examination finding were rapid weight gain, and round face with plethora, respectively. Late-night serum cortisol level was the most sensitive test for the diagnosis of hypercortisolism and morning adrenocorticotropic hormone (ACTH) level to demonstrate the pituitary origin (100% and 96.8%, respectively). Adenoma was detected on magnetic resonance imaging (MRI) in 70.5% of the patients. Transsphenoidal adenomectomy (TSA) was the most preferred treatment (78.1%). At follow-up, 6 (24%) of the patients who underwent TSA were reoperated due to recurrence or surgical failure. Conclusions Herein, national data of the clinical experience on paediatric CD have been presented. Our findings highlight that presenting complaints may be subtle in children, the sensitivities of the diagnostic tests are very variable and require a careful interpretation, and MRI fails to detect adenoma in approximately one-third of cases. Finally, clinicians should be aware of the recurrence of the disease during the follow-up after surgery. From https://onlinelibrary.wiley.com/doi/10.1111/cen.14980

Abstract Cushing’s syndrome is a condition leading to overproducing of cortisol by the adrenal glands. If the pituitary gland overproduces cortisol, it is called Cushing’s disease. Cushing’s syndrome and even Cushing’s disease during and after pregnancy are rare events. There is not enough literature and guidance for managing and treating these patients. The diagnosis of Cushing’s syndrome in pregnancy is often delayed because the symptoms overlap. We presented a thin 31-year-old woman, admitted 2 months after a normal-term delivery, with an atypical presentation of Cushing’s disease, unusual clinical features, and a challenging clinical course. She had no clinical discriminatory features of Cushing’s syndrome. Given that the patient only presented with psychosis and proximal myopathy and had an uncomplicated pregnancy, our case was considered unusual. The patients also had hyperpigmentation and severe muscle weakness which are among the less common presentations of Cushing’s syndrome. Our findings suggest that an early diagnosis of Cushing’s disease is important in pregnancy period for its prevalent fetal and maternal complications, and it should be treated early to optimize fetal and maternal outcomes as there is an increasing trend toward live births in treated participants. Introduction Cushing’s syndrome is a condition that originates from excessive production of glucocorticoids. The condition is most common in women of childbearing age and is characterized by altered distribution of the adipose tissue to the central and upper regions of the trunk (central obesity and buffalo hump), face (moon face), capillary wall integrity (easy bruising), hyperglycemia, hypertension, mental status changes and psychiatric symptoms, muscle weakness, signs associated with hyperandrogenism (acne and hirsutism), and violaceous striae among other signs. Hypercortisolism and hyperandrogenism suppress the production of the pituitary gonadotropins, which in turn leads to menstrual irregularities and infertility.1-3 Moreover, the main common cause of developing Cushing’s syndrome is the use of exogenic steroid.3 Cushing’s disease is a form of Cushing’s syndrome with overproduction of adrenocorticotropic hormone (ACTH) due to pituitary adenoma. The diagnosis is made using clinical features and paraclinical tests including urinary free cortisol (UFC), serum ACTH, dexamethasone suppression tests (DSTs), pituitary magnetic resonance imaging (MRI), and sometimes by inferior petrosal sinus sampling (IPSS).4 Although women with Cushing’s disease are less likely to become pregnant, timely diagnosis and appropriate management are especially important during possible pregnancy, preventing neonatal and maternal complications and death. The diagnosis is challenging due to the overlap of the disease symptoms with the changes associated with a normal pregnancy. Moreover, the hormonal milieu during pregnancy has recently been proposed as a potential trigger for Cushing’s disease in some cases; hence, the term “pregnancy-associated Cushing’s disease” has been used for the disease in the recent literature. In this study, we presented a thin 31-year-old woman who was referred to our clinic 2 months after a normal delivery, with an atypical presentation of Cushing’s disease, unusual clinical features, and a challenging clinical course. Case Presentation Our patient was a 31-year-old woman who presented 2 months after the delivery of her second child. She had a history of type 2 diabetes mellitus and hypertension in the past 2 years prior to her presentation. She had been admitted to another center following an episode of falling and muscle weakness. Two weeks later, she was admitted to our center with an impression of pulmonary thromboembolism due to tachypnea, tachycardia, and dyspnea. During follow-up, she was found to have leukocytosis, hyperglycemia (random blood sugar: 415 mg/d; normal level: up to 180 mg/dL) and hypokalemic metabolic alkalosis (PH: 7.5, HCO3 [bicarbonate]: 44.7 mEq/L, paO2 [partial pressure of oxygen]: 73 mm Hg, pCO2: 51.7 mm Hg, potassium: 2.7 mEq/L [normal range: 3.5-5.1 mEq/L]), which was refractory to the treatment; therefore, an endocrinology consultation was first requested. On physical examination, the patient was agitated, confused, and psychotic. Her vital signs were: blood pressure 155/100 mm Hg, heart rate: 130 bpm, and respiratory rate: 22 bpm, temperature: 39°C. As it has shown in Figure 1A, her face is not typical for moon face of Cushing’s syndrome, but facial hirsutism (Figure 1A) and generalized hyperpigmentation is obvious (Figure 1A-C). She was a thin lady and had a normal weight and distribution of adiposity (Body Mass Index [BMI] = 16.4 kg/m2; weight: 40 kg, and height: 156 cm). Aside from thinness of skin, she did not have the cutaneous features of Cushing’s syndrome (e.g. purpura, acne, and violaceous striae) and did not have supraclavicular and dorsocervical fat pad (buffalo hump), or plethora. In other words, she had no clinical discriminatory features of Cushing’s syndrome despite the high levels of cortisol, as confirmed by severely elevated UFC (5000 μg/24 h and 8000 μg/24 h; normal level: 4-40 μg/24 h). In addition, as will be mentioned later, the patient had axonal neuropathy which is a very rare finding in Cushing’s syndrome. Figure 1. Clinical finding of our case with Cushing’s disease. (A) Hirsutism, (B) muscle atrophy seen in proximal portion of lower limbs, and (C) hyperpigmentation specially on the skin of the abdominal region. OPEN IN VIEWER She had a markedly diminished proximal muscle force of 1 out of 5 across all extremities; the rest of the physical examinations revealed no significant abnormalities (Figure 1B). On the contrary, based on her muscle weakness, hirsutism, psychosis and hyperpigmentation and refractory hypokalemic alkalosis, hyperglycemia, and hypertension, Cushing’s syndrome was suspected; therefore, 24-hour UFC level was checked that the results showed a severely elevated urinary cortisol (5000 μg/24 h and 8000 μg/24 h; normal level: 4-40 μg/24 h). Serum ACTH level was also inappropriately elevated (45 pg/mL; normal range: 10-60 pg/mL). High-dose dexamethasone failed to suppress plasma cortisol level and 24-hour urine cortisol level. A subsequent pituitary MRI showed an 8-mm pituitary mass, making a diagnosis of Cushing’s disease more probable. Meanwhile, the patient was suffering from severe muscle weakness that did not improve after the correction of hypokalemia. Then, a neurology consultation was requested. The neurology team evaluated laboratory data as well as EMG (Electromyography) and NCV (Nerve Conduction Velocity) of the patient, and based on their findings, “axonal neuropathy” was diagnosed for her weakness; so they ruled out the other neuromuscular diseases. A 5-day course of intravenous immunoglobulin (IVIG) was started for her neuropathy; however, the treatment did not improve her symptoms and the patient developed fungal sepsis and septic shock. Therefore, she was processed with broad-spectrum antibiotics and antifungal agents and recovered from the infection. Mitotane was started for the patient before definitive surgical treatment to suppress hormonal production due to her poor general condition. Despite the 8-mm size of the pituitary mass which is likely to be a source of ACTH, our patient was underweight and showed the atypical clinical presentation of Cushing’s disease, making us suspect an ectopic source for the ACTH. Therefore, a Gallium dotatate scan was performed to find any probable ectopic sources; however, the results were unremarkable. The patient underwent Trans-Sphenoidal Surgery (TSS) to resect the pituitary adenoma because it was not possible to perform IPSS in our center. Finally, the patient’s condition including electrolyte imbalance, muscle weakness, blood pressure, and hyperglycemia started to improve significantly. The pathologist confirmed the diagnosis of a corticotropic adenoma. Nevertheless, the patient suddenly died while having her meal a week after her surgery; most likely due to a thromboembolic event causing a cardiac accident. Discussion Our patient was significantly different from other patients with Cushing’s disease because of her atypical phenotype. She was unexpectedly thin and had psychosis, hyperpigmentation, proximal myopathy, axonal neuropathy and no clinical discriminatory features of Cushing’s syndrome such as central adiposity, dorsocervical or supraclavicular fat pad, plethora or striae. She had also a history of type 2 diabetes and hypertension 2 years before her admission. The patient was diagnosed with Cushing’s later. From what was presented, the patient did not know she had Cushing’s until after her delivery and despite the highly elevated UFC, and she completed a normal-term delivery. Given that she only presented with psychosis and proximal myopathy, her pregnancy was considered unusual. Her clinical features such as hyperpigmentation and severe muscle weakness are among less common presentations.5 11β-hydroxysteroid dehydrogenase type 1 (11-βHSD1) is an enzyme responsible for converting cortisone (inactive glucocorticoid) into cortisol (active). It is speculated that this enzyme has a role in obesity (Figure 2).6,7 Figure 2. The enzymatic actions of 11β-hydroxysteroid dehydrogenase on its substrate interconverting inactive and active glucocorticoid. OPEN IN VIEWER In a case reported by Tomlinson, a 20-year-old female was diagnosed with Cushing’s disease despite not having the classical features of the disease. It has been suggested that the mechanism is a partial defect in 11β-HSD1 activity and concomitant increase in cortisol clearance rate. Thus, the patient did not have a classic phenotype; the defect in the conversion of cortisone to cortisol rises cortisol clearance and protects the patient from the effects of cortisol excess. This observation may help explain individual susceptibility to the side effects of glucocorticoids.6 Further studies of Tomlinson et al showed that a deficit in the function of (and not a mutation related to) 11β-HSD2 might have been responsible for the absence of typical Cushing’s symptoms. 11-HSD2 keeps safe the mineralocorticoid receptor from excess cortisol. Mutation in the HSD11B2 gene explains an inherited form of hypertension, apparent mineralocorticoid excess syndrome, in which Cushing’s disease results in cortisol-mediated mineralocorticoid excess affecting the kidney and leads to both hypokalemia and hypertension.8 It is frequent in Cushing’s syndrome that the patients usually have no mineralocorticoid hypertension; however, it is still proposed that a defect in 11β-HSD1 can be responsible for the presence of mineralocorticoid hypertension in a subgroup of patients. In fact, 11β-HSD1 is expressed in several tissues like the liver, kidneys, placenta, fatty tissues and gonads,9 meaning that this enzyme may potentially affect the results of cortisol excess in Cushing’s syndrome/disease. Abnormality in the function of this enzyme could explain the absence of the symptoms like central obesity, easy bruising, and typical striae during Cushing’s disease. Several factors affect the action of glucocorticoids. In this regard, the impact of the different types and levels of impairment in glucocorticoid receptors have been highlighted in some studies, as it can lead to different levels of response to glucocorticoids10 as well as a variety in the symptoms observed in Cushing’s disease. The predominant reaction of the NADP(H)-dependent enzyme 11-Tukey’s honestly significant difference (HSD)1 happens through the catalysis of the conversion of inactive cortisol into receptor-active cortisol. The reverse reaction is mediated through the unidirectional NAD-dependent 11-HSD type 2 (Figure 2).11 In another case reported by Ved V. Gossein, a 41-year-old female was evaluated for hirsutism and irregular menstrual cycles. Her BMI was 22.6 kg/m2. The patient had no signs or symptoms of overnight recurrent Cushing’s syndrome, the 48-hour DST failed to suppress cortisol levels, and 24-hour urinary cortisol levels were persistently elevated on multiple occasions. Adrenocorticotropic hormone levels were unreasonably normal, suggesting ACTH-dependent hypercortisolism. Despite these disorders, she had 2 children. Magnetic resonance imaging (MRI) of the pituitary did not show any abnormalities. Moreover, abdominal MRI did not show adrenal mass or enlargement. Genetic testing to determine glucocorticoid resistance syndrome showed no mutation.12 Primary generalized glucocorticoid resistance is a rare genetic disorder characterized by generalized or partial insensitivity of target tissues to glucocorticoids.13-17 There is a compensatory increase in hypothalamic-pituitary activity due to decreased sensitivity of peripheral tissues to glucocorticoids systems.13-17 Excessive ACTH secretion leads to high secretion of cortisol and mineralocorticoids and/or androgens. However, the clinical features of Cushing’s syndrome do not develop after resistance to the effects of cortisol. Generalized glucocorticoid resistance is a rare condition characterized by high cortisol levels but no scarring of Cushing’s syndrome.18 An important aspect of our case was her pregnancy. Our patient had a history of hypertension and diabetes type 2, 2 years before her presentation to our center that could be because of an undiagnosed Cushing’s disease. The patient’s pregnancy terminated 2 months prior the admission and she had a normal vaginal delivery. So, we suspect that she become pregnant while involved with the disease. Aside from focusing on how this can happen in a patient with such high levels of glucocorticoids, more attention should be paid to occurring pregnancy in the background of Cushing’s disease. In fact, up to 250 patients were reported, of which less than 100 were actively treated.19-22 Cushing’s disease is associated with serious complications in up to 70% of the cases coinciding with pregnancy.21 The most frequent maternal complications reported in the literature are hypertension and impaired glucose tolerance, followed by preeclampsia, osteoporosis, severe psychiatric complications, and maternal death (in about 2% of the cases). Prematurity and intrauterine growth retardation account for the most prevalent fetal complications. Stillbirth, intrauterine deaths, intrauterine hemorrhage, and hypoadrenalism have also been reported.23 Early diagnosis is especially challenging during pregnancy because of many clinical and biochemical shared features of the 2 conditions.23,24 These features include an increase in ACTH production, corticosteroid-binding globulin (CBG) 1 level, level of cortisol (urinary, plasma and free), hyperglycemia, weight gain, and an increased chance for occurrence of bruising, hypertension (mistaken with preeclampsia), gestational diabetes mellitus, weight gain, and mood swings.3 There are some suggestions proposed in the studies that help in screening and differentiation of Cushing’s from the normal and abnormal effects of pregnancy and Cushing’s disease from Cushing’s syndrome in suspected pregnant patients. Contrary to Cushing’s syndrome, the nocturnal minimum level of cortisol is preserved in pregnancy.23,25 There is not yet a diagnostic cut-off determined on mentioned level; however, a few studies elucidate the evaluation of hypercortisolemia in a pregnant patient.26-28 Urinary free cortisol, a measure that reflects the amount of free cortisol in circulation, normally increases during pregnancy, and it can increase up to 8 times the normal level with Cushing’s disease during the second and the third trimesters,23,29 which is a useful tool to evaluate cortisol levels in a suspected pregnant woman. Because the suppression of both UFC and plasma cortisol is decreased in pregnancy,23,30 a low-dose DST is not very helpful for screening Cushing’s disease in pregnant patients. However, a high-dose DST with a <80% cortisol suppression might only indicate Cushing’s disease.3,31 Thus, it helps differentiating between ectopic ACTH syndrome and Cushing’s disease.32 The use of high-dose DST can distinguish between adrenal and pituitary sources of CS in pregnancy. Owing to the limited evidence available and the lack of data on normal pregnancies, the use of corticotropin-releasing hormone (CRH), desmopressin, and high-dose DST in pregnancy is not recommended yet.33 More timely diagnosis as well as timely intervention may have saved the life of our patient. To differentiate between ectopic ACTH syndrome and Cushing’s disease, adrenal imaging should be considered. For higher plasma levels, combined employment of CRH stimulation test and an 8-mg DST can be helpful.3 Bilateral inferior petrosal sinus sampling (B-IPSS) might be needed when the findings are not in accordance with other results, but it is recommended to perform B-IPSS only if the noninvasive studies are inconclusive and only if there is enough expertise, experience, and technique for its performance.3 Although axonal neuropathy has been reported as a rare syndrome associated with paraneoplastic ectopic Cushing’s syndrome and exogenous Cushing’s syndrome, its association with Cushing’s disease has not been reported.5,32 Our patient had severe muscle weakness that we initially attributed it to myopathy and hypokalemia associated with Cushing’s syndrome. In our study, the diagnosis of axonal neuropathy was made based on electrophysiological studies by a neurology consultant and then IVIG was administered; however, the patient’s weakness did not improve after this treatment. The co-occurrence of Guillain-Barré syndrome which may also be classified as axonal neuropathy has also been reported in a pregnant woman with ectopic Cushing’s syndrome.34,35 Whether this finding is coincidental or the result of complex immune reactions driven by Cushing’s disease, or the direct effect of steroids, these results cannot be deduced from current data.36 Some data suggest that the fluctuations and inferior petrosal sinus sampling may trigger the flare of autoimmune processes, specifically when the cortisol levels start to decline during the course of Cushing’s syndrome.35,8 Also, due to COVID-19 pandemic affecting vital organs like kidney, paying attention to COVID-19 is suggested.37-40 Conclusions We presented a thin young female with psychosis, proximal myopathy, and axonal neuropathy with Cushing’s disease who had a recent pregnancy that was terminated without any fetal or maternal complications despite the repeated elevated serum cortisol and 24-hour UFC; therefore, we suggest that she might have glucocorticoid resistance. Glucocorticoid resistance is a rare disease in which the majority, but not all, of patients have a genetic mutation in the hGR-NR3C1 gene. As we did not perform genetic testing for our patient, the data are lacking. Another clue to the absence of the classic Cushing’s disease phenotype in our case is the role of isoenzymes of 11-HSD1 and 11-HSD2. Other mechanisms, such as the defect somewhere in the glucocorticoid pathway of action such as a decreased number of receptors, a reduction in ligand affinity, or a postreceptor defect, play an important role in nonclassical clinical manifestations of Cushing’s syndrome. Acknowledgments The authors thank the patient for allowing us to publish this case report. The authors show their gratitude to the of the staff of the Rasool Akram Medical Complex Clinical Research Development Center (RCRDC) specially Mrs. Farahnaz Nikkhah for its technical and editorial assists. Ethics Approval Our institution does not require ethical approval for reporting individual cases or case series. Informed Consent Written informed consent was obtained from the patient and for her anonymized information to be published in this article. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Guilhaume B, Sanson ML, Billaud L, Bertagna X, Laudat MH, Luton JP. Cushing’s syndrome and pregnancy: aetiologies and prognosis in twenty-two patients. Eur J Med. 1992; 1(2):83-89. GO TO REFERENCE PubMed Google Scholar 2. Lin W, Huang HB, Wen JP, et al. Approach to Cushing’s syndrome in pregnancy: two cases of Cushing’s syndrome in pregnancy and a review of the literature. Ann Transl Med. 2019; 7(18):490. Crossref PubMed Google Scholar 3. Vilar L, Freitas MdC, Lima LHC, Lyra R, Kater CE. Cushing’s syndrome in pregnancy: an overview. Arq Bras Endocrinol Metabol. 2007;51(8):1293-1302. Crossref PubMed Google Scholar 4. Pecori Giraldi F, Cavallo LM, P, et al. The role of inferior petrosal sinus sampling in ACTH-dependent Cushing’s syndrome: review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology. Neurosurg Focus. 2015;38(2):E5. GO TO REFERENCE PubMed Google Scholar 5. Molina Garrido MJ, Guillén Ponce C, Maciá Escalante S, Pons Sanz V, Carrato Mena A. Cushing’s paraneoplastic syndrome as first manifestation of an adenocarcinoma of unknown origin. Clin Transl Oncol. 2006;8(8):621-623. Crossref PubMed Google Scholar 6. Tomlinson JW, Draper N, Mackie J, et al. Absence of Cushingoid phenotype in a patient with Cushing’s disease due to defective cortisone to cortisol conversion. J Clin Endocrinol Metab. 2002;87(1):57-62. PubMed Google Scholar 7. Kobayashi T, Matsumoto T, Kamata K. IGF-I-induced enhancement of contractile response in organ-cultured aortae from diabetic rats is mediated by sustained thromboxane A2 release from endothelial cells. J Endocrinol. 2005;186(2): 367-376. GO TO REFERENCE Crossref PubMed Google Scholar 8. Stewart PM. Tissue-specific Cushing’s syndrome, 11β-hydroxysteroid dehydrogenases and the redefinition of corticosteroid hormone action. Eur J Endocrinol. 2003;149:163-168. Crossref PubMed Google Scholar 9. Ricketts ML, Verhaeg JM, Bujalska I, et al. Immunohistochemical localization of type 1 11β-hydroxysteroid dehydrogenase in human tissues. J Clinl Endocrinol Metabol. 1998;83:1325-1335. GO TO REFERENCE PubMed ISI Google Scholar 10. Huizenga NA, Koper JW, De Lange P, et al. A polymorphism in the glucocorticoid receptor gene may be associated with and increased sensitivity to glucocorticoids in vivo. J Clin Endocrinol Metab. 1998;83(1):144-151. GO TO REFERENCE PubMed Google Scholar 11. Hintzpeter J, Stapelfeld C, Loerz C, Martin HJ, Maser E. Green tea and one of its constituents, Epigallocatechine-3-gallate, are potent inhibitors of human 11β-hydroxysteroid dehydrogenase type 1. PLoS ONE. 2014;9(1):e84468. GO TO REFERENCE Crossref PubMed Google Scholar 12. Gossain VV, El-Rifai M, Krishnan P, Bhavsar B. Cushing’s syndrome with no clinical stigmata—a variant of glucocorticoid resistance syndrome. Clin Diabetes Endocrinol. 2018;4:23-25. GO TO REFERENCE Crossref PubMed Google Scholar 13. Charmandari E, Kino T, Ichijo T, Chrousos GP. Generalized glucocorticoid resistance: clinical aspects, molecular mechanisms, and implications of a rare genetic disorder. J Clin Endocrinol Metab. 2008;93(5):1563-1572. Crossref PubMed Google Scholar 14. Cidlowski JA, Malchoff CD, Malchoff DM. Glucocorticoid receptors, their mechanism of action, and glucocorticoid resistance. In: Jameson JL, De Groot LJ, eds. Endocrinology: Adult and Pediatric. Saunders; 2016:1717-1726. Google Scholar 15. Charmandari E, Kino T. Chrousos syndrome: a seminal report, a phylogenetic enigma and the clinical implications of glucocorticoid signaling changes. Eur J Clin Investig. 2010;40: 932-942. Crossref PubMed Google Scholar 16. Nicolaides NC, Charmandari E. Chrousos syndrome: from molecular pathogenesis to therapeutic management. Eur J Clin Invest. 2015;45(5):504-514. Crossref PubMed Google Scholar 17. Nicolaides N, Lamprokostopoulou A, Sertedaki A, Charmandari E. Recent advances in the molecular mechanisms causing primary generalized glucocorticoid resistance. Hormones. 2016;15(1): 23-34. Crossref PubMed Google Scholar 18. Huizenga NATM De Lange P, Koper JW, et al. Five patients with biochemical and/or clinical generalized glucocorticoid resistance without alterations in the glucocorticoid receptor gene. J Clin Endocrinol Metab. 2000;85:2076-2081. GO TO REFERENCE PubMed Google Scholar 19. Luger A, Broersen LHA, Biermasz NR, et al. ESE clinical practice guideline on functioning and nonfunctioning pituitary adenomas in pregnancy. Eur J Endocrinol. 2021;185: G1-G33. GO TO REFERENCE Crossref PubMed Google Scholar 20. Sridharan K, Sahoo J, Palui R, et al. Diagnosis and treatment outcomes of Cushing’s disease during pregnancy. Pituitary. 2021;24(5):670-680. Crossref PubMed Google Scholar 21. Caimari F, Valassi E, Garbayo P, et al. Cushing’s syndrome and pregnancy outcomes: a systematic review of published cases. Endocrine. 2017;55(2):555-563. GO TO REFERENCE Crossref PubMed Google Scholar 22. Lindsay JR, Jonklaas J, Oldfield EH, Nieman LK. Cushing’s syndrome during pregnancy: personal experience and review of the literature. J Clin Endocrinol Metab. 2005;90(5):3077-3083. GO TO REFERENCE Crossref PubMed Google Scholar 23. Lindsay JR, Nieman LK. The hypothalamic-pituitary-adrenal axis in pregnancy: challenges in disease detection and treatment. Endocr Rev. 2005;26(6):775-799. Crossref PubMed Google Scholar 24. Buescher MA, McClamrock HD, Adashi EY. Cushing syndrome in pregnancy. Obstetr Gynecol. 1992;79:130-137. GO TO REFERENCE PubMed Google Scholar 25. Carr BR, Parker CR Jr, Madden JD, et al. Maternal plasma adrenocorticotropin and cortisol relationships throughout human pregnancy. Am J Obstetr Gynecol. 1981;139:416-422. GO TO REFERENCE Crossref PubMed ISI Google Scholar 26. Mellor A, Harvey RD, Pobereskin LH, Sneyd JR. Cushing’s disease treated by trans-sphenoidal selective adenomectomy in mid-pregnancy. Br J Anaesth. 1998;80(6):850-852. GO TO REFERENCE Crossref PubMed Google Scholar 27. Doshi S, Bhat A, Lim K. Cushing’s syndrome in pregnancy. J Obstetr Gynaecol. 2003;23:568-569. Crossref Google Scholar 28. Wood PJ, Barth JH, Freedman DB, Perry L, Sheridan B. Evidence for the low dose dexamethasone suppression test to screen for Cushing’s syndrome—recommendations for a protocol for biochemistry laboratories. Ann Clin Biochem. 1997;34(pt 3):222-229. GO TO REFERENCE Crossref PubMed Google Scholar 29. Lindsay JR, Jonklaas J, Oldfield EH, Nieman LK. Cushing’s syndrome during pregnancy: personal experience and review of the literature. J Clin Endocrinol Metab. 2005;90(5): 3077-3083. GO TO REFERENCE Crossref PubMed Google Scholar 30. Wallace C, Toth EL, Lewanczuk RZ, Siminoski K. Pregnancy-induced Cushing’s syndrome in multiple pregnancies. J Clin Endocrinol Metab. 1996;81(1):15-21. GO TO REFERENCE PubMed Google Scholar 31. Invitti C, Pecori Giraldi F, de Martin M, Cavagnini F. Diagnosis and management of Cushing’s syndrome: results of an Italian multicentre study. Study Group of the Italian Society of Endocrinology on the Pathophysiology of the Hypothalamic-Pituitary-Adrenal Axis. J Clin Endocrinol Metab. 1999;84(2):440-448. GO TO REFERENCE PubMed Google Scholar 32. Vilar L, Naves LA, Freitas MdC, et al. Endogenous Cushing’s syndrome: clinical and laboratorial features in 73 cases. Arq Bras Endocrinol Metabol. 2007;51(4):566-574. Crossref PubMed Google Scholar 33. Hamblin R, Coulden A, Fountas A, Karavitaki N. The diagnosis and management of Cushing’s syndrome in pregnancy. J Neuroendocrinol. 2022;34(8):e13118. GO TO REFERENCE Crossref PubMed Google Scholar 34. Bressler R, Johnson CT. Cushing’s syndrome and the Guillain-Barré syndrome. Ann Intern Med. 1959;50:1298-1303. GO TO REFERENCE Crossref PubMed Google Scholar 35. Moeindarbary S, Abbasi dalooei M, Ghahremani S, et al. Guillain-Barré syndrome following Cushing’s syndrome in a pregnant woman: a case report. Int J Pediatr. 2019;7:10651-10657. Google Scholar 36. Hasenmajer V, Sbardella E, Sciarra F, Minnetti M, Isidori AM, Venneri MA. The immune system in Cushing’s syndrome. Trends Endocrinol Metab. 2020;31(9):655-669. GO TO REFERENCE Crossref PubMed Google Scholar 37. Besharat S, Alamda NM, Dadashzadeh N, et al. Clinical and demographic characteristics of patients with COVID-19 who died in Modarres Hospital. Open Access Maced J Med Sci. 2020;8:144-149. GO TO REFERENCE Crossref Google Scholar 38. Lotfi B, Farshid S, Dadashzadeh N, Valizadeh R, Rahimi MM. Is Coronavirus Disease 2019 (COVID-19) associated with renal involvement? A review of century infection. Jundishapur J Microbiol. 2020;13:e102899. Crossref Google Scholar 39. Dadashzadeh N, Farshid S, Valizadeh R, Nanbakhsh M, Rahimi MM. Acute respiratory distress syndrome in COVId-19 disease. Immunopathol Persa. 2020;6:e16. Crossref Google Scholar 40. Petramala L, Olmati F, Conforti MG, et al. Autoimmune diseases in patients with Cushing’s syndrome after resolution of hypercortisolism: case reports and literature review. Int J Endocrinol. 2018;2018:1464967. GO TO REFERENCE Crossref PubMed Google Scholar Related content Similar articles: Open Access Ectopic ACTH Production Leading to Diagnosis of Underlying Medullary Thyroid Carcinoma Show details Open Access Muscle Weakness: A Misleading Presentation in Children With Distinctive Syndromic Entities (Clinical Case Reports) Show details Open Access A Pitfall of Falsely Elevated ACTH: A Case Report and Literature Review Show details View more Sage recommends: SAGE Knowledge Entry Hypothalamic-Pituitary-Adrenal Axis Show details SAGE Knowledge Entry Congenital Adrenal Hyperplasia Show details SAGE Knowledge Entry Guillain-Barré Syndrome Show details View more From https://journals.sagepub.com/doi/full/10.1177/23247096231204732

