MaryO

It’s Here! Dr. Cushing was born in Cleveland Ohio. The fourth generation in his family to become a physician, he showed great promise at Harvard Medical School and in his residency at Johns Hopkins Hospital (1896 to 1900), where he learned cerebral surgery under William S. Halsted After studying a year in Europe, he introduced the blood pressure sphygmomanometer to the U.S.A. He began a surgical practice in Baltimore while teaching at Johns Hopkins Hospital (1901 to 1911), and gained a national reputation for operations such as the removal of brain tumors. From 1912 until 1932 he was a professor of surgery at Harvard Medical School and surgeon in chief at Peter Bent Brigham Hospital in Boston, with time off during World War I to perform surgery for the U.S. forces in France; out of this experience came his major paper on wartime brain injuries (1918). In addition to his pioneering work in performing and teaching brain surgery, he was the reigning expert on the pituitary gland since his 1912 publication on the subject; later he discovered the condition of the pituitary now known as “Cushing’s disease“. Read more about Dr. Cushing Today, April 8th, is Cushing’s Awareness Day. Please wear your Cushing’s ribbons, t-shirts, awareness bracelets or Cushing’s colors (blue and yellow) and hand out Robin’s wonderful Awareness Cards to get a discussion going with anyone who will listen. And don’t just raise awareness on April 8. Any day is a good day to raise awareness. I found this biography fascinating! I found Dr. Cushing’s life to be most interesting. I had previously known of him mainly because his name is associated with a disease I had – Cushing’s. This book doesn’t talk nearly enough about how he came to discover the causes of Cushing’s disease, but I found it to be a valuable resource, anyway. I was so surprised to learn of all the “firsts” Dr. Cushing brought to medicine and the improvements that came about because of him. Dr. Cushing introduced the blood pressure sphygmomanometer to America, and was a pioneer in the use of X-rays. He even won a Pulitzer Prize. Not for medicine, but for writing the biography of another Doctor (Sir William Osler). Before his day, nearly all brain tumor patients died. He was able to get the number down to only 5%, unheard of in the early 1900s. This is a very good book to read if you want to learn more about this most interesting, influential and innovative brain surgeon. What Would Harvey Say? http://cushieblog.files.wordpress.com/2013/08/harvey-book.jpeg?resize=183%2C276 (BPT) – More than 80 years ago renowned neurosurgeon, Dr. Harvey Cushing, discovered a tumor on the pituitary gland as the cause of a serious, hormone disorder that leads to dramatic physical changes in the body in addition to life-threatening health concerns. The discovery was so profound it came to be known as Cushing’s disease. While much has been learned about Cushing’s disease since the 1930s, awareness of this rare pituitary condition is still low and people often struggle for years before finding the right diagnosis. Read on to meet the man behind the discovery and get his perspective on the present state of Cushing’s disease. * What would Harvey Cushing say about the time it takes for people with Cushing’s disease to receive an accurate diagnosis? Cushing’s disease still takes too long to diagnose! Despite advances in modern technology, the time to diagnosis for a person with Cushing’s disease is on average six years. This is partly due to the fact that symptoms, which may include facial rounding, thin skin and easy bruising, excess body and facial hair and central obesity, can be easily mistaken for other conditions. Further awareness of the disease is needed as early diagnosis has the potential to lead to a more favorable outcome for people with the condition. * What would Harvey Cushing say about the advances made in how the disease is diagnosed? Significant progress has been made as several options are now available for physicians to use in diagnosing Cushing’s disease. In addition to routine blood work and urine testing, health care professionals are now also able to test for biochemical markers – molecules that are found in certain parts of the body including blood and urine and can help to identify the presence of a disease or condition. * What would Harvey Cushing say about disease management for those with Cushing’s disease today? Patients now have choices but more research is still needed. There are a variety of disease management options for those living with Cushing’s disease today. The first line and most common management approach for Cushing’s disease is the surgical removal of the tumor. However, there are other management options, such as medication and radiation that may be considered for patients when surgery is not appropriate or effective. * What would Harvey Cushing say about the importance of ongoing monitoring in patients with Cushing’s disease? Routine check-ups and ongoing monitoring are key to successfully managing Cushing’s disease. The same tests used in diagnosing Cushing’s disease, along with imaging tests and