Abstract Cushing’s disease is a rare neuroendocrine disorder with excessive endogenous cortisol, impaired cognition, and psychiatric symptoms. Evidence from resting-state fMRI revealed the abnormalities of static brain connectivity in patients with Cushing’s disease (CD patients). However, it is unknown whether the CD patients’ dynamic functional connectivity would be abnormal and whether the dynamic features are associated with deficits in cognition and psychopathological symptoms. Here, we evaluated 50 patients with Cushing’s disease and 57 healthy participants by using resting-state fMRI and dynamic functional connectivity (dFNC) approach. We focused on the dynamic features of default mode network (DMN), salience network (SN), and central executive network (CEN) because these are binding sites for the cognitive-affective process, as well as vital in understanding the pathophysiology of psychiatric disorders. The dFNC was further clustered into four states by k-mean clustering. CD patients showed more dwell time in State 1 but less time in State 4. Intriguingly, group differences in dwell time in these two states can explain the cognitive deficits of CD patients. Moreover, the inter-network connections between DMN and SN and the engagement time in State 4 negatively correlated with anxiety and depression but positively correlated with cognitive performance. Finally, the classifier trained by the dynamic features of these networks successfully classified CD patients from healthy participants. Together, our study revealed the dynamic features of CD patients’ brains and found their associations with impaired cognition and emotional symptoms, which may open new avenues for understanding the cognitive and affective deficits induced by Cushing’s disease. Introduction Cushing’s disease is characterized by excess endogenous cortisol secretion [1] and served as a unique and natural model for investigating the effects of elevated endogenous cortisol levels on brain functions and structure [2]. It is also a good model for unraveling the linkage between stress-related brain dysfunctions and psychiatric symptoms [3]. Long-term exposure to hypercortisolism negatively affects patients’ physical and mental health, such as depression, anxiety, and psychosis [1, 4], as well as shows deleterious effects on cognitive function including impaired executive function, working memory, and attention [5,6,7]. Research progress on Cushing’s disease, which depends on static resting-state fMRI, revealed that patients with Cushing’s disease showed increased functional connectivity between the default mode network (DMN) and left lateral occipital cortex [2], and hippocampus [8]. Cortisol increase would induce connectivity changes within the DMN and salience network (SN) [9], and the DMN’s activity correlated with the morning cortisol level of patients with Cushing’s disease [10]. Despite these advances leading to an improved understanding of Cushing’s disease, it remains enigmatic how the abnormal brain connectivity within large-scale networks and how the different brain networks interact would contribute to the deficits in impaired cognitive function, as well as psychopathological symptoms. Furthermore, recent years have witnessed an increasing number of studies providing solid evidence that the brain is a dynamic system rather than a static one on a micro-time scale [11, 12]. Dynamic functional connectivity (dFNC), which is implemented by the sliding window method [13], is an ideal approach to characterize the dynamic nature of brain [11], as well as detect and predict diseases [14, 15]. However, to our knowledge, no studies have ever investigated dynamic brain functional connectivity for patients with CD. We focus here on dynamic functional connectivity and emphasize the role of default mode network (DMN), salience network (SN), and central executive network (CEN). These large-scale neurocognitive networks are critical for cognitive and affective processing [16] and are highly related to stress and cortisol level. Deficits or abnormal connectivity within these three networks are associated with a wide range of stress-related psychiatric disorders [17], as well as the high level of cortisol production [18, 19]. For example, the network-connectivity changes between SN and DMN [20, 21], SN and CEN [22] corresponded to increased cortisol levels. Furthermore, our previous studies also identified that CD patients would show dysregulations of resting-state functional connectivity patterns with DMN [10, 23]. Since CD patients also suffer from cognitive impairment and neuropsychological symptoms, including depression and anxiety, which DMN, SN, and CEN mainly modulate, we hypothesized that these three networks are critical to understanding Cushing’s disease and its comorbidity. Here we aimed to investigate two research questions. First, whether there are group differences (CD patients vs. healthy controls) in the dynamic functional connectivity within DMN, SN, and CEN; second, whether the differences can explain the psychiatric symptoms and cognitive impairments in CD patients. We configure our design with a sliding-window approach [11, 13] to portray the features of dynamic functional connectivity (dFNC) within DMN, SN, and CEN among patients with Cushing’s disease (N = 50) and healthy controls (N = 57). We first compared the temporal properties between healthy and CD patients. Then we conducted correlation and mediation analysis to see whether and how the differences in dFNC would contribute to patients’ psychiatric and physiological symptoms and cognitive deficits. We finally implemented a classification machine learning algorithm based on dynamic FNC features within these three networks to see whether these dynamic features would identity CD patients successfully. Materials and methods Ethic approval The experimental protocol was in accordance with principles of the Declaration of Helsinki and approved by a local research ethics Committee of The First Medical Center of Chinese PLA General Hospital (Beijing, China). All participants provided written informed consent after the experimental procedure had been fully explained and were reminded of their right to withdraw at any time during the study. Participants The current study recruited 50 patients with Cushing’s disease (CD patients) and 57 healthy controls (HC) who were matched in age, gender, and education (Table 1). The CD patients were recruited from the Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, between May 2017 and November 2019. The following criteria confirmed Cushing’s disease and its etiology: clinical features (e.g., moon face, supraclavicular fat pad, truncal obesity), elevated 24-h urinary free cortisol (24-h UFC, reference range 98.0–500.1 nmol/24 h), absence of normal cortisol circadian rhythm, elevated ACTH levels (reference range at 0800 h: <10.12 pmol/L), elevated cortisol secretion rates (reference range of cortisol level at 0800 h, 198.7–797.5 nmol/L), absence of normal suppression in midnight (1 mg) dexamethasone suppression test and low dose (2 mg) dexamethasone suppression test (but >50% suppression with a high dose (8 mg) of dexamethasone), and a central to peripheral ACTH ratio >2 for petrosal sinus sampling and pathology after surgery. Healthy controls (HC) were recruited from the local community through poster advertisements and were interviewed by experienced psychiatrists to ensure the absence of current or history of any mental disorder. Demographic information and clinical characteristics of all CD patients and healthy controls were shown in Table 1. Table 1 Demographic and clinical data from healthy controls and CD patients. Full size table Clinical data acquisition, neuropsychological and neuropsychiatric assessment Biometric measurements of the CD patients, including 24-h urinary free cortisol (UFC) levels, plasma Cortisol level (at 0000 h, 0800 h, 1600 h) and adrenocorticotropin (ACTH) level (at 0000 h, 0800 h, 1600 h) from a peripheral vein. Clinical severity of CD patients was obtained using the Cushing Quality of Life Scale (Cushing QOL) [24]. We also included the neuropsychological and neuropsychiatric assessments such as Self-Rating Depression Scale (SDS) [25], Self-Rating Anxiety Scale (SAS) [26], Montreal Cognitive Assessment-Beijing Version (MoCA-BJ) [27], and Chinese version of neuropsychiatric inventory (CNPI) [28]. Image acquisition Functional brain images were acquired using a 3-Tesla GE750 scanner at the First Medical Center of Chinese PLA General Hospital (Beijing, China). Blood oxygen level-dependent (BOLD) gradient echo planar images (EPIs) were obtained using an 8-channel head coil [64 × 64 × 36 matrix with 3.5 × 3.5 × 3.5 mm spatial resolution, repetition time (TR) = 2000 ms, echo time (TE) = 30 ms, flip angle = 90°, field of view (FOV) = 256 × 256 mm2]. A high-resolution T1-weighted structural image (256 × 256 × 144 matrix with a spatial resolution of 1 × 1 × 1 mm, repetition time (TR) = 6700 ms, echo time (TE) = 29 ms, flip angle = 7°) was subsequently acquired. During scanning, all participants were fitted with soft earplugs, and were requested to keep their eyes closed, to stay awake and not to think of anything. Data preprocessing The fMRI data was preprocessed using SPM12 (Wellcome Trust Centre for Neuroimaging, London). The first 10 volume of the functional images were discarded to avoid initial steady-state problems. Then functional images were spatially realigned to the first image for motion correction and corrected for slice acquisition temporal delay. Subsequently, functional images were co-registered to each participant’s segmented gray matter T1 image, then spatially normalized to the Montreal Neurological Institute (MNI) coordinate system, resampled to 3 × 3 × 3 mm voxels. Finally, all functional images were spatially smoothed with an isotropic 4 mm FWHM Gaussian kernel. Group ICA and post-processing Preprocessed data were decomposed into functional components that exhibited a unique time course profile using the group-level spatial independent component analysis, which was implemented in the GIFT toolbox (http://mialab.mrn.org/software/gift/) [29]. First, a subject-specific data reduction principal component analysis (PCA) was performed in which 120 principal components remained. Then at group level, we adopted a high model order ICA to reduce the resting state data into 100 group independent components [30] using the expectation-maximization (EM) algorithm [31] in GIFT. Further, the Infomax ICA algorithm in ICASSO [32] was repeated 20 times [33] to ensure the reliability and stability. Subject-specific spatial maps and time-courses were estimated using the back-reconstruction approach (GICA) [34]. We characterized 50 components as intrinsic connectivity networks (ICNs) by applying the following criteria:[13, 35] whether the peak activation coordinates of the functional components were primarily located in gray matter, and with minimal spatial overlap with white matter structures, vascular, ventricular, edge regions corresponding to artefacts, and susceptibility artifacts. We sorted these 50 meaningful independent components into the interested functional networks including: default mode network (DMN), central executive network (CEN) and salience network (SN) (Fig. 1) according to the spatial correlation values between independent components and the given template [36]. Additional post-processing was conducted to remove remaining noise. Time-courses of the seven components were detrended, despiked and low-pass filtered with a high-frequency cutoff of 0.15 Hz [13]. Moreover, we regressed out the six parameters of head movement. Fig. 1: Composite map of the three networks. And the pipeline of dynamic functional connectivity and clustering analyses. A The three brain networks, default mode network (DMN, including 7 components), central executive network (CEN, including 9 components) and salience network (SN, including 7 components) are derived from group spatial independent components analyses among all participants. B First, for each participant, the dynamic functional connectivity (FNC) matrices are estimated on each sliding window (200 windows) of a set of components within the three networks. Then we applied k-means clustering algorithm on the dynamic FNC matrices across all subjects to assess the reoccurring FNC’s states. Optimal number of states was determined by elbow method. We showed the averaged FNC pattern and the corresponding total number of windows in each state, percentage of each occurrence was presented in parentheses. The color bar represents the z value of FNC. Full size image Dynamic functional connectivity Sliding window approach is the most common way to investigate the nonstationary nature of functional connectivity (FC) of fMRI data. We conducted dynamic FC analysis using the DFC network toolbox in GIFT. In line with previous studies [13, 36], a window of 60 s width (30 TR), sliding in steps of one repetition time was applied to divide the time-courses of each independent components into 200 windows. As covariance estimation using time series of shorter length can be noisy, the regularized inverse covariance matrix (ICOV) was adopted [37]. Following graphic LASSO framework [38], we imposed an additional L1 norm of the precision matrix to enforce sparsity. Clustering analysis Based on previous studies, we applied a k-means clustering algorithm on windowed functional connectivity matrices [39] to assess the frequency and structure of reoccurring functional connectivity patterns (states) across all subjects. We used Manhattan distance function to estimate the similarity between different time windows of FC matrices, which had been demonstrated as an effective measure for high-dimensional data [40]. To obtain the optimal number of states, a cluster validity analysis (silhouette) was conducted on the exemplars of all the subjects. To avoid cost function convergence to the local optimal solution, all clustering analyses were iterated 5 times in GIFT, and the best result was used. Finally, we determined the optimal number of clusters as equal to four (k = 4). According to the clustering results, three temporal properties of dynamic FC states derived from each subject’s state vector were calculated: (i) mean dwell time, measured as the average number of consecutive windows belonging to one state; (ii) fraction of time, measured as the proportions of total windows in one state; (iii) number of transitions, defined as the number of state transitions during the entire scan. Mediation analyses Bootstrapping method was used to estimate the mediation effect. Bootstrapping is a nonparametric approach to effect-size estimation and hypothesis testing that is increasingly recommended for many types of analyses, including mediation [41, 42]. Bootstrapping generates an empirical approximation of the sampling distribution of a statistic by repeated random resampling from the available data and uses this distribution to calculate p-values and construct confidence intervals (5000 resamples were taken for these analyses). Moreover, this procedure supplies superior confidence intervals (CIs) that are bias-corrected and accelerated [43, 44]. Classification analyses using dynamic functional connectivity We conducted classification analyses based on dynamic FNC features [35] to classify each kind of patients. Specifically, we firstly formed a regression matrix, Rgroups × cluster centroids, then regressed out the windowed FNC matrices at each time window using the regression matrix for each participant. These analyses end up with eight β coefficients for each time window for each participant. Next, we computed the mean β coefficients for all time windows. Thus, we got eight mean β coefficients for each participant. These mean β coefficients served as the dynamic FNC features for the classification analysis. The classification analysis using supervised machine learning method, linear support vector machine algorithm (http://www.csie.ntu.edu.tw/~cjlin/libsvm/) with a standard 10-fold cross-validation. We randomly divided the data into 10 subgroups, used the trained classifier from the nine subgroups to predict the performance on the left one subgroup, and repeated the procedure for 100 times. We reported the averaged classification accuracy for each group across these 100 times. Results Neuropsychological and neuropsychiatric difference between healthy controls and CD patients Patients with Cushing’s disease reported higher depression, anxiety, and higher frequency and severity mental illness than healthy controls. Additionally, CD patients also behaved impaired cognitive ability than healthy controls (see Table 1) Functional connectivity within DMN, CEN and SN networks in the four states Spatial map of default mode network, central executive network and salience network identified using the group independent component analysis was shown in Fig. 1A. Independent components were grouped based on their anatomical and presumed functional properties: default mode network (ICs, 9, 12, 27, 28, 32, 44, 74), central executive network (ICs, 15, 21, 26, 48, 50, 63, 85, 89, 97), and salience network (ICs, 20, 43, 57, 59, 76, 82, 92). We adopted a k-means clustering algorithm on the dynamic functional connectivity (dFNC) from all subjects into four connectivity states. Figure 1B shows the cluster centroid and the percentage of occurrences of each state (arranged in the order of emergence). Different temporal properties between HC and CD patients We firstly compared the mean dwell time between healthy controls and CD patients in each state (Fig. 2A–D). Using independent T test, we found that the CD patients had higher mean dwell time than HC in State 1 (CD patients: 89.040 ± 59.216 vs. HC: 57.491 ± 40.671; t(105) = 3.244, p = 0.002), but less mean dwell time than HC in State 4 (CD patients: 31.300 ± 39.413 vs. HC: 66.438 ± 45.734; t(105) = −4.227, p < 0.001). We did not observe significant difference in State 2 (CD patients vs. HC: t(105) = 1.700, p = 0.092), nor in State3 (CD patients vs. HC: t(105) = −1.517, p = 0.132). For the switch time (i.e., the number of transitions), CD patients revealed less transition number than healthy controls did (CD patients: 6.600 ± 3.187 vs. HC: 7.824 ± 3.059; t(105) = −2.205, p = 0.045; Fig. 2E). Multiple comparisons were corrected by false-discovery rate (FDR), p < 0.05. All contrasts remained the same after FDR correction excepted the results of switch time became marginally significant, FDR corrected p = 0.075. Group difference on fraction of time in each state was similar with the mean dwell time (see Supplementary Table S1). Levene’s test is used to check that variances are equal for all samples. Fig. 2: Mean dwell time of dynamic FNC states and number of transitions between CD patients and healthy controls. A In State 1, CD patients engaged higher mean dwell time than healthy control did. B, C In State 2 and State 3, no difference was found between CD patients and healthy controls. D In State 4, CD patients showed significant less mean dwell time than healthy controls. E There was marginally significant difference (after FDR correction) on number of transitions between CD patients and healthy controls. Multiple comparisons were corrected by FDR, p < 0.05 (Error bars represent standard error. p < 0.01**, p < 0.001***, p < 0.08+, N.S not significant). HC Healthy controls, CD patients with Cushing’s disease. Full size image Correlation between dynamic FNC properties and clinical characteristics To examined whether the dynamic FNC properties were associated with clinical characteristics, we did Pearson correlation analyses. Since the group differences were found in State 1 and State 4, we only restricted our analyses on these two states. Notably, we found that the dwell time in State 1 positively correlated with the self-reported anxiety (SAS), and cortisol level at 8:00, 16:00, 00:00, ACTH at 8:00, 16:00, as well as elevated 24-h urinary free cortisol. That is, the longer time spent on State 1 which with more sparsely connected pattern, the worse the mental health and higher cortisol level. We also detected a robust negative correlation between dwell time of State 1 and global cognitive scales (MoCA), which indicated that more time spent in State 1, the worse cognitive ability would be. In the contrary, dwell time in State 4 showed significant negative correlation with the self-reported depression, anxiety, and cortisol level at 8:00, 16:00, 00:00. More dwell time in State 4 predicted better cognitive performance measured by MoCA (all results see Table 2). Multiple comparisons were conducted by FDR, p < 0.05. Table 2 Correlations between dynamic functional connectivity temporal properties in cognitive control network and clinical data. Full size table Dwell time in State 1 and State 4 within cognitive control network mediate group difference in cognitive performance Interestingly, we found the dwell time in State 1 and State 4 significantly mediated the difference between individuals with excessive high cortisol level (CD patients) and healthy controls on cognitive performance. That is, lower cognitive performance in CD patients was linked with more dwell time in State 1 (Fig. 3A), and less dwell time in State 4 (Fig. 3B) within the three networks. Fig. 3: Mediation effect of dwell time in State 1 and State 4 on group difference on cognitive performance. A Dwell time in State 1 and B dwell time in State 4 significant partially mediated the difference between CD patients and healthy controls on cognitive performance measured by MoCA. HC Healthy controls, CD patients with Cushing’s disease. Full size image Distinct network-based functional connectivity between CD patients and healthy controls and its associations with psychiatric symptoms and cognitive performance We have already known that the difference on dwell time in State 1 and State 4 can explain the group difference (i.e., CD patients vs. healthy controls) on cognitive performance. We further characterized the State 1 and State 4 by analyzing functional connectivity between the three networks, as well as the functional connectivity within each network. Results showed that in State 1, the CD patients had weaker connectivity within DMN (t(104)1 = −2.584, p = 0.011), and the connections between CEN and DMN (t(104) = −5.141, p < 0.001), CEN and SN (t(104) = −4.732, p < 0.001) were also weaker than healthy controls. And in State 4, CD patients showed weaker functional connections between DMN and SN (t (84)2 = −4.203, p < 0.001), as well as DMN and CEN (t(84) = −3.547, p = 0.001). Moreover, in State 4, functional connection between DMN and SN was negatively correlated with anxiety level measured by SAS (r(68) = −0.336, p = 0.005), and depression level measured by SDS (r(68) = −0.320, p = 0.008), but positively correlated with cognitive performance measured by MoCA (r(65) = 0.421, p < 0.001). Since CD patients showed decreased connection between DMN and SN, these results may suggest that the connection between DMN and SN was critical for understanding the psychiatric symptoms and cognitive deficits in CD patients. All significant results reported here were survived after FDR (p < 0.05) correction. We did not find significant associations between functional connectivity of neither inter-network and intra-network and psychiatric symptoms and cognitive deficits in State 1. No significant correlation results were found between the inter-network and intra-network connectivity and physiological indices (i.e., cortisol, ACTH, and UFC) in these two states, which may suggest that the dwell time in specific state would be more sensitive to physiological change. Classification results based on dynamic FNC features The support vector machine (SVM) based on dynamic FNC approach (Fig. 4A, details see Method) showed classification accuracy of 84.76% for CD patients, 88.98% for healthy controls (Fig. 4B). The classification scores were evaluated using a receiver operating characteristic (ROC) curve aiming to visualize the performance of the classifier. The classification results may further indicate that the dynamic functional connectivity pattern within these three networks would be the potential biomarker of individuals with excessive higher cortisol level. Fig. 4: The results of classification. A An overview of classification approach. We first extracted the averaged FNC pattern for each state for each group. Then we performed Pearson correlation between the FNC in each window and the FNC pattern in all states among all groups. These procedures ended up with 8 averaged features for each participant. B Receiver Operating Characteristic (ROC) curves for classification. SVM support vector machine, AUC area under the curve. Full size image Discussion In the current study, we adopted independent component analysis (ICA) and dynamic functional connectivity (FNC) approaches to reveal the difference in dynamic FNC within DMN, SN, and CEN networks between CD patients and healthy controls. Using clustering algorithm, we defined four reoccurring FNC states during resting-state scanning. Wherein State 1 and State 4 exhibited significant differences between healthy control and CD patients. Patients generally showed more dwell time in State 1 but less in State 4 than healthy controls. Specifically, in State 1, the CD patients showed weaker connections within DMN, as well as weaker intra-network connectivity between DMN and CEN, SN and CEN than healthy controls. In State 4, connections between DMN and SN, DMN and CEN showed weaker connection in CD patients than in healthy participants. Further correlation and mediation analyses showed that the dwell time in State 1 significantly negatively correlated with cognitive performance. While dwell time in State 4, as well as the connections between DMN and SN in State 4, were found to positively correlate with cognitive performance, and negatively associated with depression and anxiety symptoms. Both states were associated with physiological indices including cortisol, ACTH and 24-hour UFC. Importantly, results from mediation analysis indicated the difference between CD patients and healthy controls on dwell time in State 1 and State 4 can be used to explain their cognitive performance difference. Intriguingly, adopting support vector machine algorithm based on dynamic FNC within DMN, SN and CEN network generally showed ideal classification accuracy for CD patients and healthy controls. These findings begin to delineate the dynamic properties of the three brain networks, which are critical for cognitive and neuropsychiatric, and open new avenues for understanding and explaining the impaired cognitive performance and psychiatric symptoms induced by Cushing’s disease. We found two distinct functional connectivity states across two groups. State 1 can be characterized as having weak connections among the three networks, while State 4 showed relatively strong inter-network and intra-network connections. We observed that in patients with Cushing’s disease, State 1 occurred more often, while State 4 occurred less than in healthy controls. These results help to confirm CD patients’ weaker connections within DMN, SN, and CEN. Previous studies identified that white matter integrity was generally decreased throughout the whole brain rather than just on individual fasciculus [45,46,47]. One possible explanation is that the extensive decline in white matter structural integrity leads to the decreased connectivity of the three networks, which are critical for the cognitive-affective process. We found that in State 1, CD patients showed decreased local synchronization (i.e., within network connectivity) of DMN, and weak inter-network connections between CEN and DMN, CEN and SN. The DMN’s integrity appears crucial for cognitive performance. For example, patients with Alzheimer’s disease showed decreased connectivity within DMN [48]. Since dwell time of State 1 was negatively correlated with MoCA and mediated the group differences on MoCA. We may infer that cognitive deficit may be due to that CD patients engaged more time in State 1 with weak connections of DMN. Interestingly, the more dwell time in State 4, the less anxiety and depression symptoms individuals would have. Moreover, our further analyses found that connections between DMN and SN during State 4 would also negatively affect anxiety and depression. And the CD patients had weaker DMN-SN connections than healthy controls in this state. In line with previous studies, effective connectivity from DMN to SN was lower in major depression disorders compared to healthy controls when processing negative information [49]. And the inter-network connections between the SN and DMN were inversely associated with trait anxiety levels [50]. Therefore, the time engaged in State 4 and the weak inter-network connectivity between SN and DMN may contribute to psychopathological symptoms in CD patients. Dynamic functional connectivity provides time-varying rather than static features over time [11], and it is more effective to capture various aspects of brain connectivity. The dFNC approach has obvious advantages for classification purposes [35]. For example, previous research showed high classification accuracy for psychiatric diseases such as schizophrenia [51], and bipolar [35]. In our study, the SVM based on dynamic functional connectivity features within DMN, SN and CEN showed high classification accuracy for CD patients and healthy controls, which may indicate that the dynamic properties in these three networks would be potential biomarkers for individuals with excessive higher cortisol level. The long-term remitted CD (LTRCD)-patients still suffered from cognitive impairments and emotional symptoms such as anxiety and depression, even though their cortisol levels back to normal after the removal of the adenoma [2, 52, 53]. We revealed that the dynamic features in DMN, SN, and CEN correlate with depression and anxiety symptoms in CD patients and are strongly associated with cognitive performance. Our findings may contribute to developing further neuro-modulation targets to help CD patients improve cognitive ability and mental health. Several limitations of the present study should be mentioned. First, Cushing’s disease is rare, and it is more common in women [1, 3]. We only showed results based on a female sample (healthy controls were all female). Therefore, our conclusion may not be adaptive for the male population. Second, some research suggested that the dynamic functional connectivity analyses should be performed in resting state acquisitions of at least ten minutes [54]. The length of current resting-state scan was eight minutes, although many previous studies studied dynamic FNC based on resting-state data in eight minutes or even less [13, 20, 51], further studies should consider longer scanning to capture more dynamic spontaneous features. Thirdly, our results revealed that cortisol concentrations were significantly associated with dwell time in State 1 and 4 but were not correlated with inter-network or intra-network connections. Human cortisol secretion has apparent circadian rhythmicity [55], but our resting state acquisitions were not collected multiple times. Our conclusions may not be informative to understand the relationships between dynamic functional connections and dynamic cortisol levels. In conclusion, our study delineates the differences in dynamic properties between CD patients and healthy participants. It unravels its associations with cognitive deficits, impaired affective processes, and physiological indices in CD patients. We believe the temporal dynamics of functional connectivity within the three crucial cognitive and affective brain networks could be a promising imaging biomarker to monitor cognitive changes and psychiatric symptoms in Cushing’s disease. Data availability All datasets are available on figshare. https://figshare.com/projects/Dynamic_functional_connectivity_changes_associated_with_psychiatric_traits_and_cognitive_deficits_in_Cushing_s_disease/170343. Code availability All code used for all analyses and plots are publicly available on GitHub at https://github.com/psywalkeryanxy/paper_CD_ICA. References Lacroix A, Feelders RA, Stratakis CA, Nieman LK. Cushing’s syndrome. Lancet. 2015;386:913–27. Article CAS PubMed Google Scholar van der Werff SJA, Pannekoek JN, Andela CD, Meijer OC, van Buchem MA, Rombouts SARB, et al. Resting-state functional connectivity in patients with long-term remission of Cushing’s disease. Neuropsychopharmacology. 2015;40:1888–98. Article PubMed PubMed Central Google Scholar Swearingen B, Biller BMK, editors. Cushing’s disease. vol. 31, US: Springer; 2011. Piasecka M, Papakokkinou E, Valassi E, Santos A, Webb SM, Vries F, et al. Psychiatric and neurocognitive consequences of endogenous hypercortisolism. J Intern Med. 2020;288:168–82. Article CAS PubMed Google Scholar Na S, Fernandes MA, Ioachimescu AG, Penna S. Neuropsychological and emotional functioning in patients with Cushing’s Syndrome. Behav Neurol. 2020;2020:1–10. Article Google Scholar Starkman MN, Giordani B, Berent S, Schork MA, Schteingart DE. Elevated cortisol levels in Cushing’s Disease are associated with cognitive decrements: psychosom. Medicine 2001;63:985–93. CAS Google Scholar Tiemensma J, Biermasz NR, Middelkoop HAM, van der Mast RC, Romijn JA, Pereira AM. Increased prevalence of psychopathology and maladaptive personality traits after long-term cure of Cushing’s disease. J Clin Endocrinol Metab. 2010;95:E129–41. Article CAS PubMed Google Scholar Li C, Zhang Y, Wang W, Zhou T, Yu X, Tao H. Altered hippocampal volume and functional connectivity in patients with Cushing’s disease. Brain Behav. 2022;12:e2507. Article CAS PubMed PubMed Central Google Scholar van Oort J, Tendolkar I, Hermans EJ, Mulders PC, Beckmann CF, Schene AH, et al. How the brain connects in response to acute stress: a review at the human brain systems level. Neurosci Biobehav Rev. 2017;83:281–97. Article PubMed Google Scholar Zhang Y, Zhou T, Feng S, Liu X, Wang F, Sha Z, et al. A voxel-level brain-wide association study of cortisol at 8 a.m.: evidence from Cushing’s disease. Neurobiol Stress. 2021;15:100414. Article CAS PubMed PubMed Central Google Scholar Calhoun VD, Miller R, Pearlson G, Adalı T. The chronnectome: time-varying connectivity networks as the next frontier in fMRI data discovery. Neuron. 2014;84:262–74. Article CAS PubMed PubMed Central Google Scholar Preti MG, Bolton TA, Van De Ville D. The dynamic functional connectome: state-of-the-art and perspectives. NeuroImage. 2017;160:41–54. Article PubMed Google Scholar Allen EA, Damaraju E, Plis SM, Erhardt EB, Eichele T, Calhoun VD. Tracking whole-brain connectivity dynamics in the resting state. Cereb Cortex. 2014;24:663–76. Article PubMed Google Scholar Fiorenzato E, Strafella AP, Kim J, Schifano R, Weis L, Antonini A, et al. Dynamic functional connectivity changes associated with dementia in Parkinson’s disease. Brain. 2019;142:2860–72. Article PubMed PubMed Central Google Scholar Rashid B, Damaraju E, Pearlson GD, Calhoun VD. Dynamic connectivity states estimated from resting fMRI Identify differences among Schizophrenia, bipolar disorder, and healthy control subjects. Front Hum Neurosci. 2014;8:897. Article PubMed PubMed Central Google Scholar Menon V. Large-scale brain networks and psychopathology: a unifying triple network model. Trends Cogn Sci. 2011;15:483–506. Article PubMed Google Scholar Menon V, Uddin LQ. Saliency, switching, attention and control: a network model of insula function. Brain Struct Funct. 2010;214:655–67. Article PubMed PubMed Central Google Scholar Lyons DM, Lopez JM, Yang C, Schatzberg AF. Stress-level cortisol treatment impairs inhibitory control of behavior in monkeys. J Neurosci. 2000;20:7816–21. Article CAS PubMed PubMed Central Google Scholar Rahdar A, Galván A. The cognitive and neurobiological effects of daily stress in adolescents. NeuroImage. 2014;92:267–73. Article PubMed Google Scholar Zhang W, Hashemi MM, Kaldewaij R, Koch SBJ, Beckmann C, Klumpers F, et al. Acute stress alters the ‘default’ brain processing. NeuroImage. 2019;189:870–7. Article PubMed Google Scholar Zhang W, Kaldewaij R, Hashemi MM, Koch SBJ, Smit A, van Ast VA, et al. Acute-stress-induced change in salience network coupling prospectively predicts post-trauma symptom development. Transl Psychiatry. 2022;12:63. Article PubMed PubMed Central Google Scholar Young CB, Raz G, Everaerd D, Beckmann CF, Tendolkar I, Hendler T, et al. Dynamic shifts in large-scale brain network balance as a function of arousal. J Neurosci. 2017;37:281–90. Article CAS PubMed PubMed Central Google Scholar Wang X, Zhou T, Wang P, Zhang L, Feng S, Meng X, et al. Dysregulation of resting-state functional connectivity in patients with Cushing’s disease. Neuroradiology. 2019;61:911–20. Article PubMed Google Scholar Nelson LM, Forsythe A, McLeod L, Pulgar S, Maldonado M, Coles T, et al. Psychometric evaluation of the Cushing’s quality-of-life questionnaire. Patient Centered Outcomes Res. 2013;6:113–24. Article Google Scholar Zung WWK. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63. Article CAS PubMed Google Scholar Zung WWK. A rating instrument for anxiety disorders. Psychosomatics. 1971;12:371–9. Article CAS PubMed Google Scholar Yu J, Li J, Huang X. The Beijing version of the montreal cognitive assessment as a brief screening tool for mild cognitive impairment: a community-based study. BMC Psychiatry. 2012;12:156. Article PubMed PubMed Central Google Scholar Leung VPY, Lam LCW, Chiu HFK, Cummings JL, Chen QL. Validation study of the Chinese version of the neuropsychiatric inventory (CNPI). Int J Geriatr Psychiatry. 2001;16:789–93. Article CAS PubMed Google Scholar Calhoun VD, Adali T, Pearlson GD, Pekar JJ. A method for making group inferences from functional MRI data using independent component analysis. Hum Brain Mapp 2001;14:140–51. Article CAS PubMed PubMed Central Google Scholar Abou-Elseoud A, Starck T, Remes J, Nikkinen J, Tervonen O, Kiviniemi V. The effect of model order selection in group PICA. Hum. Brain Mapp. 2009, https://doi.org/10.1002/hbm.20929. Roweis S. EM algorithms for PCA and SPCA. Advances in neural information processing systems. 1997;10. Bell AJ, Sejnowski TJ. An information-maximization approach to blind separation and blind deconvolution. Neural Comput. 1995;7:1129–59. Article CAS PubMed Google Scholar Himberg J, Hyvärinen A, Esposito F. Validating the independent components of neuroimaging time series via clustering and visualization. NeuroImage. 2004;22:1214–22. Article PubMed Google Scholar Calhoun VD, Adali T, Pearlson GD, Pekar JJ. Spatial and temporal independent component analysis of functional MRI data containing a pair of task-related waveforms. Hum Brain Mapp. 2001;13:43–53. Article CAS PubMed PubMed Central Google Scholar Rashid B, Arbabshirani MR, Damaraju E, Cetin MS, Miller R, Pearlson GD, et al. Classification of schizophrenia and bipolar patients using static and dynamic resting-state fMRI brain connectivity. NeuroImage. 2016;134:645–57. Article PubMed Google Scholar Shirer WR, Ryali S, Rykhlevskaia E, Menon V, Greicius MD. Decoding subject-driven cognitive states with whole-brain connectivity patterns. Cereb Cortex. 2012;22:158–65. Article CAS PubMed Google Scholar Varoquaux G, Sadaghiani S, Pinel P, Kleinschmidt A, Poline JB, Thirion B. A group model for stable multi-subject ICA on fMRI datasets. NeuroImage. 2010;51:288–99. Article CAS PubMed Google Scholar Friedman J, Hastie T, Tibshirani R. Sparse inverse covariance estimation with the graphical lasso. Biostatistics. 2008;9:432–41. Article PubMed Google Scholar Lloyd S. Least squares quantization in PCM. IEEE Trans Inf Theory. 1982;28:129–37. Article Google Scholar Aggarwal CC, Yu PS. Outlier detection for high dimensional data. In Proceedings of the 2001 ACM SIGMOD international conference on Management of data 2001 May 1 (pp. 37–46). MacKinnon DP, Lockwood CM, Williams J. Confidence limits for the indirect effect: distribution of the product and resampling methods. Multivar Behav Res. 2004;39:99–128. Article Google Scholar Shrout PE, Bolger N. Mediation in experimental and nonexperimental studies: new procedures and recommendations. Psychol Methods. 2002;7:422–45. Article PubMed Google Scholar Preacher KJ, Rucker DD, Hayes AF. Addressing moderated mediation hypotheses: theory, methods, and prescriptions. Multivar Behav Res. 2007;42:185–227. Article Google Scholar Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. xvii, 507, New York, NY: Guilford Press; 2017. Bauduin SEEC, van der Wee NJA, van der Werff SJA. Structural brain abnormalities in Cushingʼs syndrome: Curr. Opin. Endocrinol Diabetes Obes 2018;25:285–9. Google Scholar Pires P, Santos A, Vives-Gilabert Y, Webb SM, Sainz-Ruiz A, Resmini E, et al. White matter alterations in the brains of patients with active, remitted, and cured cushing syndrome: a DTI study. Am J Neuroradiol. 2015;36:1043–8. Article CAS PubMed PubMed Central Google Scholar Pires P, Santos A, Vives-Gilabert Y, Webb SM, Sainz-Ruiz A, Resmini E, et al. White matter involvement on DTI-MRI in Cushing’s syndrome relates to mood disturbances and processing speed: a case-control study. Pituitary. 2017;20:340–8. Article PubMed Google Scholar Grieder M, Wang DJJ, Dierks T, Wahlund LO, Jann K. Default mode network complexity and cognitive decline in mild Alzheimer’s disease. Front Neurosci. 2018;12:770. Article PubMed PubMed Central Google Scholar Guha A, Yee CM, Heller W, Miller GA. Alterations in the default mode‐salience network circuit provide a potential mechanism supporting negativity bias in depression. Psychophysiology. 2021;58:e13918. Article PubMed Google Scholar Geng H, Li X, Chen J, Li X, Gu R. Decreased intra- and inter-salience network functional connectivity is related to trait anxiety in adolescents. Front Behav Neurosci. 2016;9:350. Article PubMed PubMed Central Google Scholar Damaraju E, Allen EA, Belger A, Ford JM, McEwen S, Mathalon DH, et al. Dynamic functional connectivity analysis reveals transient states of dysconnectivity in schizophrenia. NeuroImage Clin. 2014;5:298–308. Article CAS PubMed PubMed Central Google Scholar Bauduin SEEC, van der Pal Z, Pereira AM, Meijer OC, Giltay EJ, van der Wee NJA, et al. Cortical thickness abnormalities in long-term remitted Cushing’s disease. Transl Psychiatry. 2020;10:293. Article CAS PubMed PubMed Central Google Scholar van Aken MO, Pereira AM, Biermasz NR, van Thiel SW, Hoftijzer HC, Smit JWA, et al. Quality of life in patients after long-term biochemical cure of Cushing’s disease. J Clin Endocrinol Metab. 2005;90:3279–86. Article PubMed Google Scholar Birn RM, Molloy EK, Patriat R, Parker T, Meier TB, Kirk GR, et al. The effect of scan length on the reliability of resting-state fMRI connectivity estimates. NeuroImage. 2013;83:550–8. Article PubMed Google Scholar Weitzman ED, Fukushima D, Nogeire C, Roffwarg H, Gallagher TF, Hellman L. Twenty-four hour pattern of the episodic secretion of cortisol in normal subjects. J Clin Endocrinol Metab. 1971;33:14–22. Article CAS PubMed Google Scholar Download references Acknowledgements This work was supported by the National Natural Science Foundation of China (No. 82001798 and No. 81871087) and China Brain Project (2021ZD0200407). Author information Authors and Affiliations Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, PR China Zhebin Feng, Tao Zhou, Xinguang Yu & Yanyang Zhang Department of Respiratory Medicine, Anhui Provincial Children’s Hospital, Hefei, Anhui, PR China Haitao Zhang Neurosurgery Institute, Chinese PLA General Hospital, Beijing, PR China Xinguang Yu & Yanyang Zhang Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA Xinyuan Yan Contributions YZ and XGY, TZ conceived the project and designed research, HZ performed research, XY and ZF, YZ analyzed data and interpreted results, ZF and XY wrote the paper. All authors approved the final version of the manuscript for submission. Corresponding authors Correspondence to Yanyang Zhang or Xinyuan Yan. Ethics declarations Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary information Supporting information From https://www.nature.com/articles/s41398-023-02615-y

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Abstract Summary This case report describes a rare presentation of ectopic Cushing’s syndrome (CS) due to ectopic corticotropin-releasing hormone (CRH) production from a medullary thyroid carcinoma (MTC). The patient, a 69-year-old man, presented with symptoms of muscle weakness, facial plethora, and easy bruising. An inferior petrosal sinus sampling test (IPSS) demonstrated pituitary adrenocorticotrophic hormone (ACTH) secretion, but a whole-body somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) revealed enhanced uptake in the right thyroid lobe which, in addition to a grossly elevated serum calcitonin level, was indicative of an MTC. A 18F-DOPA PET/CT scan supported the diagnosis, and histology confirmed the presence of MTC with perinodal growth and regional lymph node metastasis. On immunohistochemical analysis, the tumor cell stained positively for calcitonin and CRH but negatively for ACTH. Distinctly elevated plasma CRH levels were documented. The patient therefore underwent thyroidectomy and bilateral adrenalectomy. This case shows that CS caused by ectopic CRH secretion may masquerade as CS due to a false positive IPSS test. It also highlights the importance of considering rare causes of CS when diagnostic test results are ambiguous. Learning points Medullary thyroid carcinoma may secrete CRH and cause ectopic CS. Ectopic CRH secretion entails a rare pitfall of inferior petrosal sinus sampling yielding a false positive test. Plasma CRH measurements can be useful in selected cases. Keywords: Adult; Male; White; Denmark; Pituitary; Pituitary; Thyroid; Error in diagnosis/pitfalls and caveats; September; 2023 Background The common denominator of Cushing’s syndrome (CS) is autonomous hypersecretion of cortisol (1) and it is subdivided into ACTH-dependent and ACTH-independent causes. The majority of CS cases are ACTH-dependent (80–85%) with a pituitary corticotroph tumor as the most prevalent cause (Cushing’s disease), and less frequently an ectopic ACTH-producing tumor (2). The gold standard method to ascertain the source of ACTH secretion in CS patients is inferior petrosal sinus sampling (IPSS) with measurement of plasma ACTH levels in response to systemic corticotropin-releasing hormone (CRH) stimulation (3). The IPSS has a very high sensitivity and specificity of 88–100% and 67–100%, respectively (4), but pitfalls do exist, including the rare ectopic CRH-producing tumor, which may yield a false positive test result (3). Here, we describe a very rare case masquerading as CS including a positive IPSS test. Case presentation A 69-year-old man presented at a local hospital with a 6-month history of progressive fatigue, muscle weakness and wasting, easy bruising, facial plethora, and fluid retention. His serum potassium level was 2.6 mmol/L (reference range: 3.5–4.2 mmol/L) without a history of diuretics use. His previous medical history included spinal stenosis, benign prostatic hyperplasia, and hypertension. An electromyography showed no sign of polyneuropathy and an echocardiography showed no signs of heart failure with an ejection fraction of 55%. MRI of the spine revealed multiple compression fractures, and the patient underwent spinal fusion and decompression surgery; during this admission he was diagnosed with type 2 diabetes (HbA1c: 55 mmol/mol). After spine surgery, the patient developed a pulmonary embolism and initiated treatment with rivaroxaban. Establishing the diagnosis of ACTH-dependent CS Six months after his spine surgery, the patient was referred to the regional department of endocrinology for osteoporosis management. Blood tests revealed a low serum testosterone level with non-elevated luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels (Table 1). An overnight 1 mg dexamethasone suppression test was positive with a morning cortisol level of 254 nmol/L and three consecutive 24-h urinary cortisol levels were markedly elevated with mean level of ≈600 nmol/24 h (reference range: 12–150 nmol/24 h). A single plasma ACTH was 37 ng/L (Table 1). Table 1 Baseline endocrine assessment. Parameters Patient’s values Reference range ACTH, ng/L 37 7–64 UFC, nmol/day 588 12–150 Urinary cortisol, nmol/L 600 171–536 OD, nmol/L 254 <50 Free testosterone, nmol/L 0.061 0.17–0.59 HbA1c, mmol/mol 55 <48 FSH, IU/L 7.4 1.2–15.8 LH, IU/L 2.2 1.7–8.6 ACTH, adrenocorticotropin; FSH, follicle-stimulating hormone; IU, international units; LH, luteinizing hormone; OD, plasma cortisol levels after a 1 mg overnight dexamethasone suppression test; UFC, urine free cortisol hormone. Differential diagnostic tests The patient was referred to a tertiary center for further examinations. Ketoconazole treatment was started to alleviate the consequences of hypercortisolism. A pituitary MRI revealed an intrasellar microtumor with a maximal diameter of 6 mm and an IPSS was ordered. A whole-body somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) was also performed to evaluate the presence of a potential neuroendocrine tumor. This revealed multiple areas of enhanced uptake including the right thyroid lobe and cervical lymph nodes in the neck (with CT correlates), as well as in the duodenum (with no CT correlate). Concomitantly, a grossly elevated serum calcitonin level of 528 pmol/L (reference range <2.79 pmol/L) was measured. Subsequently, the IPSS revealed pituitary ACTH secretion with a central-to-peripheral ACTH ratio >3 (Table 2). The right petrosal sinus was not successfully catheterized; thus, lateralization could not be determined. To corroborate the diagnosis MTC, a 18F-DOPA PET/CT scan (FDOPA) was performed (5), which showed pathologically enhanced uptake in the right thyroid lobe and regional lymph nodes (Fig. 1). An ultrasound-guided core needle biopsy from the thyroid nodule was inconclusive; however, the patient underwent total thyroidectomy and regional lymph node resection, from which histology confirmed the diagnosis of disseminated MTC. Standard replacement with levothyroxine, calcium, and vitamin D was initiated. A blood sample was collected, and genomic DNA was extracted. The DNA analysis for RET germline mutation was negative. View Full Size Figure 1 18F-DOPA PET/CT scan with pathologically enhanced uptake in the right thyroid lobe (large blue arrow on the left side) and regional lymph nodes (small blue arrows). Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0057 Download Figure Download figure as PowerPoint slide Table 2 Results from the inferior petrosal sinus sampling.* Time (min) Left IPSS Peripheral L/P -5 42 36 1.2 -1 116 33 3.5 2 120 32 3.8 5 209 28 7.5 7 180 43 4.2 10 529 34 15.6 15 431 37 11.6 *Data represents ACTH levels in ng/L. IPSS Inferior petrosal sampling ACTH Adrenocorticotropin hormone CRH Corticotropin-releasing hormone, L/P Ratio of left (L) inferior petrosal sinus to peripheral venous ACTH concentrations. Pathology Total thyroidectomy and bilateral cervical lymph node dissection (level six and seven) were performed. Macroscopic evaluation of the right thyroid lobe revealed a 24 mm, irregular solid yellow tumor. Microscopically the tumor showed an infiltrating architecture with pseudofollicles and confluent solid areas. Calcification was prominent, but no amyloid deposition was seen. The tumor cells were pleomorphic with irregular nuclei and heterogenic chromatin structure. No mitotic activity or necrosis was observed. On immunohistochemical analysis, the tumor cells expressed thyroid transcription factor 1 and stained strongly for carcinoembryonic antigen and calcitonin; tumor cells were focally positive for cytokeratin 19. The tumor was completely negative for ACTH, thyroid peroxidase, and the Hector Battifora mesothelial-1 antigen. Further analysis revealed positive immunostaining for CRH (Fig. 2). The Ki-67 index was very low (0–1%), indicating a low cellular proliferation. Molecular testing for somatic RET mutation was not performed. View Full Size Figure 2 Histopathological findings and immunohistochemical studies of MTC. (A) Microscopic features of medullary thyroid carcinoma. (B) Polygonal tumor cells (hematoxylin and eosin, ×40). (C) Tumor cells stain for calcitonin (×20). (D) Immunohistochemical stain (×400) for CRH showing cells being positive (brown). (E) Pituitary tissue from healthy control staining positive for ACTH in comparison to (F) ACTH-negative cells MTC tissue from the patient (×20). Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0057 Download Figure Download figure as PowerPoint slide No malignancy was found in the left thyroid lobe and there was no evidence of C-cell hyperplasia. Regional lymph node metastasis was found in 13 out of 15 nodes with extranodal extension. Outcome and follow-up Follow-up Serum calcitonin levels declined after neck surgery but remained grossly elevated (118 pmol/L 3 weeks post surgery) and cortisol levels remained high. Ketoconazole treatment was poorly tolerated and not sufficiently effective. Plasma levels of CRH were measured by a competitive-ELISA kit (EKX-KIZI6R-96 Nordic BioSite), according to the instructions provided by the manufacturer. The intra- and interassay %CV (coefficient of variability) were below 8% and 10%, respectively, and the assay sensitivity was 1.4 pg/mL. The plasma CRH was distinctly elevated compared to in-house healthy controls both before and after thyroid surgery (Fig. 3). View Full Size Figure 3 Plasma CRH levels before and after total thyroidectomy compared to three healthy controls. Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0057 Download Figure Download figure as PowerPoint slide The patient subsequently underwent uneventful bilateral laparoscopic adrenalectomy followed by standard replacement therapy with hydrocortisone and fludrocortisone. The symptoms and signs of his CS gradually subsided. Pathology revealed bilateral cortical hyperplasia as expected. The patient continues follow-up at the Department of Oncology and the Department of Endocrinology and Internal Medicine. At 13-month follow-up, 68Ga-DOTATOC shows residual disease with pathologically enhanced uptake in two lymph nodes, whereas the previously described focal DOTATOC uptake in the duodenum was less pronounced (still no CT correlate). Serum calcitonin was 93 pmol/L at the 13-month follow-up. Discussion Diagnostic challenges remain in the distinction between pituitary and ectopic ACTH-dependent CS, and several diagnostic tools are used in combination, none of which is infallible, including IPSS (6). Our case and others illustrate that ectopic CRH secretion may yield a false positive IPSS test result (3). Measurement of circulating CRH levels is relevant if an ectopic CRH producing tumor is suspected, but the assay is not routinely available in clinical practice (Lynnette K Nieman M. Measurement of ACTH, CRH, and other hypothalamic and pituitary peptides https://www.uptodate.com/contents/measurement-of-acth-crh-and-other-hypothalamic-and-pituitary-peptides: UpToDate; 2019). In our case, the presence of elevated plasma CRH levels after thyroidectomy strengthened the indication for bilateral adrenalectomy. The most common neoplasm causing ectopic CS is small-cell lung cancer, whereas MTC accounts for 2–8% of ectopic cases (7). The development of CS in relation to MTC is generally associated with advanced disease and poor prognosis of an otherwise relatively indolent cancer (8), and the clinical progression of CS is usually rapid, why an early recognition and rapid control of hypercortisolemia and MTC is necessary to decrease morbidity and mortality (7, 9). Our case does have residual disease; however, he remains progression-free with stable and relatively low calcitonin levels within 1-year follow-up. Only a very limited number of cases of ectopic tumors with either combined ACTH and CRH secretion or isolated CRH secretion have been reported, with ectopic CRH secretion accounting for less than 1% of CS (9). An ACTH- or CRH-producing tumor can be difficult to localize and may include gastric ACTH/CRH-secreting neuroendocrine tumors (9). In our case, the 68Ga-DOTATOC identified a possible duodenal site, in addition to the MTC, but an upper gastrointestinal endoscopy revealed no pathological findings and there was no CT correlate. Thus, we concluded that the most likely and sole source of ectopic CRH was the MTC and its metastases. To our knowledge, no official guidelines for managing ectopic ACTH-dependent CS have been established. In a recent publication by Alba et al. (10), the authors demonstrated a clinical algorithm (The Mount Sinai Clinical Pathway, MSCP) and recommendation for the management of CS due to ectopic ACTH secretion. Essentially, our approach in this particular case followed these recommendations, including source location by CT and 68Ga-DOTATATE PET/CT imaging, acute management with ketoconazole, and finally, bilateral adrenalectomy as curative MTC surgery was not possible. In retrospect, performance of the IPSS could be questioned in view of the MTC diagnosis. In real time, however, a pituitary MRI performed early in the diagnostic process revealed a microadenoma, which prompted the IPSS. In parallel, a somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) was also done, which raised the suspicion of an MTC. Conclusion We report a very rare case of an ectopic CS caused by a CRH-secreting MTC. Although IPSS has stood the test of time in the differential diagnosis of ACTH-dependent CS, this case illustrates a rare pitfall. Declaration of interest The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Funding This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector. Patient consent Written informed consent for publication of their clinical details was obtained from the patient. Author contribution statement JOJ and MJO are the physicians responsible for the patient. LR performed the thyroidectomy and bilateral adrenalectomy. SHM and SLA assessed and reassessed the histopathology and the immunohistochemical analysis. MB measured plasma CRH. VM, JOJ, and MJO drafted the manuscript. All authors contributed to critical revision of the manuscript. References 1↑ Raff H, & Carroll T. Cushing's syndrome: from physiological principles to diagnosis and clinical care. Journal of Physiology 2015 593 493–506. (https://doi.org/10.1113/jphysiol.2014.282871) PubMed Search Google Scholar Export Citation 2↑ Hatipoglu BA. Cushing's syndrome. Journal of Surgical Oncology 2012 106 565–571. (https://doi.org/10.1002/jso.23197) PubMed Search Google Scholar Export Citation 3↑ Vassiliadi DA, Mourelatos P, Kratimenos T, & Tsagarakis S. Inferior petrosal sinus sampling in Cushing’s syndrome: usefulness and pitfalls. Endocrine 2021 73 530–539. (https://doi.org/10.1007/s12020-021-02764-4) PubMed Search Google Scholar Export Citation 4↑ Zampetti B, Grossrubatscher E, Dalino Ciaramella P, Boccardi E, & Loli P. Bilateral inferior petrosal sinus sampling. Endocrine Connections 2016 5 R12–R25. (https://doi.org/10.1530/EC-16-0029) PubMed Search Google Scholar Export Citation 5↑ Treglia G, Rufini V, Salvatori M, Giordano A, & Giovanella L. PET imaging in recurrent medullary thyroid carcinoma. International Journal of Molecular Imaging 2012 2012 324686. (https://doi.org/10.1155/2012/324686) PubMed Search Google Scholar Export Citation 6↑ Fasshauer M, Lincke T, Witzigmann H, Kluge R, Tannapfel A, Moche M, Buchfelder M, Petersenn S, Kratzsch J, Paschke R, et al.Ectopic Cushing' syndrome caused by a neuroendocrine carcinoma of the mesentery. BMC Cancer 2006 6 108. (https://doi.org/10.1186/1471-2407-6-108) PubMed Search Google Scholar Export Citation 7↑ Chrisoulidou A, Pazaitou-Panayiotou K, Georgiou E, Boudina M, Kontogeorgos G, Iakovou I, Efstratiou I, Patakiouta F, & Vainas I. Ectopic Cushing's syndrome due to CRH secreting liver metastasis in a patient with medullary thyroid carcinoma. Hormones 2008 7 259–262. (https://doi.org/10.1007/BF03401514) PubMed Search Google Scholar Export Citation 8↑ Corsello A, Ramunno V, Locantore P, Pacini G, Rossi ED, Torino F, Pontecorvi A, De Crea C, Paragliola RM, Raffaelli M, et al.Medullary thyroid cancer with ectopic Cushing's syndrome: a case report and systematic review of detailed cases from the literature. Thyroid 2022 32 1281–1298. (https://doi.org/10.1089/thy.2021.0696) PubMed Search Google Scholar Export Citation 9↑ Sharma ST, Nieman LK, & Feelders RA. Cushing's syndrome: epidemiology and developments in disease management. Clinical Epidemiology 2015 7 281–293. (https://doi.org/10.2147/CLEP.S44336) PubMed Search Google Scholar Export Citation 10↑ Alba EL, Japp EA, Fernandez-Ranvier G, Badani K, Wilck E, Ghesani M, Wolf A, Wolin EM, Corbett V, Steinmetz D, et al.The Mount Sinai clinical pathway for the diagnosis and management of hypercortisolism due to ectopic ACTH syndrome. Journal of the Endocrine Society 2022 6 bvac073. (https://doi.org/10.1210/jendso/bvac073) PubMed Search Google Scholar Export Citation From https://edm.bioscientifica.com/view/journals/edm/2023/3/EDM23-0057.xml

Ball-and-stick model of the cortisol (hydrocortisone) molecule. Credit: Public Domain A first-of-its kind hormone replacement therapy that more closely replicates the natural circadian and ultradian rhythms of our hormones has shown to improve symptoms in patients with adrenal conditions. Results from the University of Bristol-led clinical trial are published today in the Journal of Internal Medicine. Low levels of a key hormone called cortisol is typically a result of conditions such as Addison's and congenital adrenal hyperplasia. The hormone regulates a range of vital processes, from cognitive processes such as memory formation, metabolism and immune responses, through to blood pressure and blood sugar levels. When low, it can trigger symptoms of debilitating fatigue, nausea, muscle weakness, dangerously low blood pressure and depression. Although rare, these adrenal conditions require lifelong daily hydrocortisone replacement therapy. Although existing oral hormone replacement treatment can restore cortisol levels, it is still associated with an impaired quality of life for patients. Scientists believe this is because the current treatment does not mimic the body's normal physiological timing, missing cortisol's anticipatory rise and lacking its underlying ultradian and circadian rhythms. The new "pulsatility" therapy, the culmination of ten years' research by the Bristol team, is designed to deliver standard hydrocortisone replacement to patients via a pump which replicates more closely cortisol's natural rhythmic secretion pattern. The pulsatile subcutaneous pump has now revealed promising results in its first clinical trial. Twenty participants aged 18 to 64 years with adrenal insufficiency conditions were assessed during the double-blinded PULSES six-week trial and treated with usual dose hydrocortisone replacement therapy administered either via the pump or the standard three times daily oral treatment. While only psychological and metabolic symptoms were assessed during the trial, results revealed the pump therapy decreased fatigue by approximately 10%, improved mood and increased patient energy levels by 30% first thing in the morning—a key time frame when many patients struggle. Patient MRI scans also revealed alteration in the way that the brain processes emotional information. Dr. Georgina Russell, Honorary Lecturer at the University's Bristol Medical School, and the lead author, explained, "Patients on cortisol replacement therapy often have side effects which makes it difficult for them to lead normal lives. We hope this new therapy will offer greater hope for the thousands of people living with hormone insufficiency conditions." Stafford Lightman, a neuroendocrinology expert and Professor of Medicine at Bristol Medical School: Translational Health Sciences (THS), and the study's joint lead author, added, "Besides reduction in dosage, cortisol replacement has remained unchanged for many decades. It is widely recognized that current replacement therapy is unphysiological due to its lack of pre-awakening surge, ultradian rhythmicity, and post dose supraphysiological peaks. The new therapy clearly shows that the timing of cortisol delivery- in line with the body's own rhythmic pattern of cortisol secretion—is important for normal cognition and behavior. "Our findings support the administration of hormone therapy that mimics natural physiology, and is one of the first major advances in adrenal insufficiency treatment to date." Joe Miles, a participant on the PULSES trial, explained, "The Crono P pump has been life-changing. I noticed a very quick improvement compared to tablets when I was on the PULSES study. I went from feeling tired all the time to having sudden energy. "When the PULSES study ended and I had to return the pump, I simply couldn't cope with going back to how I used to be, so I made it my mission to write to as many doctors to have it prescribed privately. "I've now been on it for six years and have introduced a number of other people with Addison's disease to the pump, and all of them have said it's life changing. Some have gone from being seriously ill to feeling better than they have done for years." Dr. Russell said, "Approximately 1% of the UK population is taking steroids at any moment in time; these individuals can experience debilitating psychological side effects. This trial has shown that even at physiological levels, brain functioning is disrupted and that we need to explore not only the dose but the pattern of steroids delivery when considering any type of steroid treatment." More information: Ultradian hydrocortisone replacement alters neuronal processing, emotional ambiguity, affect and fatigue in adrenal insufficiency: The PULSES trial, Journal of Internal Medicine (2023). DOI: 10.1111/joim.13721 Journal information: Journal of Internal Medicine Provided by University of Bristol From https://medicalxpress.com/news/2023-10-first-of-its-kind-hormone-treatment-patient.html

This is an older post but I think it deserves another look because people are still having trouble getting diagnosed.