clinical suspicion, are used to assess patients’ hormone levels and monitor for signs and symptoms of a relapse. Unfortunately, more than a third of patients experience a relapse in the condition so even patients who have been surgically treated require careful long-term follow up. * What would Harvey Cushing say about Cushing’s disease patient care? Cushing’s disease is complex and the best approach for patients is a multidisciplinary team of health care professionals working together guiding patient care. Whereas years ago patients may have only worked with a neurosurgeon, today patients are typically treated by a variety of health care professionals including endocrinologists, neurologists, radiologists, mental health professionals and nurses. We are much more aware of the psychosocial impact of Cushing’s disease and patients now have access to mental health professionals, literature, patient advocacy groups and support groups to help them manage the emotional aspects of the disease. Learn More Novartis is committed to helping transform the care of rare pituitary conditions and bringing meaningful solutions to people living with Cushing’s disease. Recognizing the need for increased awareness, Novartis developed the “What Would Harvey Cushing Say?” educational initiative that provides hypothetical responses from Dr. Cushing about various aspects of Cushing’s disease management based on the Endocrine Society’s Clinical Guidelines. For more information about Cushing’s disease, visit www.CushingsDisease.com or watch educational Cushing’s disease videos on the Novartis YouTube channel at www.youtube.com/Novartis. From http://www.jsonline.com/sponsoredarticles/health-wellness/what-would-harvey-cushing-say-about-cushings-disease-today8087390508-253383751.html

The above is the official Cushing’s path to a diagnosis but here’s how it seems to be in real life: http://cushieblog.files.wordpress.com/2012/03/cushie-diagnosis.gif?resize=500%2C500 Egads! I remember the naive, simple days when I thought I’d give them a tube or two of blood and they’d tell me I had Cushing’s for sure. Who knew that diagnosing Cushing’s would be years of testing, weeks of collecting every drop of urine, countless blood tests, many CT and MRI scans… Then going to NIH, repeating all the above over 6 weeks inpatient plus an IPSS test, apheresis (this was experimental at NIH) and specialty blood tests… The path to a Cushing’s diagnosis is a long and arduous one but you have to stick with it if you believe you have this Syndrome.

In Day 9 on April 9, 2015, I wrote about how we got the Cushing’s colors of blue and yellow. This post is going to be about the first Cushing’s ribbons. http://cushieblog.files.wordpress.com/2012/04/janice-ribbon.jpg?w=500 I was on vacation in September, 2001 when SuziQ called me to let me know that we had had our first Cushie casualty (that we knew about). The image at the top of the page shows the first blue and yellow ribbon which were worn at Janice’s funeral. When we had our “official ribbons” made, we sent several to Janice’s family. Janice was the first of us to die but there have been more, way too many more, over the years. I’ll write a bit more about that on Day 21.

This is one of the suggestions from the Cushing’s Awareness Challenge post: Our “Official mascot” is the zebra. Our mascot In med school, student doctors are told “When you hear hoofbeats, think horses, not zebras“. According to Wikipedia: “Zebra is a medical slang term for a surprising diagnosis. Although rare diseases are, in general, surprising when they are encountered, other diseases can be surprising in a particular person and time, and so “zebra” is the broader concept. The term derives from the aphorism ‘When you hear hoofbeats behind you, don’t expect to see a zebra’, which was coined in a slightly modified form in the late 1940s by Dr. Theodore Woodward, a former professor at the University of Maryland School of Medicine in Baltimore. Since horses are the most commonly encountered hoofed animal and zebras are very rare, logically you could confidently guess that the animal making the hoofbeats is probably a horse. A zebra cup my DH bought me 🙂 By 1960, the aphorism was widely known in medical circles.” Why? Because those of us who DO have a rare disorder know from personal experience what it feels like to be dismissed by a doctor or in many cases, multiple doctors. Many physicians have completely lost the ability to even imagine that zebras may exist! Cushing’s is too rare – you couldn’t possible have that. Well… rare means some people get it. Why couldn’t it be me? Although one of my signature images has a zebra, many have rainbows or butterflies in them so I guess that I consider those my own personal mascots. I posted this in 2010 in 40 Days of Thankfulness: Days Twenty-Two through Thirty Butterflies are something else again. I like them because I would like to think that my life has evolved like a butterfly’s, from something ugly and unattractive to something a big easier on the eye. My Cushie self was the caterpillar, post-op is more butterfly-ish, if not in looks, in good deeds. From July, 2008