I'm not sure I like this! STORY: Could artificial intelligence be used to make brain surgery safer? At this university in London, trainee surgeon Danyal Khan is taking part in a mock operation during which he's assisted by a real-time video feed, as is typical in brain surgery. But what's new here is that the footage is being analyzed by AI to help Khan better understand what he's seeing. The AI system, which is under development at University College London (UCL), highlights sensitive or critical structures in the brain. Neurosurgeon Hani Marcus believes it has the potential to make brain surgery safer and more effective: "So I'm very bullish that in the medium to long term, the A.I. will be helping lots of surgeons do lots of operations better than they otherwise can." Marcus says the AI system analyzed video of more than 200 pituitary gland tumor operations, and gained around 10 years-worth of experience in a fraction of the time. That knowledge means the AI can now not only help navigate to the correct area of the brain, but also know what should be happening at any stage of the procedure, making it a valuable training aid. "So, what we're really trying to do is apply AI or artificial intelligence to support surgeons doing brain tumor surgery at the base of the brain. And what this practically entails is us training the AI with hundreds of videos, telling it, if you like, what structures are what and then at some point over that period, the AI becomes really good itself at recognising things, and able to support other surgeons who're perhaps less experienced in advising them what to do next." Assistant Professor of Robotics and A.I. Sophia Bano explains how that might look in a real operation: "There can be scenarios where clinicians, unintentionally, are very close to a very critical structure such as the optic nerve. This can have, any damage or a slight more pressure on the optic nerve, can have long term complications on the patient side. So, this whole tool will alert the surgeon during the procedure if there is any risk of potential complication so they can recalibrate themselves during the procedure." Khan, who was also involved in developing the software that is now helping him learn, says the A.I. system has been a valuable tool in his training. It could also provide him with step-by-step guidance during a procedure, similar to having a senior surgeon standing over your shoulder. "I think as I progress as a surgeon, there might be stages where I wonder, you know, have I done enough of a particular part of the procedure and should I move on? And actually having that sort of assistant in the background as a reassurance to look at and say, 'well, yeah, actually, at this stage, out of the hundreds of videos of experts that this algorithm has watched, the experts would probably start moving on to the next phase'. It's a useful double check." According to UCL, the system could be ready to be used in operating theaters within two years. From https://news.yahoo.com/ai-could-help-brain-surgery-080156167.html

In a recent study published in Hypertension Research, scientists examine the endocrine causes of hypertension (HTN) and investigate the efficacy of treatments to alleviate HTN. What is HTN? About 30% of the global population is affected by HTN. HTN is a modifiable cardiovascular (CV) risk factor that is associated with a significant number of deaths worldwide. There are two types of HTN known as primary and secondary HTN. As compared to primary HTN, secondary HTN causes greater morbidity and mortality. The most common endocrine causes of HTN include primary aldosteronism (PA), paragangliomas and pheochromocytomas (PGL), Cushing’s syndrome (CS), and acromegaly. Other causes include congenital adrenal hyperplasia, mineralocorticoid excess, cortisol resistance, Liddle syndrome, Gordon syndrome, and thyroid and parathyroid dysfunction. What is PA? PA is the most common endocrine cause of hypertension, which is associated with excessive aldosterone secretion by the adrenal gland and low renin secretion. It is difficult to estimate the true prevalence of PA due to the complexity of its diagnosis. Typically, the plasma aldosterone-to-renin ratio (ARR) is measured to diagnose PA. The diagnosis of PA can also be confirmed using other diagnostic tools like chemiluminescent enzyme immunoassays (CLEIAs) and radio immune assay (RIA). Continuous aldosterone secretion is associated with organ damage due to chronic activation of the mineralocorticoid (MR) receptor in many organs, including fibroblasts and cardiomyocytes. An elevated level of aldosterone causes diastolic dysfunction, endothelial dysfunction, left ventricular hypertrophy, and arterial stiffness. Increased aldosterone secretion also leads to obstructive sleep apnea and increases the risk of osteoporosis. This is why individuals with PA are at a higher risk of cardiovascular events (CVDs), including heart failure, myocardial infarction, coronary artery disease, and atrial fibrillation. PA is treated by focusing on normalizing potassium and optimizing HTN and aldosterone secretion. Unilateral adrenalectomy is a surgical procedure proposed to treat PA. Young patients who are willing to stop medication are recommended surgical treatment. The most common pharmaceutical treatment for PA includes mineralocorticoid receptor antagonists such as spironolactone and eplerenone. Pheochromocytomas and paragangliomas PGL are tumors that develop at the thoracic-abdominal-pelvic sympathetic ganglia, which are present along the spine, as well as in the parasympathetic ganglia located at the base of the skull. The incidence rate of PGL is about 0.6 for every 100,000 individuals each year. PGL tumors synthesize excessive catecholamines (CTN), which induce HTN. Some of the common symptoms linked to HTN associated with PGL are palpitations, sweating, and headache. PGL can be diagnosed by determining metanephrines (MN) levels, which are degraded products of CTN. Bio-imaging tools also play an important role in confirming the diagnosis of PGL. Excessive secretion of CTN increases the risk of CVDs, including Takotsubo adrenergic heart disease, ventricular or supraventricular rhythm disorders, hypertrophic obstructive or ischaemic cardiomyopathy, myocarditis, and hemorrhagic stroke. Excessive CTN secretion also causes left ventricular systolic and diastolic dysfunction. Typically, PGL treatment is associated with surgical procedures. Two weeks before the surgery, patients are treated with alpha-blockers. For these patients, beta-blockers are not used as the first line of treatment without prior use of alpha-adrenergic receptors. Patients with high CTN secretion are treated with metyrosine, as this can inhibit tyrosine hydroxylase. Hydroxylase converts tyrosine into dihydroxyphenylalanine, which is related to CTN synthesis. What is CS? CS, which arises due to persistent exposure to glucocorticoids, is a rare disease with an incidence rate of one in five million individuals each year. The most common symptoms of CS include weight gain, purple stretch marks, muscle weakness, acne, and hirsutism. A high cortisol level causes cardiovascular complications such as HTN, hypercholesterolemia, and diabetes. CS is diagnosed based on the presence of two or more biomarkers that can be identified through pathological tests, such as salivary nocturnal cortisol, 24-hour urinary-free cortisol, and dexamethasone suppression tests. CS is treated through surgical procedures based on the detected lesions. Patients with severe CS are treated with steroidogenic inhibitors, such as metyrapone, ketoconazole, osilodrostat, and mitotane. Pituitary radiotherapy and bilateral adrenalectomy are performed when other treatments are not effective. Acromegaly Acromegaly arises due to chronic exposure to growth hormone (GH), leading to excessive insulin-like growth factor 1 (IGF1) synthesis. This condition has a relatively higher incidence rate of 3.8 million person-years. Clinical symptoms of acromegaly include thickened lips, widened nose, a rectangular face, prominent cheekbones, soft tissue overgrowth, or skeletal deformities. Prolonged exposure to GH leads to increased water and sodium retention, insulin resistance, reduced glucose uptake, and increased systemic vascular resistance. These conditions increase the risk of HTN and diabetes in patients with acromegaly. Acromegalic patients are also at a higher risk of cancer, particularly those affecting the thyroid and colon. Acromegaly is diagnosed using the IGF1 assay, which determines IGF1 levels in serum. After confirming the presence of high IGF1 levels, a GH suppression test must be performed to confirm the diagnosis. Bioimaging is also conducted to locate adenoma. Acromegaly is commonly treated through surgical procedures. Patients who refuse this line of treatment are treated with somatostatin receptor ligands, growth hormone receptor antagonists, dopaminergic agonists, or radiotherapy. Journal reference: De Freminville, J., Amar, L., & Azizi, M. (2023) Endocrine causes of hypertension: Literature review and practical approach. Hypertension Research; 1-14. doi:10.1038/s41440-023-01461-1 From https://www.news-medical.net/news/20231015/Hormones-and-high-blood-pressure-Study-reveals-endocrine-culprits-and-targeted-treatments.aspx

Niall Cavanagh, now aged 48, bravely fought and beat a brain tumour diagnosis when he was a teenager. He shared his experience with The Kerryman in an interview conducted ahead of the seventeenth annual International Brain Tumour Awareness Week. This week-long event, running from October 28th to November 4th, aims to raise awareness about brain tumours and support those affected by them. Niall’s journey was not an easy one. Leading up to his diagnosis in 1992, he experienced symptoms such as excessive thirst, urination, severe headaches, vomiting, and stunted growth. It was when he went for an eye examination for double vision that the examiner noticed something seriously wrong with his retinas. Further tests revealed a germinoma brain tumour pressing on the pituitary gland. To relieve the pressure caused by the tumour, Niall underwent an emergency ventriculoperitoneal shunt procedure. This involved inserting a tube from his brain to his abdomen to drain the excess cerebrospinal fluid. He also underwent extensive radiotherapy to shrink the tumour and prevent its spread. The tumour affected Niall’s pituitary gland, resulting in a condition known as hypopituitarism. This condition causes a deficiency in various hormones, including growth hormone and anti-diuretic hormone. Niall experienced adverse effects on his physical and mental health due to the tumour and subsequent treatments. Despite the challenges, Niall gained a clearer perspective on life. He learned to appreciate what is truly important and developed compassion through his own struggles with depression and anxiety. He emphasized that each person’s experience with a brain tumour is unique, and it’s essential to show support and understanding to others facing similar battles. Niall’s health has gradually improved over the years, although he still faces challenges due to a weakened immune system. However, he remains resilient and has pursued higher education, obtaining two degrees in IT and a Masters in information systems. He currently works part-time in an administrative role with the Renewable Energy Centre in Killarney. Throughout his journey, Niall received invaluable support from his family and various organizations, including the Cork Brain Tumour Support Group (now Brain Tumour Ireland), the Pituitary Foundation, and Headway in Tralee. Niall’s story serves as an inspiration and a reminder of the importance of raising awareness and providing support to those affected by brain tumours. International Brain Tumour Awareness Week aims to continue spreading awareness and fostering understanding of this life-changing condition. Sources: – The Kerryman From https://www.expresshealthcaremgmt.com/news2/kerry-man-reflects-on-beating-brain-tumour-diagnosis-as-a-teenager-you-have-to-sink-or-swim/156637/

Abstract Cushing’s disease (CD) is an extremely rare diagnosis in children. In this report, we present the case of an almost 16-year-old, short and thin boy with CD, the first symptoms of which were spinal pain and vertebral fractures as a result of osteoporosis. In light of his growth retardation and short stature, the boy underwent diagnostics, which excluded growth hormone (GH) deficiency, hypothyroidism and celiac disease. Finally, based on cortisol profile results, dexamethasone suppression tests and bilateral sampling during catheterization of the inferior petrosal sinuses, CD was diagnosed. Keywords: Cushing’s disease; obesity; growth retardation; osteoporosis 1. Introduction Cushing’s disease (CD) is an extremely rare diagnosis in children; however, if it occurs, it is more likely to present in older children [1,2]. It is a type of ACTH-dependent Cushing’s syndrome (CS), in which the pituitary gland is the source of ACTH secretion. The highest incidence of CD occurs in children aged 12.3–14.1 years [3]. The incidence of CD during this developmental age is approximately 5% of that seen in adults (with an annual incidence of 0.89–1 per million pediatric patients) [1,2,4]. The rarest form of ACTH-dependent CS in children is ectopic Cushing’s syndrome (ECS), associated with ectopic production of ACTH or CRH, most commonly by neuroendocrine tumors such as bronchial carcinoids, gastrointestinal tumors, medullary thyroid carcinoma, or pheochromocytomas [2,4,5]. Children with ECS constitute 1% of patients with CS in the developmental age [2]. An even rarer disease is ACTH-independent Cushing’s syndrome—associated with adrenal lesions (adenoma, carcinoma, bilateral macronodular adrenal hyperplasia (BMAH), or primary pigmented nodular adrenocortical disease (PPNAD)) [2]. Regarding CD, ACTH is secreted in an overwhelming majority of cases by pituitary corticotropic microadenomas and—less commonly—by macroadenomas, the latter occurring in only 10% of adult CD cases and even more rarely in children (2%) [1,3]. Long-term hypercortisolemia can also lead to bone-mineralization disorders, including osteoporosis, especially in the bones of the central skeleton [4,6,7]. In children, the most common features of CD are rapid weight gain (93–98%), growth retardation (63–100%) and/or facial changes (63–100%) [4]. Mood disturbances, muscle weakness, osteopenia, and headaches are less frequent symptoms. Limited data are available about bone mineral density (BMD) in children with CD. Lonser et al. [8] observed fractures in 7% of patients with CD that were studied. Chronic glucocorticoid excess associated with CD has negative effects on bone turnover, leading to bone-mineralization disorders in both adults and children. Multiple factors contribute to decreased bone mineral density in CD, including the direct effect of glucocorticoids on osteoclasts and osteoblasts, both impairing bone formation and enhancing bone resorption. Glucocorticoids also act to decrease gastrointestinal calcium absorption and renal calcium reabsorption. Bone loss occurs more frequently in Cushing’s syndrome caused by adrenal tumors in CD [6,7]. An additional factor involved in bone-mineralization disorders, particularly in adult patients with CD, may be hypogonadotropic hypogonadism. Reproductive and sexual dysfunctions are highly prevalent in CS, with higher frequency observed in patients with pituitary-related CS, compared to those with adrenal-related CS. Hypogonadism is identified in as much as 50–75% of men with CS and menstrual irregularities are present in 43–80% of women diagnosed with this condition. During active disease, there is a significant reduction in plasma testosterone and gonadotropin levels in men [7,9]. These testosterone levels typically normalize during remission of the disease. Pivonello et al. [7] suggest that the lack of testosterone normalization three months after CS treatment indicates the need for administration of testosterone to protect the patient’s bone mass. In children, cortisol excess can also suppress gonadotropin, TSH and growth hormone secretion, contributing to the absence of pubertal characteristics or inhibiting its progression in patients who have already entered puberty [1]. So far, to our knowledge, there have been no reports on children where bone-mineralization disorders (without weight gain and hirsutism) are the first sign of CD. 2. Case Presentation We present the case of an almost 16-year-old boy with short stature who, in May 2021, was referred to the Osteoporosis Outpatient Clinic of the Polish Mother’s Memorial Hospital—Research Institute (PMMH-RI) in Lodz, Poland, due to severe back pain. Low bone mass was diagnosed via dual-energy X-ray absorptiometry (DXA). Initially, it seemed that the occurrence of those symptoms might be related to steroid therapy, because in November 2020 (just after SARS-CoV-2 infection) the child had developed severe abdominal pain, accompanied by an increase in the activity of liver enzymes, and after excluding an infectious cause, autoimmune hepatitis was diagnosed. Deflazacort (Calcort) therapy was prescribed in gradually reduced doses, with the initial dose being 24 mg in the morning and 18 mg in the afternoon. This therapy was discontinued on 1 October 2021. As early as on the fifth day of glucocorticosteroid treatment, pain presented in the lumbar spine region, increasing with movement. Initially, the pain was intermittent, then it became constant. No painkillers were needed. On 7 May 2021, on the basis of DXA, low bone mass was diagnosed (Z-score Spine: −4.2, Z-score TBLH: −1.9). In June 2021 (while still undergoing treatment with steroids) the boy was admitted to the Department of Endocrinology and Metabolic Diseases PMMH-RI for further diagnostics (Table 1). Table 1. The medical history and the course of diagnostics and treatment. The patient was a second child, born at 40 weeks of gestational age, weighing 4150 g, measuring 56 cm, and achieving a 10-point Apgar score. During infancy, he received vitamin D supplementation in accordance with Polish recommendations at that time. However, after his first year of life, the supplementation was not taken regularly. The boy received vaccinations according to the standard immunization schedule. There was no significant family medical history. During the physical examination, apart from the presence of short stature, no other notable abnormalities were detected. The skin was clear, without pathological lesions; no features of hyperandrogenism were observed. The boy’s body weight was 47.4 kg (3rd–10th centile); his height, 162 cm (<3rd centile); and height SDS, −2.36; while his BMI was 18.06 kg/m2 (10th–25th centile). Pubarche was assessed as stage 4 according to the Tanner scale; the volume of the testes was 10–12 mL each. After available anthropometric measurements from the patient’s medical history were plotted on the growth chart for sex and chronological age, it became evident that the boy experienced growth retardation from the age of 11 (Figure 1). Figure 1. Growth chart for boys. The red line represents growth retardation from the age of 11. Apart from slightly increased calcium excretion in the 24 h urine collection (Calcium: 9.52 mmol/24 h), there were no significant abnormalities in the laboratory tests assessing calcium–phosphate metabolism (Calcium: 2.41 mmol/L, Phosphorus: 1.3 mmol/L). Serum parathormone (PTH) and vitamin D concentrations remained normal (PTH: 22.9 pg/mL, 25(OH)D: 46.7 ng/mL). Due to the described pain complaints, a thoracolumbar spine X-ray was performed. A decrease in the height of the Th5-Th9 vertebrae and central lowering of the upper border plate of the L4 and L5 were observed (Figure 2). Figure 2. A thoracolumbar spine X-ray with multilevel vertebral fractures. Decrease in the height of the Th5–Th9 vertebrae and central lowering of the upper border plate of the L4 and L5 were found. Magnetic resonance imaging (MRI) of the spine confirmed multilevel vertebral fractures, which, together with the presence of low bone mass on DXA examination, allowed a diagnosis (according to ISCD guidelines) of osteoporosis to be made. Treatment included calcium supplements and cholecalciferol. The parents did not consent to treatment with bisphosphonates (sodium pamidronate), which is an off-label treatment. In light of the patient’s short stature and growth retardation, an endocrinological assessment was conducted. The possibility of growth hormone (GH) deficiency and hypothyroidism as underlying causes for the growth retardation was ruled out. Gonadotropin and androgen levels were adequate for the pubertal stage (FSH—8.3 IU/L, LH—4.7 IU/L, testosterone—4.750 ng/mL, DHEA-S—230.30 µg/dL (normal range: 70.2–492), 17-OH-progesterone—0.78 ng/mL). The bone age was assessed to be 15 years. Alongside continued steroid therapy for autoimmune hepatitis, profiles of cortisol and ACTH secretion were performed. Due to the patient’s elevated cortisol levels during night hours (cortisol 24:00—10.7 µg/dL), an overnight dexamethasone suppression test (DST) and low-dose dexamethasone suppression test (LDDST) were performed. After administering 1 mg dexamethasone (23:00), his morning cortisol level (8:00) still remained elevated (cortisol—3.4 µg/dL). However, after administering 0.5 mg dexamethasone every 6 h for the next 2 days, cortisol levels (8:00) normalized (cortisol—1.0 µg/dL). An MRI of the pituitary gland showed only a poorly demarcated area in the anterior part of the glandular lobe, measuring approximately 2.0 × 3.5 × 5.0 mm on T2W images (Figure 3). A follow-up MRI examination was recommended, which was performed during the child’s next hospitalization in January 2022. The previously described area was still very faint. Figure 3. MRI examination image depicting the poorly demarcated area in the anterior part of the glandular lobe. The arrows point to a structure suspected of being an adenoma. In October 2021, the administration of deflazocort as a treatment was discontinued. During hospitalization in January 2022, the diurnal pattern of ACTH and cortisol secretion was re-evaluated, yet no consistent diurnal rhythm was observed; cortisol levels remained elevated at night. For this reason, overnight DST and then LDDST were carried out again (Figure 4), in which no suppression of cortisol concentrations was obtained. Only after a high-dose DST (HDDST), in which a high 1.5 mg of dexamethasone was administered every 6 h (125 µg/kg/24 h), was cortisol secretion suppressed. Figure 4. Laboratory findings indicating the diagnosis of ACTH-dependent Cushing’s syndrome. Based on the above results, CD was suspected as the cause of osteoporosis and growth retardation. In February 2022, a CRH test was performed upon the patient, which revealed a four-fold increase in ACTH levels and a two-fold increase in serum cortisol levels (Table 2). Table 2. The results of human CRH (hCRH) stimulation test and bilateral inferior petrosal sinus sampling (BIPSS). The CRH stimulation test was administered in the morning using human synthetic CRH (Ferring) at a dose of 1 μg/kg of body weight. During the test, cortisol and ACTH levels were measured in serum at the following time points: −15, 0, 15, 30, 60, and 90 min (see Table 2). As part of the diagnostic process, urinary free cortisol excretion was also measured over two consecutive days. Only on the first day was there a slight elevation in urinary free cortisol concentration, measuring 183.60 μg/24 h (normal range: 4.3–176). The measurement performed on the second day showed a normal urinary free cortisol concentration of 145.60 μg/24 h (normal range: 4.3–176). On 2 March 2022, the patient underwent a bilateral inferior petrosal sinus sampling (BIPSS). Human CRH stimulation was also used during the procedure. The presence of ACTH-dependent hypercortisolemia of pituitary origin was confirmed. The outcome of the CRH stimulation during the BIPSS is presented in Table 2. The boy qualified for transsphenoidal surgery (TSS) of the pituitary adenoma and was successfully operated on (8 March 2022). Postoperative histopathological examination revealed features of a corticotroph-rich pituitary adenoma. 