Sleep. Naps. Fatigue, Exhaustion. I still have them all. I wrote on my bio in 1987 after my pituitary surgery “I am still and always tired and need a nap most days. I do not, however, still need to take whole days off just to sleep.” That seems to be changing back, at least on the weekends. A recent weekend, both days, I took 7-hour naps each day and I still woke up tired. That’s awfully close to taking a whole day off to sleep again. In 2006, I flew to Chicago, IL for a Cushing’s weekend in Rockford. Someone else drove us to Lake Geneva, Wisconsin for the day. Too much travel, too Cushie, whatever, I was too tired to stay awake. I actually had put my head down on the dining room table and fallen asleep but our hostess suggested the sofa instead. Amazing that I traveled that whole distance – and missed the main event 🙁 This sleeping thing really impacts my life. Between piano lessons, I take a nap. I sleep as late as possible in the mornings and afternoons are pretty much taken up by naps. I nod off at night during TV. One time I came home between church services and missed the third service because I fell asleep. I only TiVo old tv shows that I can watch and fall asleep to since I already know the ending. A few years ago I was doing physical therapy twice a week for 2 hours at a time for a knee injury (read more about that in Bees Knees). I come home from that exhausted – and in more pain than when I went. I knew it was working and my knee got better for a while, but it’s such a time and energy sapper. Neither of which I can really spare. Maybe now that I’m nearly 15 years out from my kidney cancer (May 9, 2006) I’ve been back on Growth Hormone again. My surgeon says he “thought” it’s ok. I was sort of afraid to ask my endo about it, though but he gave me the go-ahead. I want to feel better and get the benefits of the GH again but I don’t want any type of cancer again and I certainly can’t afford to lose another kidney. I always laugh when I see that commercial online for something called Serovital. I saw it in Costco the other day and it mentions pituitary right on the package. I wish I could take the people buying this, sit them down and tell them not to mess with their pituitary glands. But I won’t. I’ll take a nap instead because I’m feeling so old and weary today, and yesterday. Eventually, I did restart the GH, this time Omnitrope. And tomorrow…

Sponsor: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Information provided by (Responsible Party): National Institutes of Health Clinical Center (CC) ( Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Brief Summary: Background: The pituitary gland produces hormones. A tumor in this gland can cause it to produce too much of the hormone cortisol. Too much cortisol in the body causes Cushing disease. This disease causes many problems. Some of these problems might persist after the disease is cured. Objective: To find out the long-term effects of exposure to high levels of cortisol during childhood and adolescence. Eligibility: People ages 10-42years who were diagnosed with Cushing disease before age 21 and are now cured and have normal or low cortisol levels People related to someone with Cushing disease Design: Participants will be screened with a medical history. Participants will complete an online survey. This will include questions about their or their child s physical and mental health. All participants will be seen at 5 -year intervals after cure of Cushing disease (5yr, 10yr, 15yr, 20yr (last visit)) Participants who have a relative with Cushing disease will have a medical history and blood tests or cheek swabs. Participants who have the disease will have: Physical exam Blood tests Cheek swab DXA scan: A machine will x-ray the participant s body to measure bone mineral content. For participants who are still growing, a hand x-ray Participants with the disease may also have: Hormone stimulation test: Participants will get a hormone or another substance that will be measured. Serial hormone sampling: Participants blood will be measured several times through a thin plastic tube in an arm vein. Urine tests: Participants urine may be collected over 24 hours. MRI: Participants may have a dye injected into a vein. They will lie on a table that slides into a machine. The machine will take pictures of the body. Read more https://clinicaltrials.gov/ct2/show/NCT03831958#eligibility

Background: In Cushing’s syndrome (CS), chronic glucocorticoid excess (GC) and disrupted circadian rhythm lead to insulin resistance (IR), diabetes mellitus, dyslipidaemia and cardiovascular comorbidities. As undifferentiated, self-renewing progenitors of adipocytes, mesenchymal stem cells (MSCs) may display the detrimental effects of excess GC, thus revealing a promising model to study the molecular mechanisms underlying the metabolic complications of CS. Methods: MSCs isolated from the abdominal skin of healthy subjects were treated thrice daily with GCs according to two different regimens: lower, circadian-decreasing (Lower, Decreasing Exposure, LDE) versus persistently higher doses (Higher, Constant Exposure, HCE), aimed at mimicking either the physiological condition or CS, respectively. Subsequently, MSCs were stimulated with insulin and glucose thrice daily, resembling food uptake and both glucose uptake/GLUT-4 translocation and the expression of LIPE, ATGL, IL-6 and TNF-α genes were analyzed at predefined timepoints over three days. Results: LDE to GCs did not impair glucose uptake by MSCs, whereas HCE significantly decreased glucose uptake by MSCs only when prolonged. Persistent signs of IR occurred after 30 hours of HCE to GCs. Compared to LDE, MSCs experiencing HCE to GCs showed a downregulation of lipolysis-related genes in the acute period, followed by overexpression once IR was established. Conclusions: Preserving circadian GC rhythmicity is crucial to prevent the occurrence of metabolic alterations. Similar to mature adipocytes, MSCs suffer from IR and impaired lipolysis due to chronic GC excess: MSCs could represent a reliable model to track the mechanisms involved in GC-induced IR throughout cellular differentiation. Introduction Glucocorticoids (GCs) regulate a variety of physiological processes, such as metabolism, immune response, cardiovascular activity and brain function (1, 2). Chronic excess and dysregulation of GCs induces Cushing’s syndrome (CS), a complex clinical condition characterized by multisystem morbidities such as central obesity, hypertension, type 2 diabetes mellitus, insulin resistance (IR), dyslipidaemia, fatty liver, hypercoagulability, myopathy and osteoporosis (3–5). In patients with CS, GC secretion does not follow the circadian rhythm and consistently high serum GC levels are observed throughout the day (6, 7). IR, defined as the reduced ability of insulin to control the breakdown of glucose in target organs, represents the common thread among obesity, metabolic syndrome and type 2 diabetes mellitus (8). GCs induce IR, but the mechanisms are complex and not completely understood. Under physiological conditions, the binding of insulin to its receptor on the cell surface induces the autophosphorylation of tyrosine in the insulin receptor substrate (IRS)-1 subunit with a consequent complex cascade of intracellular signals that leads to the inhibition of glycogen synthase kinase 3, the inhibition of apoptosis and the translocation of glucose transporter 4 (GLUT4) to the cell membrane with consequent glucose uptake (9, 10). Several studies have shown how chronic exposure to high levels of GCs reduces IRS-1 phosphorylation and protein expression, resulting in a lack of GLUT4 translocation and a reduction in glucose uptake in adipose tissue (11). In addition, the chronic excess of GCs increases lipoprotein activity and expression with subsequent release of circulating fatty acids, which, in turn, induce the phosphorylation of serine in IRS-1, thus compromising the mechanisms that lead to glucose transport into the cell (12). In recent years, the involvement of mesenchymal stem cells (MSCs) in the onset of different pathologies has been addressed, and for some of them, MSCs have been identified as the real target for lasting therapeutic approaches (13, 14). MSCs are undifferentiated cells inside many tissues that are able to self-renew and differentiate into adipocytes, osteocytes and chondrocytes (15). Adipose tissue, muscle tissue and bone are compromised in CS, so the involvement of MSCs in CS complications has been hypothesized; this was confirmed by our previous work reporting that MSCs isolated from the skin of patients affected by CS showed an altered wound healing process that is recognized as a clinical manifestation of CS (16). In this scenario, it is tempting to speculate that the detrimental effects of excess GC could also affect MSCs, which may represent a promising cellular model to study the mechanisms leading to IR. The choice to use MSCs as a model is particularly interesting, since MSCs are the progenitors of mature adipocytes that may inherit and spread dysregulated mechanisms already present in MSCs. Here, MSCs isolated from the abdominal skin of healthy subjects were treated in vitro with two different GC regimens, mimicking circadian cortisol rhythm and chronic hypercortisolism. Subsequently, cells were stimulated with insulin and glucose three times/day, resembling the normal uptake of food, and both glucose uptake and the expression of selected genes were analyzed to clarify the mechanisms underlying the development of IR and the occurrence of altered carbohydrate and lipid metabolism under chronic exposure to high levels of GCs. Materials and Methods Sample Collection Seven abdominal skin samples were collected from healthy subjects (four males and three females age matched 42.3 ± 3.4) undergoing abdominoplasty at the Clinic of Plastic and Reconstructive Surgery, Università Politecnica delle Marche. Patients gave their informed consent; the study was approved by the Università Politecnica delle Marche Ethical Committee and conducted in accordance with the Declaration of Helsinki. The main demographical and clinical characteristics of enrolled patients are summarized in Table 1. TABLE 1 Table 1 