3. Discussion Osteoporosis, like CD, is extremely rare in the developmental age population. Bone-mineralization disorders among children may be primary (e.g., osteogenesis imperfecta), or secondary to other diseases or their treatment (e.g., with glucocorticosteroids). This case report presents a boy with osteoporosis, the cause of which was originally attributed to the treatment of autoimmune hepatitis with glucocorticosteroids. Steroid therapy is the most common cause of bone-mineralization disorders in children. However, osteoporosis is a late complication of steroid treatment. Briot et al. [10] demonstrated that the risk of fractures increases as early as 3 months after initiating steroid therapy. An additional factor increasing the risk of fractures is the dose of glucocorticosteroids used, corresponding to 2.5–5 mg of prednisolone per day [10]. In the case of the present patient, the appearance of spinal pain and thus vertebral fractures could not have been related to the deflazacort treatment started 5 days earlier. The bone-mineralization disorder must therefore have occurred much earlier. For this reason, the authors considered it necessary to search for other endocrine causes of osteoporosis development, including hypogonadism, growth hormone deficiency or Cushing’s syndrome/disease. The serum vitamin D concentration can also influence bone mineral density. Every patient with mineralization disorders, especially with osteoporosis, requires a thorough assessment of calcium–phosphate metabolism [11]. Until the initiation of steroid therapy in March 2021, the patient did not undergo regular vitamin D supplementation. At the start of deflazacort treatment, his serum 25(OH)D concentration was 12.4 ng/mL. Consequently, additional cholecalciferol supplementation at a dose of 3000 IU/day was introduced. In a subsequent measurement conducted in June 2021, the concentration was within the reference range [25(OH)D: 46.7 ng/mL]. Considering the lack of regular supplementation before March 2021, it can be assumed that in October 2020, when the boy experienced SARS-CoV-2 infection, his serum vitamin D concentration was likely decreased as well, which could have had a further negative impact on the patient’s bone mineralization. Scientific reports indicate that adequate vitamin D levels reduce the risk of viral infections, including SARS-CoV-2 [12]. Di Filippo et al. [13] demonstrated that vitamin D deficiency observed in 68.2% of SARS-CoV-2-infected individuals correlated with a more severe course of the infection. In our patient, the course of COVID-19 was asymptomatic, and the diagnosis was established based on positive IgM antibody titers against SARS-CoV-2. The vitamin deficiency was most likely associated with irregular supplementation and lack of exposure to UV radiation (due to lockdown measures in Poland at that time). A reduced serum 25(OH)D concentration could have contributed to worsened bone mineral density and increased susceptibility to SARS-CoV-2 infection; however, it is the chronic hypercortisolism characteristic of CD that most likely led to the development of osteoporosis with accompanying fractures. Another factor necessitating further diagnostic investigation into CD was the patient’s growth retardation observed since the age of 11. Both the pubertal state of the boy, and his gonadotropin and testosterone serum levels, allowed us to exclude hypogonadism. Maximum spontaneous nocturnal secretion of the growth hormone was 31.84 ng/mL. The diagnosis of CD was established on the basis of elevated cortisol levels at night and the lack of cortisol suppression in the test after administering dexamethasone. Final confirmation of the diagnosis was obtained in a post-CRH stimulation test. In pediatric cases, the absence of typical diurnal variation in serum corticosolemia, especially the nocturnal decline, and the inability to suppress cortisol secretion at midnight, are highly sensitive indicators of hypercortisolemia [6,8]. Consequently, in our patient, osteoporosis was a complication of diagnosed CD. The patient in question was not obese, which is the predominant symptom of CD. This symptom, according to Ferrigno et al. [1], is present in 92–98% of examined children diagnosed with CD. Storr et al. [14] showed that facial changes and facial swelling were observed in 100% of subjects with CD, whereas Lonser et al. [8] observed this in only 63% of children with CD. In our patient, no changes in facial appearance were observed. Other symptoms typical of CS, such as hirsutism, acne, or bruises, were not noticed either. These symptoms were observed in all children with CD studied by Wędrychowicz et al. [3]. Non-specific symptoms of this condition may include mood changes, depression and emotional vacillation [1,8]. However, our patient’s parents did not observe any changes in the boy’s behavior. The indication for initiating the whole diagnostic process was (in addition to osteoporosis) growth retardation. Ferrigno et al. [1] point out that chronic hypercortisolemia most often leads to growth disorders accompanied by excessive weight gain. This is an early, highly sensitive and characteristic sign of CD. Short stature is not always observed and occurs in one in two children diagnosed with CD. The patient we present was short (height—162 cm (<3rd centile hSDS: −2.36)); growth retardation was observed from the age of 11 years. The occurrence of vertebral fractures and the accompanying pain as the initial symptoms of hypercortisolism, the absence of obesity, and the confirmation of CD, an exceedingly rare condition in the pediatric population, collectively underscore the uniqueness of our patient’s disease presentation. A case involving a child with such an atypical course of ACTH-dependent CS has not been described before. Han et al. [15] reported a case of a 28-year-old lean woman (BMI: 19 kg/m²) with ACTH-independent CS due to a left adrenal adenoma, where, similarly to our patient, the initial manifestation of hypercortisolism was compression fractures of the thoracic vertebrae. The authors emphasize that vertebral fractures may affect 30–50% of patients with Cushing’s syndrome, with a higher frequency observed in patients with ACTH-independent CS compared to those in whom hypercortisolism results from the presence of pituitary adenoma [15]. The lack of obesity in a patient with hypercortisolism could be attributed to malnutrition, which accompanies the growth process in ECS. Hence, a crucial aspect was the differential diagnosis between CD and ECS. To this end, we performed a stimulation test using hCRH. We considered cut-off points for diagnosing CD to be a 35% increase in ACTH concentration at 15 and/or 30 min, and at least a 20% increase in cortisol concentration at 30 and 45 min [16,17]. In the case of ECS, a significant rise in CRH and cortisol concentrations is not observed. Recently published reports emphasize the need to explore new cut-off points to enhance the sensitivity and specificity of this test. Detomas et al. [5] indicate that an increase in ACTH ≥ 31% and cortisol ≥ 12% in the 30th minute of CRH tests allows for a highly sensitive and specific differentiation between CD and ECS. The authors highlight that measuring these hormones at the 60 min stage of the test does not provide diagnostic benefits. Notably, the study employed ovine CRH, which exhibits stronger and more prolonged stimulatory effects compared to the hCRH available in Europe that was used to diagnose our patient [5]. Conversely, Elenius et al. [16] suggest that optimal values for distinguishing between CD and ECS in the CRH stimulation test involve an increase in ACTH and/or cortisol levels of more than 40% during the test. In our patient, an over four-fold increase in ACTH levels and a more than two-fold increase in cortisol levels were observed at the 30 min mark of the test, thus independently and definitively excluding ECS regardless of the adopted cut-off points. Our patient’s case also demonstrates that MRI is not a perfect method of visualizing an ACTH-secreting pituitary adenoma. In the first MRI examination performed upon our patient, a poorly demarcated area (2.0 × 3.5 × 5.0 mm) was described in the anterior part of the glandular lobe; in the examination performed 6 months later, this area maintained poor visibility, while laboratory results at the time clearly indicated an ACTH-dependent form of CS. It was only the bilateral inferior petrosal sinus sampling (BIPSS) that allowed a clear diagnosis. Data from the literature indicate that microadenomas smaller than 3–4 mm are visible on MRI in only half of cases. In two large studies including children, pituitary adenomas were found on MRI in 63% and 55% of cases [18]. Among the patients with CD studied by Wędrychowicz et al. [3], pituitary adenomas were described on MRI in all of them, but in two patients (50%) this was only achieved upon follow-up. In the standard procedure, in the absence of a pituitary lesion in the MRI examination, it is recommended that a BIPSS be performed. In the case of our patient, this examination was necessary to make a definitive diagnosis. When analyzing the results of the BIPSS with hCRH stimulation, we employed the classical cut-offs for the ACTH IPS:P (Inferior Petrosal Sinus: Peripheral) ratio (i.e., ≥2 at baseline and ≥3 after hCRH stimulation) [1]. This allowed the confirmation of CD and determination of the pituitary adenoma’s localization, followed by the procedure for its surgical removal. The optimal cut-off values for the IPS:P ratio remain controversial. There are ongoing efforts to establish new, more precise cut-off points. Detomas et al. [19] demonstrated that an IPS:P ratio ≥ 2.1 during desmopressin stimulation in the BIPSS most accurately differentiates CD from ECS. Conversely, Chen et al. [20] showed that the optimal pre-desmopressin stimulation IPS:P ratio cut-off is 1.4, and post-stimulation it is 2.8. Both studies suggest the utilization of lower cut-off values for the IPS:P ratio than those traditionally adopted. Chen et al. [20] also advocate for avoiding stimulation during BIPSS. In most cases, the IPS:P ratio before stimulation is sufficient for diagnosing CD. According to the authors, desmopressin stimulation should be reserved for patients with ambiguous MRI findings or with a pituitary adenoma with diameter less than 6 mm. However, considering that the concentration of ACTH in the right inferior petrosal sinus in our patient was over 4 times higher than in the peripheral vessel and nearly 14 times higher after hCRH stimulation, regardless of the applied criteria, CD could be unequivocally diagnosed in our patient, and the lateralization of the microadenoma could be determined with certainty. The rarity of CD, and the diagnostic difficulties stemming from its oligosymptomatic or atypical course, encourage description in the form of case reports. Eviz et al. [21] delineate the occurrence of cerebral cortical atrophy in two children with ECS. Additionally, other researchers have underscored the potential for thyroid disorders to manifest alongside hypercorticosolemia [22]. Although obesity typically stands out as a primary symptom of CD, Pomahacova et al. [23] reported a case involving two children with CD who maintained normal body weight, mirroring our patient’s situation. The symptoms that prompted diagnostic investigation in these instances included weakness, sleep disturbances and growth retardation. Interestingly, growth retardation, along with facial changes, was observed in all examined children with CD [23]. Nonetheless, to the best of our knowledge, we have yet to encounter a case report resembling ours. Therefore, it remains crucial to share our experiences. 4. Conclusions Cushing’s disease is an extremely rare diagnosis in children. In Poland, there is no statistical record of occurrences of this disease among children. Wędrychowicz et al. reported that in their single Polish center, between 2012 and 2018, they identified four cases of children aged 7–15 who were diagnosed with CD [3]. The case we present shows that obesity, commonly considered as a predominant symptom of CD, is not necessarily observed in patients with this diagnosis in the developmental age population. Among children, it is growth disturbance that may be the first manifestation. On the other hand, a late complication of CD may be osteoporosis, so whenever a child is diagnosed with a bone-mineralization disorder, the cause of its development should be sought. Diagnosis should be pursued until all potential causes of the described symptoms, including the rarest ones, are definitively ruled out—even if the clinical presentation, as in the case of our patient, initially does not point towards the final diagnosis. Thus far, no case of a child with CD exhibiting such subtle symptomatology has been described in the literature. The challenges in diagnosis we encountered primarily resulted from the atypical clinical outcome of CD in our patient—normal body weight, absence of hyperandrogenism, mood disturbances not apparent to caregivers and the patient’s immediate environment, as well as normal progression of puberty, did not immediately lead to the consideration of endocrinological causes of osteoporosis. The steroid therapy employed due to autoimmune hepatitis also complicated the diagnostic process. Only after discontinuing deflazacort treatment was it possible to definitively diagnose CD. Our patient required hydrocortisone replacement in gradually decreasing doses for a year following TSS. Considering that pituitary adenomas in children can be genetically predisposed (e.g., MEN 1 mutation, AIP mutation, USP8 mutation, and other rarer ones), genetic consultation was sought [1]. However, the conducted tests have thus far excluded the most common mutations in our patient. Due to the diagnosed osteoporosis, chronic supplementation with calcium and cholecalciferol was recommended, along with annual follow-up DXA scans. Studies indicate that patients in remission from CD experience a gradual improvement in bone mineral density [3]. While we can currently observe remission in our patient’s case, the advanced bone age of the child (indicating the completion of the growth process) left limited potential for significant improvement in final growth. The patient still requires regular endocrinological and neurosurgical follow-ups, hormonal assessments, and pituitary MRI examinations. Author Contributions Conceptualization—R.S. and A.Ł.; software—S.A.; formal analysis—R.S.; investigation—A.Ł. and G.Z.; data curation—A.Ł.; writing—original draft preparation—A.Ł., R.S. and S.A.; writing—review and editing—A.L.; visualization—S.A.; supervision—A.L. All authors have read and agreed to the published version of the manuscript. Funding This study was funded by statutory funds from the Medical University of Lodz, Lodz, Poland (503/1-107-03/503-11-001). Institutional Review Board Statement Not applicable. Informed Consent Statement Written informed consent has been obtained from the patient to publish this paper. Data Availability Statement Not applicable. Conflicts of Interest The authors declare no conflict of interest. References Ferrigno, R.; Hasenmajer, V.; Caiulo, S.; Minnetti, M.; Mazzotta, P.; Storr, H.L.; Isidori, A.M.; Grossman, A.B.; De Martino, M.C.; Savage, M.O. Paediatric Cushing’s disease: Epidemiology, pathogenesis, clinical management and outcome. Rev. Endocr. Metab. Disord. 2021, 22, 817–835. [Google Scholar] [CrossRef] Stratakis, A. Cushing syndrome in pediatrics. Endocrinol. Metab. Clin. N. Am. 2012, 41, 793–803. [Google Scholar] [CrossRef] Wędrychowicz, A.; Hull, B.; Tyrawa, K.; Kalicka-Kasperczyk, A.; Zieliński, G.; Starzyk, J. Cushing disease in children and adolescents—Assessment of the clinical course, diagnostic process, and effects of the treatment—Experience from a single paediatric centre. Pediatr. Endocrinol. Diabet. Metab. 2019, 25, 127–143. [Google Scholar] [CrossRef] Concepción-Zavaleta, M.J.; Armas, C.D.; Quiroz-Aldave, J.E.; García-Villasante, E.J.; Gariza-Solano, A.C.; Del Carmen Durand-Vásquez, M.; Concepción-Urteaga, L.A.; Zavaleta-Gutiérre, F.E. Cushing disease in pediatrics: An update. Ann. Pediatr. Endocrinol. Metab. 2023, 28, 87–97. [Google Scholar] [CrossRef] Detomas, M.; Ritzel, K.; Nasi-Kordhishti, I.; Wolfsberger, S.; Quinkler, M.; Losa, M.; Tröger, V.; Kroiss, M.; Fassnacht, M.; Vila, G.; et al. Outcome of CRH stimulation test and overnight 8 mg dexamethasone suppression test in 469 patients with ACTH-dependent Cushing’s syndrome. Front. Endocrinol. 2022, 13, 955945. [Google Scholar] [CrossRef] [PubMed] Lodish, M.B.; Hsiao, H.P.; Serbis, A.; Sinaii, N.; Rothenbuhler, A.; Keil, M.F.; Boikos, S.A.; Reynolds, J.C.; Stratakis, C.A. Effects of Cushing disease on bone mineral density in a pediatric population. J. Pediatr. 2010, 56, 1001–1005. [Google Scholar] [CrossRef] [PubMed] Pivonello, R.; Isidori, A.M.; De Martino, M.C.; Newell-Price, J.; Biller, B.M.; Colao, A. Complications of Cushing’s syndrome: State of the art. Lancet Diabetes Endocrinol. 2016, 4 (Suppl. S7), 611–629. [Google Scholar] [CrossRef] [PubMed] Lonser, R.R.; Wind, J.J.; Nieman, L.K.; Weil, R.J.; DeVroom, H.L.; Oldfield, E.H. Outcome of surgical treatment of 200 children with Cushing’s disease. J. Clin. Endocrinol. Metab. 2013, 98, 892–901. [Google Scholar] [CrossRef] Detomas, M.; Deutschbein, T.; Tamburello, M.; Chifu, I.; Kimpel, O.; Sbiera, S.; Kroiss, M.; Fassnacht, M.; Altieri, B. Erythropoiesis in Cushing syndrome: Sex-related and subtype-specific differences. Results from a monocentric study. J. Endocrinol. Investig. 2023; epub ahead of print. [Google Scholar] [CrossRef] Briot, K.; Roux, C. Glucocorticoid-induced osteoporosis. RMD Open 2015, 1, 14. [Google Scholar] [CrossRef] Laird, E.; Ward, M.; McSorley, E.; Strain, J.J.; Wallace, J. Vitamin D and bone health; potential mechanisms. Nutrients 2010, 2, 693–724. [Google Scholar] [CrossRef] di Filippo, L.; Frara, S.; Nannipieri, F.; Cotellessa, A.; Locatelli, M.; Querini, P.R.; Giustina, A. Low vitamin D levels are associated with long COVID syndrome in COVID-19 survivors. J. Clin. Endocrinol. Metab. 2023, 1–11. [Google Scholar] [CrossRef] [PubMed] di Filippo, L.; Allora, A.; Doga, M.; Formenti, A.M.; Locatelli, M.; Rovere Querini, P.; Frara, S.; Giustina, A. Vitamin D levels are associated with blood glucose and BMI in COVID-19 patients, predicting disease severity. J. Clin. Endocrinol. Metab. 2022, 107, 348–360. [Google Scholar] [CrossRef] Storr, H.L.; Chan, L.F.; Grossman, A.B.; Savage, M.O. Pediatric Cushing’s syndrome: Epidemiology, investigation and therapeutic advances. Trends Endocrinol. Metab. 2007, 18, 167–174. [Google Scholar] [CrossRef] [PubMed] Han, J.Y.; Lee, J.; Kim, G.E.; Yeo, J.Y.; Kim, S.H.; Nam, M.; Kim, Y.S.; Hong, S. Case of Cushing syndrome diagnosed by recurrent pathologic fractures in a young woman. J. Bone Metab. 2012, 19 (Suppl. S2), 153–158. [Google Scholar] [CrossRef] [PubMed] Elenius, H.; McGlotten, R.; Nieman, L.K. Ovine CRH stimulation and 8 mg dexamethasone suppression tests in 323 patients with ACTH-dependent Cushing’s syndrome. J. Clin. Endocrinol. Metab, 2023; Epub ahead of print. [Google Scholar] [CrossRef] Nieman, L.K.; Biller, B.M.K.; Findling, J.W.; Newell-Price, J.; Savage, M.O.; Stewart, P.M.; Montori, V.M. The diagnosis of Cushing’s syndrome: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 2008, 93 (Suppl. S5), 1526–1540. [Google Scholar] [CrossRef] [PubMed] Savage, M.O.; Storr, H.L. Pediatric Cushing’s disease: Management issues. Indian J. Endocrinol. Metab. 2012, 16 (Suppl. S2), 171–175. [Google Scholar] [CrossRef] Detomas, M.; Ritzel, K.; Nasi-Kordhishti, I.; Schernthaner-Reiter, M.H.; Losa, M.; Tröger, V.; Altieri, B.; Kroiss, M.; Kickuth, R.; Fassnacht, M.; et al. Bilateral inferior petrosal sinus sampling with human CRH stimulation in ACTH-dependent Cushing’s syndrome: Results from a retrospective multicenter study. Eur. J. Endocrinol. 2023, 188 (Suppl. S5), 448–456. [Google Scholar] [CrossRef] Chen, S.; Chen, K.; Wang, S.; Zhu, H.; Lu, L.; Zhang, X.; Tong, A.; Pan, H.; Wang, R.; Lu, Z. The optimal cut-off of BIPSS in differential diagnosis of ACTH-dependent Cushing’s syndrome: Is stimulation necessary? J. Clin. Endocrinol. Metab. 2020, 105 (Suppl. S4), 1673–1685. [Google Scholar] [CrossRef] Eviz, E.; Yesiltepe, M.G.; Arduc, A.A.; Erbey, F.; Guran, T.; Hatun, S. An overlooked manifestation of hypercortisolism—Cerebral cortical atrophy and challenges in identifying the etiology of hypercortisolism: A report of 2 pediatric cases. Horm. Res. Paediatr. 2023, 27. [Google Scholar] [CrossRef] Paragliola, R.M.; Corsello, A.; Papi, G.; Pontecorvi, A.; Corsello, S.M. Cushing’s syndrome effects on the thyroid. Int. J. Mol. Sci. 2021, 22, 3131. [Google Scholar] [CrossRef] Pomahacova, R.; Paterova, P.; Nykodymova, E.; Sykora, J.; Krsek, M. Pediatric Cushing’s disease: Case reports and retrospective review. Biomed. Pap. Med. Fac. Univ. Palacky. Olomouc. Czech Repub. 2022, 166. [Google Scholar] [CrossRef] [PubMed] Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Share and Cite MDPI and ACS Style Łupińska, A.; Aszkiełowicz, S.; Zieliński, G.; Stawerska, R.; Lewiński, A. Osteoporosis as the First Sign of Cushing’s Disease in a Thin 16-Year-Old Boy—A Case Report. J. Clin. Med. 2023, 12, 5967. https://doi.org/10.3390/jcm12185967 AMA Style Łupińska A, Aszkiełowicz S, Zieliński G, Stawerska R, Lewiński A. Osteoporosis as the First Sign of Cushing’s Disease in a Thin 16-Year-Old Boy—A Case Report. Journal of Clinical Medicine. 2023; 12(18):5967. https://doi.org/10.3390/jcm12185967 Chicago/Turabian Style Łupińska, Anna, Sara Aszkiełowicz, Grzegorz Zieliński, Renata Stawerska, and Andrzej Lewiński. 2023. "Osteoporosis as the First Sign of Cushing’s Disease in a Thin 16-Year-Old Boy—A Case Report" Journal of Clinical Medicine 12, no. 18: 5967. https://doi.org/10.3390/jcm12185967 Find Other Styles Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here. Article Metrics Citations No citations were found for this article, but you may check on Google Scholar Article Access Statistics Article access statisticsArticle Views14. Sep15. Sep16. Sep17. Sep18. Sep19. Sep20. Sep21. Sep22. Sep23. Sep24. Sep25. Sep26. Sep27. Sep28. Sep29. Sep30. Sep1. Oct2. Oct3. Oct4. Oct5. Oct6. Oct7. Oct8. Oct9. Oct10. Oct11. Oct12. Oct13. Oct14. Oct0100200300400 For more information on the journal statistics, click here. 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Abstract Background and Objectives Crooke cell adenomas (CCA) are a rare, aggressive subset of adrenocorticotrophin secreting pituitary corticotroph adenomas (sCTA) found in 5–10% of patients with Cushing’s disease. Multiple studies support worse outcomes in CCA but are limited by small sample size and single-institution databases. We compared outcomes in CCA and sCTA using a multicenter, international retrospective database of high-volume skull base centers. Methods Patients surgically treated for pituitary adenoma from January 2017 through December 2020 were included. Results 2826 patients from 12 international centers were compared (n=20 CCA and n=480 sCTA). No difference in baseline demographics, tumor characteristics or postoperative complications was seen. Microsurgical approaches (60% CCA vs. 62.3% sCTA) were most common. Gross total resection (GTR) was higher in CCA patients (100% vs. 83%, p=0.05). Among patients that had GTR according to intraoperative findings, fewer CCA patients had postoperative hormone normalization of pituitary function (50% vs. 77.8%, p<0.01) and remission of hypersecretion by 3-6 months (75% vs. 84.3%, p<0.01). This was present despite CCA having better local control rates (100% vs. 96%, p<0.01) and fewer patients with remnant on MRI (0% vs. 7.2%, p<0.01). A systematic literature review of 35 studies reporting on various treatment strategies reiterated the high rate of residual tumor, persistent hypercortisolism, and tumor-related mortality in CCA patients. Conclusion This modern, multicenter series of patients with CCA reflects their poor prognosis and reduced post-surgical hormonal normalization. Further work is necessary to better understand the pathophysiology of CCA to devise more targeted treatment approaches. References (0) Cited by (0) Previous presentations: none Previous publications: none Disclosures No relevant disclosures to report CREDIT statement Matthew Finlay: conceptualization, writing – review and editing Richard Drexler: conceptualization, writing – review and editing All: data curation, writing – review and editing Michael Karsy: conceptualization, data curation, methodology, writing – original draft, writing – review and editing, supervision Funding and Disclosures: none View full text From https://www.sciencedirect.com/science/article/abs/pii/S187887502301344X

Context: Intensity-modulated radiotherapy (IMRT) is a modern precision radiotherapy technique for the treatment of the pituitary adenoma. Objective: Aim to investigate the efficacy and toxicity of IMRT in treating Cushing’s Disease (CD). Methods: 70 of 115 patients with CD treated with IMRT at our institute from April 2012 to August 2021 were included in the study. The radiation doses were usually 45-50 Gy in 25 fractions. After IMRT, endocrine evaluations were performed every 6 months and magnetic resonance imaging (MRI) annually. Endocrine remission was defined as suppression of 1 mg dexamethasone test (DST) or normal 24-hour urinary free cortisol level (24hUFC). The outcome of endocrine remission, endocrine recurrence, tumor control and complications were retrieved from medical record. Results: At a median follow-up time of 36.8 months, the endocrine remission rate at 1, 2, 3 and 5 years were 28.5%, 50.2%, 62.5% and 74.0%, respectively. The median time to remission was 24 months (95%CI: 14.0-34.0). Endocrine recurrence was found in 5 patients (13.5%) till the last follow-up. The recurrence-free rate at 1, 2, 3 and 5 years after endocrine remission was 98.2%, 93.9%, 88.7% and 88.7%, respectively. The tumor control rate was 98%. The overall incidence of new onset hypopituitarism was 22.9%, with hypothyroidism serving as the most common individual axis deficiency. Univariate analysis indicated that only higher Ki-67 index (P=0.044) was significant favorable factors for endocrine remission. Conclusion: IMRT was a highly effective second-line therapy with low side effect profile for CD patients. Endocrine remission, tumor control and recurrence rates were comparable to previous reports on FRT and SRS. Introduction Cushing’s disease (CD) is characterized by hypersecretion of adrenocorticotropic hormone (ACTH) from pituitary adenoma. As the state of hypercortisolemia considerably increases morbidity and mortality, normalizing cortisol levels is regarded as the major treatment goal in patients with CD (1). Transsphenoidal selective adenomectomy (TSS) is now established as the first-line treatment of CD. Despite the satisfactory remission rate that can be achieved with TSS (ranging from 59-97%), delayed recurrences have also been reported in up to 50% of patients (2). The Endocrine Society guidelines suggest a shared decision-making approach in patients who underwent a noncurative surgery or for whom surgery was not possible (3). Second-line therapeutic options include repeat transsphenoidal surgery, medical therapy, radiotherapy and bilateral adrenalectomy. Radiotherapy (RT) is generally used in patients who have failed TSS or have recurrent CD, as well as in progressively growing or invasive corticotroph tumors (3, 4). Both stereotactic radiosurgery(SRS)and fractionated radiotherapy (FRT) have been used in the treatment of CD. Conventional radiotherapy as one of the technique for FRT has been used with a long experience, but its benefits were hindered by high risk of toxicity, mainly attributed to the harm to healthy surrounding structures (4). Previous studies on conventional RT in treating CD showed high efficacy (tumor control rate of 92-100% and hormonal control rate of 46-89%), but RT-induced hypopituitarism (30-58%) and recurrence (16-21%) were also commonly reported (1, 4–7). Modern precise radiotherapy, especially intensity-modulated radiotherapy (IMRT), can spare the surrounding normal structure better by a more conformal and precise dose distribution (8). However, a large cohort study on long-term efficacy and toxicity of IMRT for CD is still lacking. Therefore, in the current study, we aim to analyze the efficacy and toxicity of intensity-modulated radiotherapy (IMRT) in treating CD. We also investigated the predictors of endocrine remission in aid of further management. Methods Patient We collected 115 cases of Cushing’s disease treated at our center from April 2012 to August 2021. Patients were excluded under the following conditions: (1) follow-up time less than 3 months, (2) lacking evaluation of serum cortisol (F), adrenocorticotropic hormone (ACTH) or 24-hour urinary free cortisol (24hUFC) before or after RT, (3) underwent uni or bilateral adrenalectomy, (4) having received RT at other institutes before admitted to our center. At last, a total of 70 cases were included in this study. Radiotherapy parameters RT was administrated by a linear accelerator (6 MV X-ray). Intensity-modulated radiation therapy was applied for all patients. Including fix-filde IMRT (FF-IMRT), volumetric modulated arc therapy (VMAT) or Tomotherapy. We immobilized the patient with an individualized thermoplastic head mask and then conducted a computed tomography (CT) simulation scan at 2- to 3-mm intervals. The target volume and organs at risks (OARs) were delined with a contrast enhanced T1-weighted image (T1WI) magnetic resonance imaging (MRI) fusing with planning CT. The gross tumor volume (GTV) was defined with the lesion visible on MRI or CT. The clinical target volume (CTV) included microscopic disease, especially when the tumor invaded cavernous sinus and surrounding bones. The planning target volume (PTV) was defined as CTV plus a margin of 2- to 3-mm in three dimensions. The prescription dose was defined at 100% isodoseline to cover at least 95% PTV. The maximum dose was limited to less than 54 Gy for the brain stem and optic pathway structures. Radiotherapy was performed once a day and five fractions a week during five to six weeks. The total dose was 45-60 Gy, delivered in 25-30 fractions, with most patients (78.6%) receiving 45-50 Gy in 25 fractions. The fractionated dose was 1.8-2.0 Gy. Data collection and clinical evaluation Baseline characteristics were collected at the last outpatient visit before RT, including demographic characteristics, biochemical data, tumor characteristics and details of previous treatments. After RT, endocrine evaluations were performed every 6 months. Endocrine remission was considered when 1 mg dexamethasone suppression test (DST)<1.8 mg/dl. If 1mg DST results were lacking, then 24hUFC within the normal range was used as a remission criterion. Patients who regained elevated hormone levels after achieving remission were considered to have endocrine recurrence. For patients receiving medications that could interfere with the metabolism of cortisol, hormonal evaluation was performed at least 3 months after the cessation of the therapy. Tumor size was measured on magnetic resonance imaging (MRI) before RT and annually after the completion of RT. Any reduction in or stabilization of tumor size was considered as tumor control. Tumor recurrence was defined as an increase of 2 millimeters in 2 dimensions comparing to MRI before RT, or from invisible tumor to a visible tumor on MRI (9). Anterior pituitary function was assessed before RT and every 6 months during the follow-up after RT. RT-induced hypopituitarism was defined as the development of new onset hormone deficiency after RT. The diagnostic criteria for growth hormone deficiency (GHD), central hypothyroidism and hypogonadotropic hypogonadism (HH) refer to previous literature (10–12). Panhypopituitarism referred to three or more anterior pituitary hormone deficiencies (13). Statistical analysis Statistical analysis was performed with SPSS version 25.0. Longitudinal analysis was performed with Kaplan-Meier method. For time-dependent variable, Log rank test was used for univariate analysis and Cox regression for multivariate analysis. The cut-off of F, ACTH and 24hUFC were defined as their median value. All variants in the univariate analysis were included in the model of multivariate analysis. P value < 0.05 was considered statistically significant. Plot was created with GraphPad Prism version 9.4. Results Patient characteristics Of 70 cases included in the study, the median age was 32 years (range, 11-66 years). 