Demographical and functional characteristics of enrolled patients. Isolation and Characterization of MSCs Cells were isolated from abdominal skin and then cultured with a Mesenchymal Stem Cell Growth Medium bullet kit (MSCGM, Lonza Group® Ltd) as previously described (16) and characterized according to the criteria by Dominici (15). Plastic adherence, immunophenotype and multipotency were tested as already described (17–19). After the Oil Red staining, a semiquantitative analysis was carried out by dissolving the staining with 100% isopropanol and the absorbance was measured at 510nm in a microplate reader (Thermo Scientific Multiskan GO Microplate Spectrophotometer, Milano, Italy). In addition, the expression of PPAR-γ (peroxisome proliferator-activated receptor gamma) and C/EBP-α (CCAAT/enhancer-binding protein alpha) was tested by Real time PCR to confirm the adipocytes differentiation. Undifferentiated MSCs were used as control (C-MSCs). Briefly, after 21 days of culture in adipocytes differentiation medium, 2.5x105 cells from the 7 patients were collected; cDNA synthesis and qRT–PCR were carried out as previously described (20). The primer sequences are summarized in Table 2. mRNA expression was calculated by the 2−ΔΔCt method (21), where ΔCt=Ct (gene of interest)—Ct (control gene) and Δ (ΔCt)=ΔCt (differentiated MSCs)—ΔCt (undifferentiated MSCs). Genes were amplified in triplicate with the housekeeping genes RPLP0 (Ribosomal Protein Lateral Stalk Subunit P0) and GAPDH (Glyceraldehyde-3-Phosphate Dehydrogenase) for data normalization. Of the two, GAPDH was the most stable and was used for subsequent normalization. The values of the relative expression of the genes are mean ± SD of three independent experiments. TABLE 2 Table 2 Primer sequences. Experimental Design: In Vitro Reproduction of Both Circadian Rhythm and Chronic Excess GCs and Food Uptake Cells were treated with two different GC regimens: some were given lower, circadian-decreasing GC doses (Lower and Decreasing Exposure, LDE), some were exposed to persistently higher GC doses (Higher and Constant Exposure, HCE), to mimic in vitro either the preserved circadian rhythm or its pathologic abolishment in CS, as shown in Figure 1A and described in detail below. LDE cells were first exposed (8:00 a.m.-9:50 a.m.) to 500 nM hydrocortisone (MedChemExpress, MCE, Monmouth Junction, NJ, USA) and then to decreasing concentrations by replacing the medium with a fresh medium containing 250 nM hydrocortisone (9:50 a.m.-01:50 p.m.) and 100 nM (01:50 p.m.-05:50 p.m. and 05:50 p.m.-08:00 a.m.) of hydrocortisone (22). To mimic CS, HCE cells were exposed to 500 nM hydrocortisone for 24/24 hours. The 500 nM hydrocortisone medium was replaced with fresh medium at the same time as the physiological condition medium was changed. FIGURE 1 Figure 1 (A) In vitro reproduction of preserved versus abolished GC circadian rhythm. (B). Daily experimental design. Cells were starved and exposed three times/day to 10 mM glucose with or without prestimulation with 1 μM insulin (Sigma–Aldrich, Milano, Italy) to resemble daily food uptake. Protocol is resumed in Figure 1B. Cells derived from each single patient were divided into six experimental groups (Exp): 1) Exp 1, GLU: Cells exposed to glucose; 2) Exp 2, INS+GLU: Cells stimulated with insulin before glucose exposure; 3) Exp 3, LDE+GLU: LDE cells treated with glucose; 4) Exp 4, HCE+GLU: HCE cells treated with glucose; 5) Exp 5, LDE+INS+GLU: LDE cells stimulated with insulin before glucose exposure; 6) Exp 6, HCE+INS+GLU: HCE cells stimulated with insulin before glucose exposure. In detail, cells were seeded in DMEM/F-12+10% FBS (Corning, NY, USA). After 24 hours, the medium was changed, and the cells were starved overnight with Advanced DMEM/F-12 w/o glucose (Lonza) with 0.5% FBS. At 8:00 a.m., starvation medium was replaced with a new medium containing hydrocortisone 500 nM for 30 minutes in groups exposed to GCs. After washing, the cells were glucose starved with KRPH buffer (20 mM HEPES, 5 mM KH2PO4, 1 mM MgSO4, 1 mM CaCl2, 136 mM NaCl and 4.7 mM KCl, pH 7.4) containing 2% BSA (Sigma–Aldrich) and hydrocortisone for 40 minutes. Cells from Exp 2, 5 and 6 were then stimulated with 1 μM insulin (Sigma–Aldrich) for 20 minutes. Finally, 10 mM glucose was added, and the time sampling was after 20 minutes. The same protocol starting with starvation for 2 hours in DMEM/F-12 w/o glucose was repeated two times during the day, and the hydrocortisone concentration in the medium of LDE and HCE cells varied accordingly. To evaluate the long-term impact on metabolism and IR, the experiment was performed for three days with repeated sampling times after glucose administration: T1, T2 and T3 at 9:50 a.m., 1:50 p.m., 5:50 p.m. of the first day; T4, T5 and T6 at 9:50 a.m., 1:50 p.m., 5:50 p.m. of the second day; T7 at 1:50 p.m. of the third day (Figure 1A). The entire experiment (Exp 1-6, from T1 to T7) was repeated thrice, and data are reported as mean± standard deviation (SD) over the three independent experiments. XTT Assay To evaluate whether repeated starvation steps and treatments would affect cell viability and consequently influence the measurement of glucose uptake, an XTT assay (Sigma–Aldrich) was initially performed. A total of 3x103 cells/well belonging to Exp 1, 2, 4 and 6 derived from the 7 patients were plated in a 96-well plate and treated as previously described. Another experimental group was included as a control, consisting of cells continuously cultured in starvation medium (STARVED CTRL). The XTT assay was performed at the end of each day (T3, T6 and T7 sampling times) following the manufacturer’s instructions. The experiment was repeated thrice, and data are reported as mean ± SD over the three independent experiments. MSCs Responsiveness to Insulin To evaluate whether MSCs were responsive to insulin, glucose uptake and the cellular localization of GLUT4 were first evaluated in MSCs not treated with GCs (Exp 1 and 2) from T1 to T6. For the glucose uptake assay, 3x103 cells/well were plated in a 96-well plate and treated according to the above protocol; after insulin stimulation, 10 mM of 2-deoxyglucose (2-DG) was added for 20 minutes, and a colorimetric assay was performed following the manufacturer’s instructions. The readings were at 420 nm in a microplate reader (Thermo Scientific Multiskan GO Microplate Spectrophotometer, Milano, Italy). For the cellular distribution of GLUT4, 1.5x104 cells (Exp 1 and 2 derived from the 7 patients) were seeded in triplicate on coverslips and treated as indicated before until T5 sampling time. Cells were then washed, fixed with 4% PFA and permeabilized for 30 min. Subsequently, cells were incubated with anti-GLUT4 antibody (Santa Cruz Biotechnology, USA) followed by treatment for 30 min with a goat anti-mouse FITC-conjugated antibody (23). Finally, coverslips were mounted on glass slides in Vectashield (Vectorlabs, CA, USA), and confocal imaging was performed using a Zeiss LSM510/Axiovert 200 M microscope with an objective lens at 20× magnification (24). Line scans were acquired excluding nuclear regions, and GLUT4 immunofluorescence was analyzed as described elsewhere. Effects of Different GC Regimens on Glucose Uptake and GLUT4 Translocation After having proven that MSCs could function as a cellular model, since they were responsive to insulin, the potential effects of both GC regimens on glucose uptake were evaluated. Glucose uptake was measured in the experimental groups treated with GCs (Exp 3, 4, 5 and 6 derived from the 7 patients), and GLUT4 translocation was evaluated in cells from Exp 4 and 6 as described above. Expression of Genes Involved in the Development of IR The expression of selected genes, such as LIPE, ATGL, IL-6 and TNF-α (coding for hormone-sensitive Lipase E, Adipose TriGlyceride Lipase, InterLeukin-6 and Tumour Necrosis Factor-α, respectively), was evaluated to clarify the mechanisms involved in the development of IR in MSCs (25–28). A total of 2.5x105 cells/well belonging to Exp 5 and 6 from the 7 patients were seeded in triplicates in a 6-well plate and treated following the experimental design. Pellets were collected at T2 and T7, which were chosen as sampling times representing acute and chronic exposure to GCs. RNA extraction, cDNA synthesis and qRT–PCR were carried out as previously described (20). The primer sequences are summarized in Table 2. mRNA expression was calculated by the 2−ΔΔCt method (21), where ΔCt=Ct (gene of interest)—Ct (control gene) and Δ (ΔCt)=ΔCt (HCE+INS+GLU)—ΔCt (LDE+INS+GLU). All selected genes were amplified in triplicate with the housekeeping genes RPLP0 and GAPDH for data normalization. Of the two, GAPDH was the most stable and was used for subsequent normalization. The values of the relative expression of the genes are mean ± SD of three independent experiments. Statistical Analysis For statistical analysis, GraphPad Prism 6 Software was used. All data are expressed as the mean ± standard deviation (SD). For parametric analysis all groups were first tested for normal distribution by the Shapiro–Wilk test (29) and comparison between 2 groups were performed by unpaired Student’s t test. For two-sample comparisons, significance was calculated by unpaired t-Student’s test while the ordinary one-way ANOVA test was used for multiple comparison (Tukey’s multiple comparisons test). Significance was set at p value < 0.05. Results MSCs Isolation and Characterization From Abdominal Skin MSCs isolated from abdominal skin appeared homogeneous with a fibroblastoid morphology and showed adherence to plastic. According to Dominici’s criteria (17), cells were positive for CD73, CD90 and CD105, and negative for HLA-DR, CD14, CD19, CD34 and CD45. Cells were also able to differentiate towards osteogenic, chondrogenic and adipogenic lineages. After 7 days of osteogenic differentiation, cells showed alkaline phosphatase activity (Figure 2A), and after 14 days, cells were strongly positive for alizarin red staining (Figure 2B). Chondrogenic differentiation was achieved after 30 days, as shown by safranin-O staining (Figure 2C). MSCs differentiation into adipocytes occurred after 21 days, as evidenced by the presence of lipid vacuoles after oil red