60 (85.7%) were female and 10 (14.3%) were male (F:M= 6:1). The median follow-up time was 36.8 months (range, 3.0-111.0 months). 68 patients received RT as a second-line treatment because of incomplete tumor resection, failure to achieve complete endocrine remission or recurrence postoperative, and 2 were treated with RT alone because of contraindication of surgery. The frequency of surgical treatment was 1 for 42 patients, 2 for 21 and more than 3 for 5. A total of 8 patients received medical treatment before RT. 5 of them used pasireotide, 2 used ketoconazole and 1 used mifepristone. The median ACTH level was 58.7 pg/ml (range 14.9-265 pg/ml), F, 26.2μg/dl (range 11.8-72.6 μg/dl) and 24hUFC, 355.7 μg/24hr (range 53.5-3065 μg/24hr) before RT. Tumor size evaluation was performed in all 70 patients before RT. Among them, 36 patients showed no visible residual tumor identified on MRI and only 5 patients showed tumor size more than 1 cm. Hypopituitarism was found in 31 patients (38.8%) before RT. HH was the most common (21 patients, 26.3%), followed by central hypothyroidism (13 patients, 16.3%) and GHD (9 patients, 11.3%). Panhypopituitarism was found in 4 patients (5.0%). (Table 1). Table 1 Table 1 Patient characteristics. Endocrine remission Endocrine remission was achieved in 37 of 70 patients during the follow-up. Six of them were evaluated by 1mg DST. The hormonal remission rate at 1, 2, 3 and 5 years were 28.5%, 50.2%, 62.5% and 74.0%, respectively, gradually increasing with follow-up time (Figure 1). The median time to remission was 24.0 months (95%CI: 14.0-34.0 months). Univariate analysis indicated that only higher Ki-67 index (P=0.044) was significant favorable factors for endocrine remission. There was no significant correlation between remission and age, sex, tumor size, the frequency of surgery, medication prior RT. The hormone levels (F, ACTH and 24hUFC prior RT) were divided into high and low groups by the median value, and were also not found to be associated with endocrine remission (Table 2). Since only Ki-67 was significant in the univariate analysis and all other parameters were far from significant, a multivariate analysis was no longer performed. Figure 1 Figure 1 Endocrine remission rate during the follow-up after RT. Table 2 Table 2 Univariate predictors of endocrine remission. Endocrine recurrence was found in 5 patients till the last follow-up, with an overall recurrence rate of 13.5% (5/37). The median time to recurrence after reaching endocrine remission was 22.5 months. The recurrence-free rate at 1, 2, 3 and 5 years after endocrine remission was 98.2%, 93.9%, 88.7% and 88.7%, respectively (Figure 2). Figure 2 Figure 2 Recurrence free rate after endocrine emission. Tumor control A total of 51 patients had repeated MRI examinations before and after treatment. During the follow-up, 20 patients showed reduction and 30 patoents remained stable in tumor size, with a tumor control rate of 98%. Only 1 patient showed enlargement tumor 1 year after RT, with F, ACTH and 24hUFC increase continuously. Complications At the last follow-up, 16 patients developed new onset hypopituitarism after RT. The overall incidence of RT-induced hypopituitarism was 22.9%. Hypothyroidism was the most common of hypopituitarism (8 patients), followed by HH (7 patients), adrenal insufficiency (4 patients) and GHD (3 patients). Only 1 patient (1.3%) with systemic lupus erythematosus (SLE) comorbidity complained of progressively worsening visual impairment during the follow up. No cerebrovascular event or radiation associated intracranial malignancy was found in our cohort. Discussion Efficacy and radiotherapy techniques RT has been emerged as an effective second-line treatment for CD for many years. Although conventional fractionated RT has been used for a long experience in patients with CD, study on the modern precise radiotherapy, particularly IMRT, is rare and reports limited evidence on its long-term treatment outcome. IMRT can be implemented in many different techniques, such as fixed-field intensity-modulated radiotherapy (FF-IMRT), volumetric-modulated arc therapy (VMAT) and tomotherapy. Compared with conventional RT, IMRT allows a better target volume conformity while preserves adequate coverage to the target (14, 15). Our study reported that IMRT for CD has an endocrine remission rate of 74.0% at 5 years, with a median time to remission of 24.0 months (95%CI: 14.0-34.0 months). The endocrine remission rate at 5 years was comparable to those reported in previous series of FRT, with a median time to remission within the reported range (4.5-44 months) (9, 16–18) (Table 3). Compared with SRS in treating CD, the endocrine remission rate and median time to remission were also similar. Pivonello et al (19) summarized 36 studies of SRS for CD between 1986 to 2014, the mean endocrine remission rate was 60.8% and the median time to remission was 24.5 months. Tumor control rate was 98% in our cohort, only one patient showed enlargement tumor with elevating hormones. This local control rate was also comparable to that reported in a series of pituitary adenoma treated with FRT (93-100%) and SRS(92-96%) (9, 16–18, 20, 21). Indeed, despite the lack of controlled studies about SRS and FRT in treating CD, many reviews that summarize the biochemical control and tumor contral of both are similar (2, 6, 19). Table 3 Table 3 Literature review of FRT and SRS in patients with CD published in recent years. The overall endocrine recurrence rate in our study was 13.5%, with a median time to recurrence of 22.5 months. We, for the first time, reported the actuarial recurrence free rate at 1, 2, 3 and 5 years in CD patients treated with IMRT. The recurrence free rate at 3 and 5 years was 88.7% in our study. Outcomes were comparable to those reported in patients treated with conventional RT or SRS, with a mean recurrence rate and a median recurrence time of 15.9% (range, 0-62.5%) and 28.1 months, or 12.3% (range, 0-100%) and 33.5 months, according to a review conducted by Pivonello et al (19). At 2020, we reported the outcomes of pituitary somatotroph adenomas treated with IMRT at our institution (20). Compared with pituitary somatotroph adenomas, CD has a similar 5-year remission rate (74.0% vs 74.3%) but a shorter median time to remission (24.0m vs 36.2m) (Figure 3). The tumor contral rates were similar, at 98% and 99%, respectively. The endocrine recurrence rate was significantly different, with CD being about one-fold higher than the pituitary somatotroph adenoma (13.8% vs 6.1%). This may be due to the majority of microadenomas in CD and that of macroadenomas in pituitary somatotroph adenomas. Figure 3 Figure 3 Endocrine remission rate of CD and pituitary somatotroph adenoma. Predictors of endocrine remission In the univariate analysis, we found that only Ki-67 index ≥ 3% was correlated with better endocrine remission (p=0.044). Cortisol levels before RT and tumor size were not predictors of endocrine remission. For surgery in treating CD, higher preoperative ACTH level was considered as unfavorable prognostic factor for endocrine remission in a few studies (22, 23). For radiotherapy, some previous studies also have reported a faster endocrine remission in patients with lower serum cortisol level. Minniti et al. reported that hormone level was normalized faster in patients with lower urinary and plasma cortisol level at the time of RT (16). Apaydin also reported that low postoperative cortisol and 1mg DST was a favorable factors for faster remission in patients treated with gamma knife surgery (GKS) and hypofractionated radiotherapy (HFRT), although no significant relationship was found between remission rate and plasma cortisol level prior RT in both studies (9, 16). Castinetti et al. found that initial 24hUFC was a predicative factor of endocrine remission in patients treated with GKS, which was not reported in our cohort treated with IMRT (24). However, the discrepancy between the results can be attributed to various factors, including selection bias of retrospective study, duration of follow-up, endocrine remission criteria and cut-off value. Tumor size before RT was considered as a significant predictor for endocrine remission in some published series of patients treated with SRS. Jagannathan et al. reported a significant relationship between preoperative tumor volume and endocrine remission in patients with CD treated with GKS (25). However no significant correlation between tumor size and endocrine remission was found in series of patients treated with FRT (5, 9, 16, 17). But our study found no significant correlation between tumor size (visible or no-visible residual tumor on MRI) before RT and endocrine remission. The frequency of surgery before RT was also not found to be associated with endocrine remission in our study, which reached a similar conclusion with some previous studies (9, 17, 18, 26). Abu Dabrh et al. reported a higher remission rate in patients receiving TSS prior RT in their meta-analysis (5). Similar result was also reported in a review on the treatment outcome of GKS in patients with CD, that postoperative GKS was more effective than primary GK (19). However, analysis on this parameter was difficult in our cohort considering the low number of patients who received IMRT as the first-line treatment. Reports on the effect of medical treatment on endocrine remission have been controversial. Some studies reported a negative effect of medical treatment at the time of SRS on endocrine remission in patients with CD. Castinetti et al. showed a significant higher rate of endocrine remission in patients who were not receiving ketoconazole at the time of GKS, compared to those who were (27). Sheehan et al. also found a significantly shorter time to remission in patients who discontinued ketoconazole at the time of GKS (28). However, no such correlation was found in patients treated with FRT (9, 17). Like previous studies on FRT, we also noted no significant relationship between preradiation use of medication and endocrine remission, but our statistical analysis may be hindered by the low proportion of patients undergoing medical treatment before RT. Moreover, the anticortisolic drugs used in previous studies were mainly ketoconazole or cabergoline, while most of our patient have received pasireotide, whose effect have not been well-studied yet. Further studies are necessary to understand the effect of somatostatin receptor ligands on the outcome of radiotherapy in patients with CD. Complications Hypopituitarism is the most common complication secondary to radiotherapy, with the rate of new-onset hypopituitarism ranging widely in previous report. Pivonello et al. reviewed series of CD patients who were treated with conventional RT with a follow-up of at least 5 years (19). The reported mean and median rates of hypopituitarism were 50% and 48.3%, respectively (range, 0-100%). As regards FRT, the overall rate of new-onset hypopituitarism was 22.2-40% at a median follow-up ranging from 29-108 months, with both incidence and severity increasing with longer follow-up (9, 16–19). The incidence of hypopituitarism in our series was 22.9%, which was within the reported range of new onset hypopituitarism after FRT. Lower rate of hypopituitarism after SRS compared to conventional RT has been recognized in previous reviews (2, 6). Our study showed that new onset hypopituitarism was less prevalent after IMRT than after conventional RT. This can be attributed to a higher precision in contouring the target volume and OARs, allowing these modern radiotherapy techniques to provide a better protection to hypothalamus-pituitary axes. In previous studies, potential risk factors for new onset hypopituitarism included suprasellar extension, higher radiation dose to the tumor margin and lower isodose line prescribed (29, 30). Sensitivity of individual hormonal axes to RT varies in different series. In our study, central hypothyroidism was the most common individual axis deficiency, followed by HH, adrenal insufficiency and GHD. This sequence was similar to that reported by Sheehan et al., whose series included 64 CD patients treated with SRS, as well as some other series (29, 31). It is noted in some studies that GHD is the most vulnerable axes (19, 32, 33). Limited number of patients undergoing stimulation test may underestimate the prevalence of GHD in our study and some previous series, and longer follow-up is needed to generate a more accurate, time-dependent rate of new onset hypopituitarism. In our study, only one patient complained of mild visual impairment, which was comparable to the rate ranging from 0-4.5% in previous series of FRT treating pituitary adenoma (9, 16–18, 26, 32, 34, 35). This patient had concomitant SLE and the associated microangiopathy may render the optic nerve intolerant to radiotherapy. Cranial nerve damage was acknowledged as an uncommon complication, with an estimated risk of vision deterioration below 1% if single radiation dose was no more than 2.0 Gy and total dose no more than 45-50 Gy (2, 36). The actuarial rate of optic neuropathy at 10 years was 0.8% in a series containing 385 patients with pituitary adenoma (37). No patient in our cohort developed cerebrovascular accident or secondary brain tumor. This finding was consistent with the low actuarial prevalence of these complications reported in other published series of FRT. Secondary brain tumor was extremely rare after SRS, with an overall incidence of 6.80 per patients-year, or a cumulative incidence of 0.00045% over 10 years in a multicenter cohort study containing 4905 patients treated with GKS (38). Ecemis et al. reviewed cohort studies of conventional RT in treating pituitary adenoma from 1990 to 2013 and found that 1.42% of patients developed secondary brain tumor, with a latency period of 19.6 years for meningioma, 11 years for glioma and 9 years for astrocytoma (39). As for cerebrovascular accident, Minniti et al. reported two patients (in a total of 40 patients) who had stroke 6 and 8 years after FRT (16). Data was still limited for FRT. Considering the low incidence and long latency period, large, controlled cohort study with long follow-up of FRT is still needed to accurately evaluate these complications. Limitations Our study has several limitations. First, not all patients rigorously followed regular follow-up time points, making time-dependent statistical analysis less accurate. In addition, the excessively low number of cases with 1mg DST as the endocrine remission criterion may affect the accuracy of the remission rate.Moreover, a median follow-up time of about 3 years hampered evaluation on some late complications, including cerebrovascular events and secondary brain tumor. In conclusion, our study revealed that IMRT was a highly effective second-line therapy with low side effect profile for CD patients, and it’s endocrine remission, tumor control and recurrence rates were comparable to previous reports on FRT and SRS. Data availability statement The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author. Author contributions 1. Conceptualization: FZ and HZ 2. Data curation: XL and ZX. 3. Funding acquisition: FZ. 4. Investigation: XL and ZX 5. Methodology: WW 6. Resources: XL, SS and XH 7. Validation: LL and HZ. 8. Writing – original draft: ZX 9. Writing – review and editing: XL. All authors contributed to the article and approved the submitted version. Funding Supported by grants National High Level Hospital Clinical Research Funding (No.2022-PUMCH-B-052) and National Key R&D Program of China, Ministry of Science and Technology of the People’s Republic of China.(Grant No. 2022YFC2407100, 2022YFC2407101). Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. References 1. Katznelson L. Role of radiation in the treatment of Cushing disease. Pituitary (2022) 25(5):740–2. doi: 10.1007/s11102-022-01234-y PubMed Abstract | CrossRef Full Text | Google Scholar 2. Ironside N, Chen CJ, Lee CC, Trifiletti DM, Vance ML, Sheehan JP. Outcomes of pituitary radiation for Cushing’s disease. Endocrinol Metab Clin North Am (2018) 47(2):349–65. doi: 10.1016/j.ecl.2018.01.002 PubMed Abstract | CrossRef Full Text | Google Scholar 3. Nieman LK, Biller BM, Findling JW, Murad MH, Newell-Price J, Savage MO, et al. Treatment of Cushing’s syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metab (2015) 100(8):2807–31. doi: 10.1210/jc.2015-1818 PubMed Abstract | CrossRef Full Text | Google Scholar 4. Gheorghiu ML, Fleseriu M. Stereotactic radiation therapy in pituitary adenomas, is it better than conventional radiation therapy? Acta Endocrinol (Buchar) (2017) 13(4):476–90. doi: 10.4183/aeb.2017.476 PubMed Abstract | CrossRef Full Text | Google Scholar 5. Abu Dabrh AM, Singh Ospina NM, Al Nofal A, Farah WH, Barrionuevo P, Sarigianni M, et al. Predictors of biochemical remission and recurrence after surgical and radiation treatments of cushing disease: A systematic review and meta-analysis. Endocr Pract (2016) 22(4):466–75. doi: 10.4158/EP15922.RA PubMed Abstract | CrossRef Full Text | Google Scholar 6. Gheorghiu ML. Updates in the outcomes of radiation therapy for Cushing’s disease. Best Pract Res Clin Endocrinol Metab (2021) 35(2):101514. doi: 10.1016/j.beem.2021.101514 PubMed Abstract | CrossRef Full Text | Google Scholar 7. Minniti G, Brada M. Radiotherapy and radiosurgery for Cushing’s disease. Arq Bras Endocrinol Metabol (2007) 51(8):1373–80. doi: 10.1590/s0004-27302007000800024 PubMed Abstract | CrossRef Full Text | Google Scholar 8. Castinetti F, Brue T, Ragnarsson O. Radiotherapy as a tool for the treatment of Cushing’s disease. Eur J Endocrinol/European Fed Endocr Societies (2019) 180(5):D9–D18. doi: 10.1530/EJE-19-0092 CrossRef Full Text | Google Scholar 9. Apaydin T, Ozkaya HM, Durmaz SM, Meral R, Kadioglu P. Efficacy and safety of stereotactic radiotherapy in Cushing’s disease: A single center experience. Exp Clin Endocrinol Diabetes (2021) 129(7):482–91. doi: 10.1055/a-1217-7365 PubMed Abstract | CrossRef Full Text | Google Scholar 10. Fleseriu M, Hashim IA, Karavitaki N, Melmed S, Murad MH, Salvatori R, et al. Hormonal replacement in hypopituitarism in adults: an endocrine society clinical practice guideline. J Clin Endocrinol Metab (2016) 101(11):3888–921. doi: 10.1210/jc.2016-2118 PubMed Abstract | CrossRef Full Text | Google Scholar 11. Higham CE, Johannsson G, Shalet SM. Hypopituitarism. Lancet (2016) 388(10058):2403–15. doi: 10.1016/S0140-6736(16)30053-8 PubMed Abstract | CrossRef Full Text | Google Scholar 12. Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, et al. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab (2010) 95(6):2536–59. doi: 10.1210/jc.2009-2354 PubMed Abstract | CrossRef Full Text | Google Scholar 13. Jazbinsek S, Kolenc D, Bosnjak R, Faganel Kotnik B, Zaletel Zadravec L, et al. Prevalence of endocrine and metabolic comorbidities in a national cohort of patients with craniopharyngioma. Horm Res Paediatr (2020) 93(1):46–57. doi: 10.1159/000507702 PubMed Abstract | CrossRef Full Text | Google Scholar 14. Ramos-Prudencio R, Perez-Alvarez SI, Flores-Balcazar CH, de Leon-Alfaro MA, Herrera-Gonzalez JA, Elizalde-Cabrera J, et al. Radiotherapy for the treatment of pituitary adenomas: A dosimetric comparison of three planning techniques. Rep Pract Oncol Radiother (2020) 25(4):586–93. doi: 10.1016/j.rpor.2020.04.020 PubMed Abstract | CrossRef Full Text | Google Scholar 15. Bortfeld T. IMRT: a review and preview. Phys Med Biol (2006) 51(13):R363–79. doi: 10.1088/0031-9155/51/13/R21 PubMed Abstract | CrossRef Full Text | Google Scholar 16. Minniti G, Osti M, Jaffrain-Rea ML, Esposito V, Cantore G, Maurizi Enrici R. Long-term follow-up results of postoperative radiation therapy for Cushing’s disease. J Neurooncol (2007) 84(1):79–84. doi: 10.1007/s11060-007-9344-0 PubMed Abstract | CrossRef Full Text | Google Scholar 17. Budyal S, Lila AR, Jalali R, Gupta T, Kasliwal R, Jagtap VS, et al. Encouraging efficacy of modern conformal fractionated radiotherapy in patients with uncured Cushing’s disease. Pituitary (2014) 17(1):60–7. doi: 10.1007/s11102-013-0466-4 PubMed Abstract | CrossRef Full Text | Google Scholar 18. Sherry AD, Khattab MH, Xu MC, Kelly P, Anderson JL, Luo G, et al. Outcomes of stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for refractory Cushing’s disease. Pituitary (2019) 22(6):607–13. doi: 10.1007/s11102-019-00992-6 PubMed Abstract | CrossRef Full Text | Google Scholar 19. Pivonello R, De Leo M, Cozzolino A, Colao A. The treatment of Cushing’s disease. Endocr Rev (2015) 36(4):385–486. doi: 10.1210/er.2013-1048 PubMed Abstract | CrossRef Full Text | Google Scholar 20. Lian X, Shen J, Gu Z, Yan J, Sun S, Hou X, et al. Intensity-modulated radiotherapy for pituitary somatotroph adenomas. J Clin Endocrinol Metab (2020) 105(12):4712–e4721. doi: 10.1210/clinem/dgaa651 CrossRef Full Text | Google Scholar 21. Mackley HB, Reddy CA, Lee SY, Harnisch GA, Mayberg MR, Hamrahian AH, et al. Intensity-modulated radiotherapy for pituitary adenomas: the preliminary report of the Cleveland Clinic experience. Int J Radiat Oncol Biol Phys (2007) 67(1):232–9. doi: 10.1016/j.ijrobp.2006.08.039 PubMed Abstract | CrossRef Full Text | Google Scholar 22. Dai C, Fan Y, Liu X, Bao X, Yao Y, Wang R, et al. Predictors of immediate remission after surgery in Cushing’s disease patients: A large retrospective study from a single center. Neuroendocrinol (2021) 111(11):1141–50. doi: 10.1159/000509221 CrossRef Full Text | Google Scholar 23. Cannavo S, Almoto B, Dall’Asta C, Corsello S, Lovicu RM, De Menis E, et al. Long-term results of treatment in patients with ACTH-secreting pituitary macroadenomas. Eur J Endocrinol/European Fed Endocr Societies (2003) 149(3):195–200. doi: 10.1530/eje.0.1490195 CrossRef Full Text | Google Scholar 24. Castinetti F, Nagai M, Morange I, Dufour H, Caron P, Chanson P, et al. Long-term results of stereotactic radiosurgery in secretory pituitary adenomas. J Clin Endocrinol Metab (2009) 94(9):3400–7. doi: 10.1210/jc.2008-2772 PubMed Abstract | CrossRef Full Text | Google Scholar 25. Jagannathan J, Sheehan JP, Pouratian N, Laws ER, Steiner L, Vance ML. Gamma Knife surgery for Cushing’s disease. J Neurosurg (2007) 106(6):980–7. doi: 10.3171/jns.2007.106.6.980 PubMed Abstract | CrossRef Full Text | Google Scholar 26. Colin P, Jovenin N, Delemer B, Caron J, Grulet H, Hecart AC, et al. Treatment of pituitary adenomas by fractionated stereotactic radiotherapy: a prospective study of 110 patients. Int J Radiat Oncol Biol Phys (2005) 62(2):333–41. doi: 10.1016/j.ijrobp.2004.09.058 PubMed Abstract | CrossRef Full Text | Google Scholar 27. Castinetti F, Nagai M, Dufour H, Kuhn JM, Morange I, Jaquet P, et al. Gamma knife radiosurgery is a successful adjunctive treatment in Cushing’s disease. Eur J Endocrinol/European Fed Endocr Societies (2007) 156(1):91–8. doi: 10.1530/eje.1.02323 CrossRef Full Text | Google Scholar 28. Sheehan JP, Xu Z, Salvetti DJ, Schmitt PJ, Vance ML. Results of gamma knife surgery for Cushing’s disease. J Neurosurg (2013) 119(6):1486–92. doi: 10.3171/2013.7.JNS13217 PubMed Abstract | CrossRef Full Text | Google Scholar 29. Xu Z, Lee Vance M, Schlesinger D, Sheehan JP. Hypopituitarism after stereotactic radiosurgery for pituitary adenomas. Neurosurgery (2013) 72(4):630–7. doi: 10.1227/NEU.0b013e3182846e44 PubMed Abstract | CrossRef Full Text | Google Scholar 30. Cordeiro D, Xu Z, Mehta GU, Ding D, Vance ML, Kano H, et al. Hypopituitarism after Gamma Knife radiosurgery for pituitary adenomas: a multicenter, international study. J Neurosurg (2018), 1188–96. doi: 10.3171/2018.5.Jns18509 CrossRef Full Text | Google Scholar 31. Scheick S, Amdur RJ, Kirwan JM, Morris CG, Mendenhall WM, Roper S, et al. Long-term outcome after fractionated radiotherapy for pituitary adenoma: the curse of the secretory tumor. Am J Clin Oncol (2016) 39(1):49–54. doi: 10.1097/COC.0000000000000014 PubMed Abstract | CrossRef Full Text | Google Scholar 32. Minniti G, Traish D, Ashley S, Gonsalves A, Brada M. Fractionated stereotactic conformal radiotherapy for secreting and nonsecreting pituitary adenomas. Clin Endocrinol (Oxf) (2006) 64(5):542–8. doi: 10.1111/j.1365-2265.2006.02506.x PubMed Abstract | CrossRef Full Text | Google Scholar 33. Degerblad M, Brismar K, Rahn T, Thoren M. The hypothalamus-pituitary function after pituitary stereotactic radiosurgery: evaluation of growth hormone deficiency. J Intern Med (2003) 253(4):454–62. doi: 10.1046/j.1365-2796.2003.01125.x PubMed Abstract | CrossRef Full Text | Google Scholar 34. Plitt AR, El Ahmadieh TY, Aoun SG, Wardak Z, Barnett SL. Fractionated cyberKnife stereotactic radiotherapy for perioptic pituitary adenomas. World Neurosurg (2019) 126:e1359–64. doi: 10.1016/j.wneu.2019.03.102 PubMed Abstract | CrossRef Full Text | Google Scholar 35. Kong DS, Lee JI, Lim DH, Kim KW, Shin HJ, Nam DH, et al. The efficacy of fractionated radiotherapy and stereotactic radiosurgery for pituitary adenomas: long-term results of 125 consecutive patients treated in a single institution. Cancer (2007) 110(4):854–60. doi: 10.1002/cncr.22860 PubMed Abstract | CrossRef Full Text | Google Scholar 36. Becker G, Kocher M, Kortmann RD, Paulsen F, Jeremic B, Muller RP, et al. Radiation therapy in the multimodal treatment approach of pituitary adenoma. Strahlenther Onkol (2002) 178(4):173–86. doi: 10.1007/s00066-002-0826-x PubMed Abstract | CrossRef Full Text | Google Scholar 37. Erridge SC, Conkey DS, Stockton D, Strachan MW, Statham PF, Whittle IR, et al. Radiotherapy for pituitary adenomas: long-term efficacy and toxicity. Radiother Oncol (2009) 93(3):597–601. doi: 10.1016/j.radonc.2009.09.011 PubMed Abstract | CrossRef Full Text | Google Scholar 38. Wolf A, Naylor K, Tam M, Habibi A, Novotny J, Liscak R, et al. Risk of radiation-associated intracranial Malignancy after stereotactic radiosurgery: a retrospective, multicentre, cohort study. Lancet Oncol (2019) 20(1):159–64. doi: 10.1016/S1470-2045(18)30659-4 PubMed Abstract | CrossRef Full Text | Google Scholar 39. Ecemis GC, Atmaca A, Meydan D. Radiation-associated secondary brain tumors after conventional radiotherapy and radiosurgery. Expert Rev Neurother (2013) 13(5):557–65. doi: 10.1586/ern.13.37 PubMed Abstract | CrossRef Full Text | Google Scholar Keywords: cushing’s disease, intensity-modulated radiotherapy, radiotherapy, pituitary adenoma, ACTH Citation: Lian X, Xu Z, Sun S, Wang W, Zhu H, Lu L, Hou X and Zhang F (2023) Intensity-modulated radiotherapy for cushing’s disease: single-center experience in 70 patients. Front. Endocrinol. 