staining (Figure 2D). Its quantification confirmed as the amount of lipid vacuoles was higher in differentiated cells than in control cells (C-MSCs; Figure 2E). The expression of PPAR-γ and C/EBP-α was tested after 21 days of culture in differentiating medium and it was higher in differentiated than in undifferentiated MSCs (Figures 2F, G). FIGURE 2 Figure 2 Multilineage differentiation of MSCs from abdominal skin. Representative images of MSCs derived from the seven patients and differentiated towards osteogenic lineage as assessed by ALP reaction (A, Scale bar 100μm) and Alizarin red staining (B, Scale bar 100μm); chondrogenic lineage as indicated by Safranin-O staining (C, Scale bar 100 μm); adipocyte lineage as confirmed by Oil red staining (D, Scale bar 100μm); (E) Oil Red staining quantification. Data are expressed as mean ± SD of the absorbance read for undifferentiated and differentiated cells (C-MSCs and DIFF-MSCs respectively). (F, G) Expression of PPAR-γ and C/EBP-α by RT-PCR in differentiated vs undifferentiated MSCs towards adipogenic lineage. Data are expressed as mean ± SD (over three independent experiments) of the X-fold (2−ΔΔCt method) of differentiated MSCs compared to undifferentiated MSCs, arbitrarily expressed as 1, where ΔCt=Ct (gene of interest)—Ct (control gene) and Δ (ΔCt)=ΔCt (DIFF-MSCs)—ΔCt (C-MSCs). Unpaired t-Student’s test; ***p<0.001, ****p<0.0001. Cell Viability by XTT Assay Figure 3 shows that the viability of the STARVED CTRL (cells continuously cultured in starvation medium) was significantly increased compared to that of the HCE cells at T3 but not thereafter. Although repeated interventions caused a proliferation block earlier than starvation alone, the different treatments did not interfere with vitality, and further analyses on glucose uptake were unaffected by different cell mortality during the experiment. FIGURE 3 Figure 3 XTT test. The bars indicate cells’ viability at T3, T6 and T7 sampling times. One-way ANOVA; **p < 0.01 vs STARVED CTRL inside each time sampling. STARVED CTRL: cells continuously cultured in starvation medium; GLU: Cells exposed to glucose; INS+GLU: Cells stimulated with insulin before glucose exposure; HCE+GLU: HCE (Higher and Constant Exposure) cells treated with glucose; HCE+INS+GLU: HCE cells stimulated with insulin before glucose exposure. Data are expressed as mean ± SD of the absorbance read for MSCs derived from each single patient over three independent experiments. MSCs Responsiveness to Insulin As shown in Figure 4, stimulation with insulin significantly increased glucose uptake at T1, T2, T4 and T5, whereas at T3 and T6, the level of glucose uptake did not differ significantly between insulin-treated (Exp2, INS+GLU) and nontreated (Exp1, GLU) cells. FIGURE 4 Figure 4 Responsiveness of MSCs to insulin. The bars show the glucose uptake expressed in pM at T1, T2, T3, T4, T5 and T6 in insulin-stimulated or non-stimulated MSCs. Unpaired t-Student’s test; *p < 0.05, **p < 0.01. GLU: Cells exposed to glucose; INS+GLU: Cells stimulated with insulin before glucose exposure. Data are expressed as mean ± SD of the readings for MSCs derived from each single patient over three independent experiments. Notably, in the absence of insulin, GLUT4 was more localized in the perinuclear area of the cells (Figures 5A, E). Insulin stimulation enhanced GLUT4 translocation towards the plasma membrane (Figures 5B, F). FIGURE 5 Figure 5 GLUT4 translocation. Representative confocal images of GLUT4 in MSCs derived from the seven patients and stimulated (B, D) or not (A, C) with insulin and exposed to 500nM of GCs (C, D). The graphs (E–H) show the fluorescence ratio between the edge and the centre of the cell; yellow arrows indicate the portion of cell subjected to analysis. GLU: Cells exposed to glucose; INS+GLU: Cells stimulated with insulin before glucose exposure; HCE+GLU: HCE (Higher and Constant Exposure) cells treated with glucose; HCE+INS+GLU: HCE cells stimulated with insulin before glucose exposure. Effects of LDE and HCE on GCs on Glucose Uptake and GLUT4 Translocation In LDE cells, insulin induced a significant increase in glucose uptake at all sampling times (Figure 6). Conversely, GC administration did not interfere with glucose uptake by HCE cells in the acute period (T1, T2) but led to a significant decrease in glucose uptake when prolonged (T3, T5, T6, T7). Accordingly, GLUT4 translocation was inhibited irrespective of insulin stimulation (Figures 5C, G and D, H) in HCE cells. FIGURE 6 Figure 6 Glucose uptake in MSCs undergoing a LDE or a HCE to GCs. The bars represent the glucose uptake expressed in pM at T1 (9:50 a.m. first day, A), T2 (1:50 p.m. first day, B), T3 (5:50 p.m. first day, C), T4 (9:50 a.m. second day, D), T5 (1:50 p.m. second day, E), T6 (5:50 p.m. second day, F) and T7(1:50 p.m. third day, G) in MSCs undergoing a LDE or a HCE to GCs and stimulated or not with insulin. One-way ANOVA; *p < 0.05,**p < 0,01,***p < 0,001. LDE+GLU: LDE (Lower and Decreasing Exposure) cells treated with glucose; HCE+GLU: HCE (higher and Constant Exposure) cells treated with glucose; LDE+INS+GLU: LDE