14:1241669. doi: 10.3389/fendo.2023.1241669 Received: 17 June 2023; Accepted: 31 August 2023; Published: 26 September 2023. Edited by: Luiz Augusto Casulari, University of Brasilia, Brazil Reviewed by: Luiz Eduardo Armondi Wildemberg, Instituto Estadual do Cérebro Paulo Niemeyer (IECPN), Brazil Carolina Leães Rech, Federal University of Health Sciences of Porto Alegre, Brazil Copyright © 2023 Lian, Xu, Sun, Wang, Zhu, Lu, Hou and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Fuquan Zhang, zhangfq@pumch.cn †These authors have contributed equally to this work Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. From https://www.frontiersin.org/articles/10.3389/fendo.2023.1241669/full

Bridget Houser felt despairing. In the months before her 2018 wedding, Houser, who had never struggled with her weight, noticed that it inexplicably began to creep up. In response she doubled the length of her runs to eight miles, took back-to-back high intensity workout classes and often consumed only water, coffee and fruit during the day before a spartan, mostly vegetable, dinner. Yet no matter what Houser did, her weight stubbornly increased and her oval face grew round, a transformation that was glaringly obvious in comparison with her identical twin sister. Houser wondered whether the five pounds she gained despite her herculean effort was a corollary of other problems. For the previous two years she had battled a string of maladies: first daily headaches, then crippling anxiety, followed by insomnia, hair loss and acne, something she’d never endured as a teenager. “Stress was the universal explanation,” recalled Houser, a controller for a small business in Chicago. When doctors suggested that her upcoming marriage might be a cause of her problems, Houser considered, then rejected, the theory. It just didn’t jibe with her feelings. In early 2019, about six months after her wedding, Houser insisted that her doctors perform several tests. They ultimately revealed that her symptoms weren’t the result of stress or marital misgivings but of a serious illness that had been smoldering for years. After successful treatment followed by a long recovery Houser, now 34, feels far better than she did during those miserable years in her late 20s. “I wish I’d been nicer to myself and not blamed myself for what was going on,” she said. Getting through the wedding In 2016 Houser began experiencing daily pain in the back of her head, a common spot for tension headaches. When the headaches failed to improve with dietary changes or nonprescription pain relievers, she consulted her primary care doctor, followed by a neurologist who told her she had migraines. Houser, then 27, noticed that the headaches were worse when she wore contact lenses. “It was affecting my daily life and I talked myself into thinking the problem was my contacts,” she said. She decided Lasik surgery might help and in October 2017 underwent the procedure, which uses a laser to reshape the cornea, reducing or eliminating dependence on contacts or glasses. Her vision improved and the pain disappeared — briefly. A week after eye surgery, her headaches returned. “I wasn’t overly concerned,” Houser said. “I know a lot of people have headaches.” A few months later for no apparent reason Houser developed “really bad anxiety. It wasn’t just like I was anxious,” she recalled. “I couldn’t function. I’m Type A so I knew what anxiety is, but not to this degree.” One weekday morning in early 2018 she felt so overwhelmed that she took a sick day, then called her twin, Molly, and their mother and told them she needed help immediately. They managed to schedule a same-day appointment with a psychiatrist whom Houser began seeing regularly, along with a therapist. The psychiatrist zeroed in on her impending wedding and told Houser that the event can cause “huge anxiety.” She began taking an antidepressant along with Ativan, an anti-anxiety drug she used when things got really bad. She also ramped up her yoga practice, hoping it might calm her. Houser vividly remembers riding the escalator to her office one morning “and in my head I kept saying, ‘I’m in trouble, I’m in trouble,’” although she didn’t know what was wrong. Her changing appearance had become a source of great unhappiness. Although her weight remained in the normal range, Houser couldn’t figure out why she was gaining weight after drastically slashing her food intake and dramatically ramping up exercise. Her normally thick hair had thinned so noticeably that her hairdresser gently advised her to consult a doctor. Houser’s psychiatrist thought her hair loss might be caused by her antidepressant and switched medications. That didn’t seem to help. Houser was particularly bothered by her newly chubby face. “It was like a joke in my family,” she said, adding that she was teased about being overly sensitive. Even her wedding day was colored by unhappiness about her appearance and the intense amorphous anxiety that seemed omnipresent. “Rather than think about how excited I was,” Houser recalled, “it was ‘How can I get through this day?’” Normal thyroid After her wedding Houser felt worse. She developed severe insomnia, night sweats and acne. In February 2019 a nurse practitioner in her primary care practice ordered tests of her thyroid, which were normal. When Houser pressed for additional testing, she was referred to an endocrinologist. He told her she was stressed. Dissatisfied, she saw a second endocrinologist who agreed with the first. “She said ‘I don’t think there’s anything wrong with you’” metabolically, Houser recalled. The second endocrinologist’s nurse even revisited the marriage question in the presence of Houser’s husband, Doug, who had accompanied her to the appointment. “She said ‘I knew on my honeymoon I shouldn’t have gotten married,’” Houser remembered her saying. “‘Are you in a happy marriage?’ I couldn’t believe it.” Months earlier, the nurse practitioner who ordered the thyroid tests briefly mentioned measuring levels of cortisol, a hormone involved in the body’s response to stress and other functions. Elevated levels of cortisol can indicate Cushing’s syndrome, an uncommon hormonal disorder that occurs when the body produces too much of the hormone over a prolonged period. “She had thrown cortisol testing out there and I think it was always in the back of my mind,” Houser said. She asked the second endocrinologist to order cortisol tests. The doctor agreed, but not before telling Houser that she didn’t think she had Cushing’s because she lacked the classic symptoms: major weight gain, purple stretch marks and a fatty hump between the shoulders. Houser did have the “moon face” characteristic of Cushing’s that is also seen in people who take high doses of steroids for long periods to treat various illnesses — but Houser wasn’t taking steroids. Insomnia, headaches, acne and anxiety can be symptoms of Cushing’s. There are several forms of Cushing’s syndrome, which typically results from a tumor — usually benign but sometimes cancerous — in the pituitary or adrenal gland that pumps out excess cortisol. Sometimes tumors develop elsewhere in the body such as the lungs or pancreas. Cushing’s affects roughly five times as many women as men and typically occurs between the ages of 30 and 50. If left untreated, it can be fatal. A trio of tests measuring cortisol levels in Houser’s blood, urine and saliva were significantly elevated; the amount in her urine was eight times higher than normal. The formerly skeptical Chicago endocrinologist told Houser she had Cushing’s and referred her to James Findling, a Milwaukee endocrinologist who is internationally recognized for his treatment of the disease. “I was just so happy to have a diagnosis,” Houser recalled. Revealing photos Findling asked Houser to bring photographs taken several years earlier to her October 2018 appointment. It is a request he makes of patients as a way of spotting telltale physical manifestations. In Houser’s case, the facial change was particularly striking because she is an identical twin. Findling noted that delayed diagnosis is typical, because physical changes and other symptoms tend to occur gradually and insidiously. Houser, he added, “didn’t look like the typical Cushing’s patient. She wasn’t obese and she didn’t have diabetes or hypertension. It was more subtle than many cases.” The next step was determining the location of the tiny tumor. Tests found nothing in Houser’s pituitary or adrenal glands, and CT scans of her pelvis, chest and abdomen were clean. Findling ordered a dotatate PET scan, a highly sensitive CT scan that can find tumors that elude conventional imaging. The scan revealed a nodule in Houser’s left lung. Houser sought a second opinion from a thoracic surgeon in Chicago. While Findling and a thoracic surgeon at Milwaukee’s Froedtert Hospital strongly recommended that she undergo surgery to remove the tumor, the Chicago doctor disagreed. He said he didn’t think the lung nodule was causing Cushing’s and recommended that Houser continue therapy and anti-anxiety medication. “Do you know what it’s like to wake up from surgery and to not be better?” she remembers him asking her. After deliberating with her husband and conferring with her Milwaukee doctors, Houser opted for surgery performed Oct. 30, which removed part of her left lung. A pathologist determined that the nodule was a rare, slow-growing neuroendocrine lung cancer known as a bronchial carcinoid, which can cause Cushing’s. The Stage 2 cancer had spread to a nearby lymph node. “Fortunately I think we got it early,” Findling said. “She’s had a sustained remission and a cure of her Cushing’s.” “The cancer didn’t rock my world,” said Houser, who had previously had a melanoma skin cancer removed. (Doctors have told her they don’t think the cancers are related.) “It was about not having Cushing’s anymore, which was more important.” So why didn’t Houser’s doctors, among them endocrinologists, suspect Cushing’s? Findling, who estimates he has treated as many as 2,000 people with the disease in his 40-year career, said that while doctors are taught that Cushing’s is rare, it’s not. He cites a 2016 study, which that found that 26 of 353 endocrinology patients were found to have the disease. Textbook descriptions, which include the presence of purple stretch marks and a hump, are “almost a caricature,” Findling observed. “It’s pretty well recognized that Cushing’s is more subtle than that … and can cause neuropsychiatric and neurocognitive problems.” Houser’s normal weight and the fact that she didn’t have high blood pressure or diabetes may have misled doctors. “I think we’ve moved the needle a little bit, especially among endocrinologists,” he continued, adding that “the threshold for screening has got to change. Once you tell a primary care doctor that it’s a rare disorder, it goes in one ear and out the other. They think they’ll never see it.” “When you make this diagnosis it can have fabulous outcomes,” he added, citing Houser’s case. “That’s why I’m still doing this at my age.” Houser considers Findling to be her “literal lifesaver.” She spent the next year seeing him as she was slowly weaned off medications to normalize her hormone levels and recover her strength. She is monitored for Cushing’s annually, remains cancer-free and, other than residual fatigue, feels well. In October 2021 she gave birth to a daughter. Her son was born eight weeks ago. Houser regards the help provided by her family, particularly her husband whom she called “my biggest supporter,” as essential. That seems especially ironic because stress about their marriage had been blamed for symptoms that were actually caused by a cancer. “He was a huge help in calling doctors and making the necessary appointments when I didn’t have the energy to fight anymore.” His unwavering love, she said, was “a testament to our strong marriage.” From https://www.washingtonpost.com/wellness/2023/10/07/weight-anxiety-wedding-medical-mysteries/

Highlights The most common cause of ectopic ACTH syndrome is pulmonary carcinoid tumors and squamous cell lung cancer; however it is a relatively uncommon complication of pulmonary neoplasms. The most common cause of Cushing syndrome is iatrogenic corticosteroid use and it should be considered in all patients regardless of clinical background. Low urine cortisol levels may be associated with exogenous glucocorticoid exposure. Occult glucocorticoid exposure is rare but can be evaluated with liquid chromatography. Consumers should be aware of the potential risks of taking supplements, especially those advertised as joint pain relief products. Abstract Background Well differentiated bronchial neuroendocrine neoplasms often follow a clinically indolent course and rarely cause Ectopic ACTH syndrome. Iatrogenic corticosteroid use is the most common cause of Cushing syndrome and should be considered in all patients regardless of clinical background. Case report A 59 year old woman with an 11 year history of a 1.5 cm well differentiated bronchial carcinoid, presented with Cushingoid features. Laboratory results were not consistent with an ACTH dependent Cushing Syndrome and exogenous steroids were suspected. The patient received an FDA alert regarding a glucosamine supplement she had started 4 months prior for joint pain. Discussion Ectopic ACTH production is reported in less than 5% of patients with squamous cell lung cancer and 3% of patients with lung or pancreatic (non-MEN1) neuroendocrine tumors. Factitious corticoid exposure is rare and can be evaluated with synthetic corticosteroid serum testing. Conclusion Cushing syndrome due to supplements containing unreported corticosteroid doses should be considered in patients with typical Cushingoid features and contradictory hormonal testing. 1. Introduction Well differentiated bronchial neuroendocrine neoplasms often follow a clinically indolent course and can rarely exhibit Cushing syndrome due to ectopic production of adrenocorticotropic hormone (ACTH). However the most common cause of Cushing syndrome is iatrogenic corticosteroid use and should be considered in all patients regardless of clinical background (see Fig. 1, Fig. 2, Fig. 3, Fig. 4). Download : Download high-res image (243KB) Download : Download full-size image Fig. 1. DOTATATE PET/CT demonstrates a right upper lobe pulmonary nodule with intense uptake. Download : Download high-res image (201KB) Download : Download full-size image Fig. 2. DOTATATE PET/CT demonstrates intense uptake within a right upper lobe pulmonary nodule, consistent with biopsy-proven carcinoid tumor. There are no distant sites of abnormal uptake to suggest metastatic disease. Download : Download high-res image (399KB) Download : Download full-size image Fig. 3. Artri Ajo King Supplement (Source: FDA). The label claims that the product contains glucosamine, chondroitin, collagen, vitamin C, curcumin, nettle, omega 3, and methylsulfonylmethane. Download : Download high-res image (288KB) Download : Download full-size image Fig. 4. Artri King Supplement (Source: FDA). 2. Case report A 59–year old woman with an 11 year history of a 1.5 cm well-differentiated bronchial carcinoid, presented with 20 lb. weight gain, facial swelling, flushing, lower extremity edema and shortness of breath over 3 months. On exam, the patient was normotensive, centrally obese with mild hirsutism, facial fullness and ruddiness with evidence of a dorsocervical fat pad. Initially there was concern for hormonal activation of her known bronchial carcinoid. Testing resulted in a normal 24-hour urine 5-HIAA (6 mg/d, n < 15 mg/dL), elevated chromogranin A (201 ng/mL, n < 103 ng/mL), normal histamine (<1.5 ng/mL, n < 1.7 ng mL), low-normal 7 AM serum cortisol (5.1 μg/dL, n 3.6–19.3 μg/dL), normal 7 AM ACTH (17 pg/mL, n < 46 pg/mL) and a surprisingly low 24-hr urinary free cortisol (1.8 mcg/hr, n 4.0–50.0 mcg/hr). A late night saliva cortisol was 0.03 mcg/dL (n 3.4–16.8 mcg/dL). Testosterone, IGF-1, glucose and electrolytes were appropriate. An echocardiogram showed an ejection fraction of 60% with no evidence of carcinoid heart disease. A Dotatate PET-CT was obtained to evaluate for progression of the neuro-endocrine tumor and revealed a stable right upper lobe pulmonary nodule with no evidence of metastatic disease. Given low cortisol levels, ectopic Cushing syndrome was excluded and exogenous steroids were suspected, however the patient denied use of oral,inhaled, or injected steroids. A cosyntropin stimulation study yielded a pre-stimulation cortisol 6.2 μg/dL with an adequate post-stimulation cortisol 23.5 μg/dL. At this stage of evaluation, the patient received an FDA alert regarding a glucosamine supplement she had started 4 months prior for joint pain. The notification advised of hidden drug ingredients including dexamethasone, diclofenac, and methocarbamol contained within Artri King Glucosamine supplements not listed on the product label but verified by FDA lab analysis. The FDA had received several adverse event reports including liver toxicity and even death associated with such products. The patient's symptoms gradually improved after discontinuation of the supplement. 3. Discussion 3.1. Ectopic ACTH syndrome This patient's Cushingoid features were initially suspected to be secondary to the known bronchial neuroendocrine tumor. Ectopic ACTH production accounts for about 5–10% of all Cushing Syndrome cases [1]. The most common location of ectopic ACTH is the lungs with pulmonary carcinoid tumors being the most common cause, followed by squamous cell lung cancer [2]. Despite this patient's history of bronchial carcinoid tumor and positive chromogranin histopathological marker, her laboratory results were not consistent with an ACTH dependent Cushing Syndrome. In fact, Cushing syndrome is a relatively uncommon neuroendocrine neoplasm complication. The prevalence of ectopic ACTH production in patients with lung tumors is rare, at less than 5% in squamous cell lung cancer and about 3% in patients with lung or pancreatic (non-MEN1) neuroendocrine tumors1. Patients with ACTH dependent Cushing syndrome not suspected to originate from the pituitary, undergo further testing to evaluate for an ectopic ACTH secreting tumor. These tests include conventional imaging of the chest, abdomen and pelvis, as well as functional imaging such as octreotide scans, fluoride 18-fluorodeoxyglucose-positron emission tomography [18F-FDG PET], and gallium-68 DOTATATE positron emission tomography-computed tomography [Dotatate PET-CT] scan [3]. In our literature review, we found that there was insufficient evidence to determine the sensitivity and specificity of nuclear medicine imaging techniques [4,5]. In this case, the patient had no laboratory evidence for ACTH dependent Cushing Syndrome, but given the known bronchial carcinoid tumor, a repeat Dotatate PET-CT scan was obtained which demonstrated no indication of growth or spread of the known bronchial tumor. 3.2. Supplement induced Cushing Syndrome One of the most remarkable findings in this case was the patient's low urine cortisol level in the setting of her overt Cushingoid features. In our survey of the literature, we found that low urine cortisol levels were associated with exogenous glucocorticoid use [6,7]. The low urine cortisol levels may be reflective of intermittent glucocorticoid exposure. Indeed, this patient's Cushingoid features were determined to be secondary to prolonged use of Artri King supplement. Occult glucocorticoid use is difficult to diagnose even after performing a thorough medication reconciliation as patients may unknowingly consume unregulated doses of glucocorticoids in seemingly harmless supplements and medications. The incidence of supplement induced Cushing Syndrome is currently unknown as supplements are not regularly tested to detect hidden glucocorticoid doses. Additionally, the likelihood of developing supplement induced Cushing syndrome is dependent on dosage and duration of use. In our literature review we found nine published articles describing supplement induced Cushing Syndrome [[7], [8], [9], [10], [11], [12], [13], [14], [15]], one case report of tainted counterfeit medication causing Cushing Syndrome [16], and two cases of substances with probable glucocorticoid-like activity [17,18]. Of the nine published articles of supplement induced Cushing Syndrome, six were associated with supplements marketed as arthritic joint pain relief products including ArtriKing, Maajun, and AtriVid [[7], [8], [9], [10], [11], [12]]. These products later received government issued warnings in Mexico, Malaysia, and Colombia respectively [[19], [20], [21]]. To our knowledge there have been four published reports of ArtiKing supplement induced Cushing Syndrome [[7], [8], [9], [10]]. The first documented cases were reported in 2021 in Vera Cruz, Mexico; since then the Mexican medical community reported seeing a disproportionate increase in cases of iatrogenic Cushing Syndrome due to these supplements [7]. There have also been three American published articles describing a total of 4 cases of ArtriKing supplement induced Cushing syndrome [[8], [9], [10]]. In January 2022 the FDA issued a warning about Atri Ajo King containing diclofenac, which was not listed in the product label [22]. In April 2022 the FDA expanded its warning, advising consumers to avoid all Artri and Ortiga products after the FDA found these products contained dexamethasone and diclofenac [23]. In October 2022 the FDA issued warning letters to Amazon, Walmart, and Latin Foods market for distributing Artri and Ortiga products [24]. Many supplements are not regulated by the government and may contain hidden ingredients such as glucocorticoids. In these cases further evaluation of suspected products [25], medications [16], and patient serum [26] and urine [6] utilizing techniques such as liquid chromatography may be used to confirm occult glucocorticoid exposure. This case highlights the importance of educating patients to exercise caution when purchasing health products both online and abroad. Consumers should be aware of the potential risks of taking supplements, especially those advertised as joint pain relief products. 4. Conclusion Although the most common cause of ectopic ACTH syndrome is pulmonary carcinoid tumors and squamous cell lung cancer, it is a relatively uncommon complication of pulmonary neoplasms. Exogenous Cushing syndrome due to supplements containing unreported corticosteroid doses should be considered in patients with typical Cushingoid features and contradictory hormonal testing. Occult glucocorticoid exposure is rare but can be evaluated with liquid chromatography. This case report emphasizes the importance of teaching patients to be vigilant and appropriately research their health supplements. Patient consent Formal informed consent was obtained from the patient for publication of this case report. Declaration of competing interest The authors (Tomas Morales and Shanika Samarasinghe) of this case report declare that they have no financial conflicts of interest. Shanika Samrasinghe is an editorial member of the Journal of Clinical and Translational Endocrinology: Case Reports, and declares that she was not involved in the peer review and editorial decision making process for the publishing of this article. References [1] A.R. Hayes, A.B. Grossman The ectopic adrenocorticotropic hormone syndrome: rarely easy, always challenging Endocrinol Metab Clin N Am, 47 (2) (2018 Jun), pp. 409-425, 10.1016/j.ecl.2018.01.005 PMID: 29754641 View PDFView articleView in ScopusGoogle Scholar [2] A.M. Isidori, A. Lenzi Ectopic ACTH syndrome Arq Bras Endocrinol Metabol, 51 (8) (2007 Nov), pp. 1217-1225, 10.1590/s0004-27302007000800007 PMID: 18209859 View article View in ScopusGoogle Scholar [3] J. Young, M. Haissaguerre, O. Viera-Pinto, O. Chabre, E. Baudin, A. Tabarin Management of endocrine disease: cushing's syndrome due to ectopic ACTH secretion: an expert operational opinion Eur J Endocrinol, 182 (4) (2020 Apr), pp. R29-R58, 10.1530/EJE-19-0877 PMID: 31999619 View article View in ScopusGoogle Scholar [4] E. Varlamov, J.M. Hinojosa-Amaya, M. Stack, M. Fleseriu Diagnostic utility of Gallium-68-somatostatin receptor PET/CT in ectopic ACTH-secreting tumors: a systematic literature review and single-center clinical experience Pituitary, 22 (5) (2019 Oct), pp. 445-455, 10.1007/s11102-019-00972-w PMID: 31236798 View article View in ScopusGoogle Scholar [5] A.M. Isidori, E. Sbardella, M.C. Zatelli, M. Boschetti, G. Vitale, A. Colao, R. Pivonello, ABC Study Group Conventional and nuclear medicine imaging in ectopic cushing's syndrome: a systematic review J Clin Endocrinol Metab, 100 (9) (2015 Sep), pp. 3231-3244, 10.1210/JC.2015-1589 PMID: 26158607; PMCID: PMC4570166 View article View in ScopusGoogle Scholar [6] G. Cizza, L.K. Nieman, J.L. Doppman, M.D. Passaro, F.S. Czerwiec, G.P. Chrousos, G.B. Cutler Jr. Factitious cushing syndrome J Clin Endocrinol Metab, 81 (10) (1996 Oct), pp. 3573-3577, 10.1210/jcem.81.10.8855803 PMID: 8855803 View article View in ScopusGoogle Scholar [7] R. Patel, S. Sherf, N.B. Lai, R. Yu Exogenous cushing syndrome caused by a "herbal" supplement AACE Clin Case Rep, 8 (6) (2022 Aug 5), pp. 239-242, 10.1016/j.aace.2022.08.001 PMID: 36447831; PMCID: PMC9701910 View PDFView articleView in ScopusGoogle Scholar [8] C. Dunn, J. Amaya, P. Green A case of iatrogenic cushing's syndrome following use of an over-the-counter arthritis supplement 2023 Case Rep Endocrinol (2023 Mar 11), Article 4769258, 10.1155/2023/4769258 PMID: 36941974; PMCID: PMC10024620 View article View in ScopusGoogle Scholar [9] N. Mikhail, K. Kurator, E. Martey, A. Gaitonde, C. Cabrera, P. Balingit Iatrogenic cushing's syndrome caused by adulteration of a health product with dexamethasone Int J Endovascul Treatment Innovat Techn, 3 (1) (2022 Nov 23), pp. 6-9 Google Scholar [10] L. Del Carpio-Orantes, A.Q. Barrat-Hernández, A. Salas-González Iatrogenic Cushing syndrome due to fallacious herbal supplements. The case of ortiga ajo rey and Artri king Colegio de Medicina Interna de México, 37 (4) (2021), pp. 599-602 https://doi:10.24245/mim.v37i4.3912 Google Scholar [11] F. Wahab, R.A. Rahman, L.H. Yaacob, N.M. Noor, N. Draman A case report of steroid withdrawal syndrome Korean J Fam Med, 41 (5) (2020 Sep), pp. 359-362, 10.4082/kjfm.18.0181 Epub 2020 Sep 18. PMID: 32961047; PMCID: PMC7509117 View article View in ScopusGoogle Scholar [12] M. Zuluaga Quintero, A. Ramírez, A. Palacio, J.F. Botero, A. Clavijo Síndrome de Cushing exógeno e insuficiencia adrenal relacionada con consumo de producto natural Acta Méd Colomb, 42 (4) (2017), pp. 243-246, 10.36104/amc.2017.1006 View article Google Scholar [13] R. Patell, R. Dosi, S. Sheth, P. Jariwala Averting a crisis by 'add'ing up the clues 2014:bcr2014204685 BMJ Case Rep (2014 Jun 2), 10.1136/bcr-2014-204685 PMID: 24891489; PMCID: PMC4054156 View article Google Scholar [14] H. Hendarto Iatrogenic Cushing's syndrome caused by treatment with traditional herbal medicine, a case report 1st International Integrative Conference on Health, Life and Social Sciences (ICHLaS 2017) (2017 Dec), 10.2991/ichlas-17.2017.9 Atlantis Press View article Google Scholar [15] P.C. Oldenburg-Ligtenberg, M.M. van der Westerlaken A woman with Cushing's syndrome after use of an Indonesian herb: a case report Neth J Med, 65 (4) (2007 Apr), pp. 150-152 PMID: 17452765 View in ScopusGoogle Scholar [16] F. Azizi, A. Jahed, M. Hedayati, M. Lankarani, H.S. Bejestani, F. Esfahanian, N. Beyraghi, A. Noroozi, F. Kobarfard Outbreak of exogenous Cushing's syndrome due to unlicensed medications Clin Endocrinol, 69 (6) (2008 Dec), pp. 921-925, 10.1111/j.1365-2265.2008.03290.x Epub 2008 May 6. PMID: 18462262 View article View in ScopusGoogle Scholar [17] C. Martini, E. Zanchetta, M. Di Ruvo, A. Nalesso, M. Battocchio, E. Gentilin, E. Degli Uberti, R. Vettor, M.C. Zatelli Cushing in a leaf: endocrine disruption from a natural remedy J Clin Endocrinol Metab, 101 (8) (2016 Aug), pp. 3054-3060, 10.1210/jc.2016-1490 Epub 2016 May 24. PMID: 27218272 View article View in ScopusGoogle Scholar [18] A.J. Razenberg, J.W. Elte, A.P. Rietveld, H.C. van Zaanen, M.C. Cabezas A 'smart' type of Cushing's syndrome Eur J Endocrinol, 157 (6) (2007 Dec), pp. 779-781, 10.1530/EJE-07-0538 PMID: 18057386 View article View in ScopusGoogle Scholar [19] COFEPRIS (Federal Committee for Protection from Sanitary Risks) Public notification: COFEPRIS alerts about the illegal marketing of the product "ARTRI AJO KING", Which does not have a sanitary registration https://www.gob.mx/cofepris/articulos/cofepris-alerta-sobre-comercializacion-ilegal-del-producto-artri-ajo-king-el-cual-no-cuenta-con-registro-sanitario?idiom=es Google Scholar [20] Ministry of Health Malaysia Public notification: the truth about Maahun/Jamu http://www.myhealth.gov.my/en/the-truth-about-maajunjamu/ (2023) Google Scholar [21] INVIMA (National Food and Drug Surveillance Institute of Colombia) Health Alert: safety information about the product "ARTRIVID PLUS" promoted in different media of the country https://app.invima.gov.co/alertas/ckfinder/userfiles/files/ALERTAS%20SANITARIAS/medicamentos_pbiologicos/2015/Abril/ARTRIVID%20PLUS.pdf Google Scholar [22] FDA Public notification: Artri ajo king contains hidden drug ingredient https://www.fda.gov/drugs/medication-health-fraud/public-notification-artri-ajo-king-contains-hidden-drug-ingredient (2022) Google Scholar [23] FDA Public Notification: Artri King contains hidden drug ingredients https://www.fda.gov/drugs/medication-health-fraud/public-notification-artri-king-contains-hidden-drug-ingredients (2022) Google Scholar [24] FDA warns consumers not to purchase or use Artri and Ortiga products, which may contain hidden drug ingredients https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-consumers-not-purchase-or-use-artri-and-ortiga-products-which-may-contain-hidden-drug Google Scholar [25] P. Kempegowda, L. Quinn, L. Shepherd, S. Kauser, B. Johnson, A. Lawson, A. Bates Adrenal insufficiency from steroid-containing complementary therapy: importance of detailed history Endocrinol Diabetes Metab Case Rep, 2019 (1) (2019 Jul 26), pp. 1-4, 10.1530/EDM-19-0047 PMID: 31352697; PMCID: PMC6685090 View article Google Scholar [26] M.M. Pineyro, L. Redes, S. De Mattos, L. Sanchez, E. Brignardello, V. Bianchi, V. Ems, D. Centurión, M. Viola Factitious cushing's syndrome: a diagnosis to consider when evaluating hypercortisolism Front Endocrinol, 10 (2019 Mar 4), p. 129, 10.3389/fendo.2019.00129 PMID: 30886602; PMCID: PMC6409302 View article View in ScopusGoogle Scholar From https://www.sciencedirect.com/science/article/pii/S2214624523000199

Adrenal incidentalomas (AI) are associated with an increased risk of cardiometabolic complications due to adrenal hyperfunction. Obtaining accurate prevalence estimates of distinct types of functioning AIs is crucial for efficient resource allocation and effective management strategies. For a study, researchers sought to ascertain the prevalence of various forms of autonomous hormone secretion in individuals diagnosed with adrenal incidentaloma, including autonomous/possible autonomous cortisol secretion (ACS), primary aldosteronism (PA), pheochromocytoma (PHEO), and Cushing syndrome (CS). A comprehensive and systematic search was conducted across multiple databases (PubMed, Ovid MEDLINE, Web of Science) up to February 2022. Among the 1,661 publications initially screened at the title and abstract levels, 161 articles underwent full-text examination, and ultimately, 36 studies were included for analysis. Three independent reviewers meticulously extracted clinical data from these selected studies. The overarching prevalence of functioning adrenal incidentalomas was 27.5% (95% CI 23.0, 32.5). The highest prevalence was observed for ACS/possible ACS, with a rate of 11.7% (95% CI 8.6, 15.7), followed by PA at 4.4% (95% CI 3.1, 6.2). Subgroup analysis unveiled a greater prevalence of PA in patients from Asian regions than those from Europe/America. Conversely, the prevalence of ACS/possible ACS was comparatively lower in Asian countries. Meta-regression analysis elucidated that the proportion of female patients influenced the prevalence of ACS/possible ACS, while PA prevalence positively correlated with the proportion of patients with hypertension and the publication year. PHEO and CS demonstrated prevalences of 3.8% (95% CI 2.8, 5.0) and 3.1% (95% CI 2.3, 4.3), respectively. The comprehensive meta-analysis offered valuable insights into the prevalence rates of diverse types of functioning adrenal incidentalomas and identified influential factors contributing to heterogeneity in these estimates. The findings contributed significantly to understanding clinical implications and aided in devising effective management strategies for individuals diagnosed with these adrenal disorders. Source: academic.oup.com/jcem/article-abstract/108/7/1813/7015785?redirectedFrom=fulltext

Abstract Background As the population ages, the number of elderly patients with an indication for pituitary surgery is rising. Information on the outcome of patients aged over 75 is limited. This study reports a large series assessing the feasibility of surgical resection in this specific age range, focusing on surgical complications and postoperative results. Methods A retrospective cohort study of patients with pituitary adenomas and Rathke’s cleft cysts was conducted. All patients were aged 75 years or over and treated by a single expert neurosurgical team. A control population included 2379 younger adult patients operated by the same surgeons during the same period. Results Between 2008 and 2022, 155 patients underwent surgery. Indication was based on vision impairment in most patients (79%). Median follow-up was 13 months (range: 3–96). The first surgery was performed with an endoscopic transsellar approach, an extended endonasal transtuberculum approach and a microscopic transcranial approach in 96%, 3%, and 1% of patients, respectively. Single surgery was sufficient to obtain volume control in 97% of patients. From Kaplan-Meier estimates, 2-year and 5-year disease control with a single surgery were 97.3% and 86.2%, respectively. Resection higher than 80% was achieved in 77% of patients. No vision worsening occurred. In acromegaly and Cushing’s disease, endocrine remission was obtained in 90% of non-invasive adenomas. Surgical complications were noted in 5% of patients, with 30-day mortality, hematoma, cerebrospinal fluid leak, meningitis, and epistaxis occurring in 0.6%, 0.6%, 1.9%, 0.6%, and 1.3% respectively. New endocrine anterior deficits occurred in only 5%, while no persistent diabetes insipidus was noted. Compared with younger patients, the complication rate was not statistically different. Conclusions Surgery beyond the age of 75, mainly relying on an endoscopic endonasal transsellar approach, is effective and safe, provided that patients are managed in tertiary centers. This is a preview of subscription content, access via your institution. Abbreviations CSF: Cerebrospinal fluid ASA: American Society of Anesthesiologists Physical Status Classification System References Albano L, Losa M, Barzaghi LR, Niranjan A, Siddiqui Z, Flickinger JC, Lunsford LD, Mortini P (2021) Gamma Knife radiosurgery for pituitary tumors: a systematic review and meta-analysis. Cancers (Basel) 13(19):4998 Article PubMed Google Scholar Alexander TD, Chitguppi C, Collopy S et al (2022) Surgical outcomes of endoscopic transsphenoidal pituitary adenoma resection in elderly versus younger patients. J Neurol Surg B Skull Base 83(4):405–410 Article PubMed PubMed Central Google Scholar Baussart B, Declerck A, Gaillard S (2021) Mononostril endoscopic endonasal approach for pituitary surgery. Acta Neurochir (Wien) 163(3):655–659 Article PubMed Google Scholar Baussart B, Racy E, Gaillard S (2022) Double pedicled nasoseptal flap for skull base repair after endoscopic expanded endonasal approach. Acta Neurochir (Wien) 164(4):1111–1114 Article PubMed Google Scholar Baussart B, Venier A, Jouinot A, Reuter G, Gaillard S (2022) Closure strategy for endoscopic pituitary surgery: experience from 3015 patients. Front Oncol 12:1067312 Article PubMed Google Scholar Biamonte E, Betella N, Milani D, Lasio GB, Ariano S, Radice S, Lavezzi E, Mazziotti G, Lania A (2021) Impact of age on postsurgical outcomes of nonfunctioning pituitary adenomas. Endocrine 72(3):915–922 Article CAS PubMed Google Scholar Castinetti F, Nagai M, Dufour H, Kuhn J-M, Morange I, Jaquet P, Conte-Devolx B, Regis J, Brue T (2007) Gamma Knife radiosurgery is a successful adjunctive treatment in Cushing’s disease. Eur J Endocrinol 156(1):91–98 Article CAS PubMed Google Scholar Chalif EJ, Couldwell WT, Aghi MK (2022) Effect of facility volume on giant pituitary adenoma neurosurgical outcomes. J Neurosurg 14:1–10 Google Scholar Chen SH, Sprau A, Chieng L, Buttrick S, Alam ES, Ali SC, Madhavan K, Sargi ZB, Komotar R (2019) Transsphenoidal approach for pituitary adenomas in elderly patients. World Neurosurg 121:e670–e674 Article PubMed Google Scholar Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40(2):225–236 (discussion 236-237) Article CAS PubMed Google Scholar Cossu G, Jouanneau E, Cavallo LM et al (2022) Surgical management of giant pituitary neuroendocrine tumors: meta-analysis and consensus statement on behalf of the EANS skull base section. Brain Spine 2:100878 Article PubMed PubMed Central Google Scholar Ding D, Mehta GU, Patibandla MR et al (2019) Stereotactic radiosurgery for acromegaly: an international multicenter retrospective cohort study. Neurosurg 84(3):717–725 Article Google Scholar Eichberg DG, Di L, Shah AH, Luther E, Richardson AM, Sarkiss CA, Ivan ME, Komotar RJ (2019) Brain tumor surgery is safe in octogenarians and nonagenarians: a single-surgeon 741 patient series. World Neurosurg 132:e185–e192 Article PubMed Google Scholar Engel JS, Tran J, Khalil N, Hladkowicz E, Lalu MM, Huang A, Wong CL, Hutton B, Dhesi JK, McIsaac DI (2023) A systematic review of perioperative clinical practice guidelines for care of older adults living with frailty. Br J Anaesth 130(3):262–271 Article PubMed Google Scholar Ezzat S, Asa SL, Couldwell WT, Barr CE, Dodge WE, Vance ML, McCutcheon IE (2004) The prevalence of pituitary adenomas: a systematic review. Cancer 101(3):613–619 Article PubMed Google Scholar Falk Erhag H, Guðnadóttir G, Alfredsson J, Cederholm T, Ekerstad N, Religa D, Nellgård B, Wilhelmson K (2023) The association between the clinical frailty scale and adverse health outcomes in older adults in acute clinical settings - a systematic review of the literature. Clin Interv Aging 18:249–261 Article PubMed PubMed Central Google Scholar Fleseriu M, Auchus R, Bancos I et al (2021) Consensus on diagnosis and management of Cushing’s disease: a guideline update. Lancet Diabetes Endocrinol 9(12):847–875 Article PubMed PubMed Central Google Scholar Frara S, Rodriguez-Carnero G, Formenti AM, Martinez-Olmos MA, Giustina A, Casanueva FF (2020) Pituitary tumors centers of excellence. Endocrinol Metab Clin North Am 49(3):553–564 Article PubMed Google Scholar Gaillard S (2014) The transition from microscopic to endoscopic transsphenoidal surgery in high-caseload neurosurgical centers: the experience of Foch Hospital. World Neurosurg 82(6 Suppl):S116-120 Article PubMed Google Scholar Giustina A, Chanson P, Bronstein MD et al (2010) A consensus on criteria for cure of acromegaly. J Clin Endocrinol Metab 95(7):3141–3148 Article CAS PubMed Google Scholar Gondim JA, Almeida JP, de Albuquerque LAF, Gomes E, Schops M, Mota JI (2015) Endoscopic endonasal transsphenoidal surgery in elderly patients with pituitary adenomas. J Neurosurg 123(1):31–38 Article PubMed Google Scholar Horvath B, Kloesel B, Todd MM, Cole DJ, Prielipp RC (2021) The evolution, current value, and future of the American Society of Anesthesiologists Physical Status Classification System. Anesthesiology 135(5):904–919 Article PubMed Google Scholar Kinoshita Y, Taguchi A, Tominaga A, Arita K, Yamasaki F (2021) Pseudocapsular resection in elderly patients with non-functioning pituitary adenoma. Clin Neurol Neurosurg 210:106997 Article PubMed Google Scholar Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33(4):610–617 (discussion 617-618) CAS PubMed Google Scholar Lee C-C, Sheehan JP (2016) Advances in Gamma Knife radiosurgery for pituitary tumors. Curr Opin Endocrinol Diabetes Obes 23(4):331–338 Article CAS PubMed Google Scholar Leiner T, Nemeth D, Hegyi P, Ocskay K, Virag M, Kiss S, Rottler M, Vajda M, Varadi A, Molnar Z (2022) Frailty and emergency surgery: results of a systematic review and meta-analysis. Front Med (Lausanne) 9:811524 Article PubMed Google Scholar Lin H-S, Watts JN, Peel NM, Hubbard RE (2016) Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 16(1):157 Article PubMed PubMed Central Google Scholar Lu VM, Ravindran K, Perry A, Graffeo CS, Dawood HY, Van Gompel JJ, Mekary RA, Smith TR (2020) Recurrence of Rathke’s cleft cysts based on gross total resection of cyst wall: a meta-analysis. Neurosurg Rev 43(3):957–966 Article PubMed Google Scholar Maiuri F, Corvino S, Lorenzetti M, Franca RA, Esposito F, Caro Del Basso De M (2023) Intracranial meningiomas in patients aged ≥80 years: pathological features and surgical problems. World Neurosurg 173:e498–e508 Article PubMed Google Scholar Marcus HJ, Khan DZ, Borg A et al (2021) Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection. Pituitary 24(6):839–853 Article PubMed PubMed Central Google Scholar Melmed S (ed) (2017) The pituitary, 4th edn. Elsevier/Academic Press, London, United Kingdom, San Diego Google Scholar Melmed S, Kaiser UB, Lopes MB et al (2022) Clinical biology of the pituitary adenoma. Endocr Rev 43(6):1003–1037 Article PubMed PubMed Central Google Scholar Memel Z, Chesney K, Pangal DJ, Bonney PA, Carmichael JD, Zada G (2019) Outcomes following transsphenoidal pituitary surgery in the elderly: a retrospective single-center review. Oper Neurosurg (Hagerstown) 16(3):302–309 Article PubMed Google Scholar Messerer M, De Battista JC, Raverot G, Kassis S, Dubourg J, Lapras V, Trouillas J, Perrin G, Jouanneau E (2011) Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus 30(4):E11 Article PubMed Google Scholar Micko A, Oberndorfer J, Weninger WJ, Vila G, Höftberger R, Wolfsberger S, Knosp E (2019) Challenging Knosp high-grade pituitary adenomas. J Neurosurg 132(6):1739–1746 Article PubMed Google Scholar Minniti G, Esposito V, Piccirilli M, Fratticci A, Santoro A, Jaffrain-Rea M-L (2005) Diagnosis and management of pituitary tumours in the elderly: a review based on personal experience and evidence of literature. Eur J Endocrinol 153(6):723–735 Article CAS PubMed Google Scholar Minniti G, Filippi AR, Osti MF, Ricardi U (2017) Radiation therapy for older patients with brain tumors. Radiat Oncol 12(1):101 Article PubMed PubMed Central Google Scholar Minniti G, Scaringi C, Poggi M, Jaffrain Rea ML, Trillò G, Esposito V, Bozzao A, Enrici MM, Toscano V, Enrici RM (2015) Fractionated stereotactic radiotherapy for large and invasive non-functioning pituitary adenomas: long-term clinical outcomes and volumetric MRI assessment of tumor response. Eur J Endocrinol 172(4):433–441 Article CAS PubMed Google Scholar Mortini P, Nocera G, Roncelli F, Losa M, Formenti AM, Giustina A (2020) The optimal numerosity of the referral population of pituitary tumors centers of excellence (PTCOE): a surgical perspective. Rev Endocr Metab Disord 21(4):527–536 Article PubMed Google Scholar Nidadavolu LS, Ehrlich AL, Sieber FE, Oh ES (2020) Preoperative evaluation of the frail patient. Anesth Analg 130(6):1493–1503 Article PubMed PubMed Central Google Scholar Ostrom QT, Cioffi G, Gittleman H, Patil N, Waite K, Kruchko C, Barnholtz-Sloan JS (2019) CBTRUS statistical report: primary brain and other central nervous system tumors diagnosed in the United States in 2012–2016. Neuro Oncol 21(Suppl 5):v1–v100 Article PubMed PubMed Central Google Scholar Pereira MP, Oh T, Joshi RS et al (2020) Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma. Neurosurg Focus 49(4):E19 Article PubMed Google Scholar Quah BL, Edwards-Bailey A, Gnanalingham K, Pathmanaban O, Vasilopoulos H, Roncaroli F, Kearney T, Balogun J, Karabatsou K (2022) Endoscopic transsphenoidal surgery for biochemically and clinically non-functioning adenohypophyseal tumours in the elderly: experience from a single UK centre. Endocrine 75(3):872–882 Article CAS PubMed Google Scholar Robenshtok E, Benbassat CA, Hirsch D, Tzvetov G, Cohen ZR, Iraqi HM, Gorshtein A, Toledano Y, Shimon I (2014) Clinical course and outcome of nonfunctioning pituitary adenomas in the elderly compared with younger age groups. Endocr Pract 20(2):159–164 Article PubMed Google Scholar Saleh A, Thirukumaran C, Mesfin A, Molinari RW (2017) Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients. Spine J 17(8):1106–1112 Article PubMed Google Scholar Sheehan JM, Douds GL, Hill K, Farace E (2008) Transsphenoidal surgery for pituitary adenoma in elderly patients. Acta Neurochir (Wien) 150(6):571–574 (discussion 574) Article CAS PubMed Google Scholar Sheehan JP, Starke RM, Mathieu D et al (2013) Gamma Knife radiosurgery for the management of nonfunctioning pituitary adenomas: a multicenter study: clinical article. JNS 119(2):446–456 Article Google Scholar Sherlock M, Ayuk J, Tomlinson JW, Toogood AA, Aragon-Alonso A, Sheppard MC, Bates AS, Stewart PM (2010) Mortality in patients with pituitary disease. Endocr Rev 31(3):301–342 Article PubMed Google Scholar Spina A, Losa M, Mortini P (2019) Pituitary adenomas in elderly patients: clinical and surgical outcome analysis in a large series. Endocrine 65(3):637–645 Article CAS PubMed Google Scholar Tardivo V, Penner F, Garbossa D, Di Perna G, Pacca P, Salvati L, Altieri R, Grottoli S, Zenga F (2020) Surgical management of pituitary adenomas: does age matter? Pituitary 23(2):92–102 Article PubMed Google Scholar Thakur JD, Corlin A, Mallari RJ et al (2021) Pituitary adenomas in older adults (≥ 65 years): 90-day outcomes and readmissions: a 10-year endoscopic endonasal surgical experience. Pituitary 24(1):14–26 Article CAS PubMed Google Scholar Trouillas J, Jaffrain-Rea M-L, Vasiljevic A, Raverot G, Roncaroli F, Villa C (2020) How to classify the pituitary neuroendocrine tumors (PitNET)s in 2020. Cancers (Basel) 12(2):E514 Article Google Scholar Tuleasca C, Ducos Y, Leroy H-A, Chanson P, Knafo S, Levivier M, Aghakhani N, Parker F (2020) Transsphenoidal resection for pituitary adenoma in elderly versus younger patients: a systematic review and meta-analysis. Acta Neurochir (Wien) 162(6):1297–1308 Article PubMed Google Scholar Villa C, Vasiljevic A, Jaffrain-Rea ML et al (2019) A standardised diagnostic approach to pituitary neuroendocrine tumours (PitNETs): a European Pituitary Pathology Group (EPPG) proposal. Virchows Arch 475(6):687–692 Article CAS PubMed Google Scholar Wilson PJ, Omay SB, Kacker A, Anand VK, Schwartz TH (2018) Endonasal endoscopic pituitary surgery in the elderly. J Neurosurg 128(2):429–436 Article PubMed Google Scholar Yunoue S, Tokimura H, Tominaga A et al (2014) Transsphenoidal surgical treatment of pituitary adenomas in patients aged 80 years or older. Neurosurg Rev 37(2):269–276 (discussion 276-277) Article PubMed Google Scholar Zhan R, Ma Z, Wang D, Li X (2015) Pure endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary adenomas in the elderly: surgical outcomes and complications in 158 patients. World Neurosurg 84(6):1572–1578 Article PubMed Google Scholar Zietlow KE, Wong S, Heflin MT, McDonald SR, Sickeler R, Devinney M, Blitz J, Lagoo-Deenadayalan S, Berger M (2022) Geriatric preoperative optimization: a review. Am J Med 135(1):39–48 Article PubMed Google Scholar Download references Author information Authors and Affiliations Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de L’Hôpital, 75013, Paris, France Marta Garvayo, Vincent Reina, Stephan Gaillard & Bertrand Baussart Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland Marta Garvayo & Mahmoud Messerer Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France Chiara Villa, Anne Jouinot, Jérôme Bertherat, Guillaume Assié & Bertrand Baussart Department of Neuropathology, La Pitié-Salpêtière University Hospital, AP-HP, Sorbonne University, Paris, France Chiara Villa Department of Endocrinology, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne Billancourt, France Mirella Hage & Marie-Laure Raffin-Sanson Université de Versailles Saint-Quentin-en-Yvelines UFR Des Sciences de La Santé Simone Veil, Montigny-Le-Bretonneux, France Mirella Hage & Marie-Laure Raffin-Sanson Department of Endocrinology and Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement, CRMERC, Endo-ERN, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France Carine Courtillot & Anne Bachelot 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, Le Kremlin-Bicêtre, France Peter Kamenicky & Philippe Chanson Sorbonne University, Endocrine Unit, Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement (CRMERC), Endo-ERN (Id 739527), Saint-Antoine Hospital, AP-HP, Paris, France Camille Vatier & Sophie Christin-Maitre Inserm UMRS938, Saint-Antoine Research Center, Sorbonne University, 75012, Paris, France Camille Vatier INSERM UMR-833, Trousseau Hospital, Paris, France Sophie Christin-Maitre Department of Endocrinology, Center of Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France Jérôme Bertherat & Guillaume Assié Corresponding author Correspondence to Bertrand Baussart. 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