cells stimulated with insulin before glucose exposure; HCE+INS+GLU: HCE cells stimulated with insulin before glucose exposure. Data are expressed as mean ± SD of the readings for MSCs derived from each single patient over three independent experiments. Effect on Lipolysis and Development of IR: Gene Expression A downregulation of both genes involved in the breakdown of triglycerides to fatty acids (LIPE and ATGL) was found at T2, whereas at T7, their expression was significantly increased in HCE cells compared to LDE cells. At T7, HCE cells showed a significant increase in the expression of both IL-6 and TNF-α genes, whereas at T2, only the expression of TNF-α was lower than that of LDE cells (Figure 7). FIGURE 7 Figure 7 Gene expression in MSCs undergoing a LDE or a HCE to GCs. The bars display the expression of genes referred specifically to the development of IR: (A): LIPE, (B): ATGL, (C): IL-6 and (D): TNF-α at T2 and T7 sampling times. LDE+GLU+INS: LDE (Lower and Decreasing Exposure) cells stimulated with insulin before glucose exposure; HCE+GLU +INS: HCE (higher and Constant Exposure) cells stimulated with insulin before glucose exposure. Data are expressed as mean ± SD (over three independent experiments) of the X-fold (2−ΔΔCt method) of HCE+INS+GLU compared to LDE+INS+GLU arbitrarily expressed as 1, where ΔCt=Ct (gene of interest)—Ct (control gene) and Δ (ΔCt)=ΔCt (HCE+INS+GLU)—ΔCt (LDE+INS+GLU). Unpaired t-Student’s test; *p < 0.05,**p < 0.01,***p < 0.001;****p < 0.0001. Discussion The clinical presentation of CS is well established, but the mechanisms underlying the onset of some of its complications, IR above all, have not yet been fully understood and may involve tissue-specific players. As progenitors of specialized cellular lines that are directly implicated in the progression of chronic GC excess-induced damage (such as adipocytes, skeletal muscle cells and osteocytes), MSCs are of particular interest: in a previous study, we showed that MSCs derived from the skin of patients with CS displayed dysregulated inflammatory markers and altered expression of genes related to wound healing, demonstrating not only how they could be a useful cellular model to study this event but also their potential contribution to the development of CS manifestations (16). With this premise, we hypothesized that MSCs exposed to excess GC encounter altered glucose uptake mechanisms, which are then inherited and consolidated by their derived, specialized cells. Our work aimed to explore and compare the effects of two different GC regimens (LDE- Lower and Decreasing Exposure- and HCE- Higher and Constant Exposure) on glucose and lipid metabolism in MSCs. First, MSCs were isolated from abdominal skin and characterized by confirming their undifferentiated state (15). To faithfully reproduce the circadian variations in GC concentrations and food intake, cells were treated by following an articulated protocol (Figure 1). It is well established that insulin stimulation promotes glucose uptake via GLUT4 translocation (30–32) in adipocytes and skeletal muscle cells, but the same mechanism has not yet been demonstrated for MSCs. Therefore, the responsiveness of MSCs to insulin, as well as the involvement of GLUT4 in glucose uptake, were addressed before evaluating the effects of GCs. We demonstrated that the exposure of MCSs to insulin increased their glucose uptake and insulin-induced GLUT4 translocation with mechanisms that are similar to those described for adipocytes and muscle cells by confocal imaging. In contrast to what was previously reported for adipocytes (33, 34), GLUT4 expression before insulin stimulation occurred in the cytoplasmic, perinuclear and nuclear compartments in a nonvacuolized pattern. The same localization was observed by Tonack et al. in mouse embryonic stem cells (35). As in adipocytes, the protein translocated on the cell surface, favoring glucose uptake after insulin stimulation. These results opened the second part of the research aimed at evaluating the IR-inducing effects of GCs on MSCs. MSCs were exposed to two different GC regimens: in LDE cells, insulin stimulation always caused an increase in glucose uptake, confirming that insulin sensitivity of MSCs is not altered when cortisol circadian rhythm is preserved; conversely, in HCE cells, an impaired response to insulin was observed, as demonstrated by their decreased glucose uptake. These observations were also confirmed by confocal data, showing how excess GC blocked the insulin-induced translocation of GLUT4 from the intracellular compartment to the cell surface. Of note, a reduction in glucose uptake was not detected in earlier sampling times (T1, T2) but later (T3, T5, T6, T7). These results, taken together with the lack of GLUT4 translocation, suggest that IR develops over time. The development of IR following chronic exposure to GCs has been widely demonstrated in differentiated cells such as adipocytes, hepatocytes, muscle and endothelial cells (36–38), but to our knowledge, this has never been observed in human stem cells before. Our results are in line with those by Gathercole et al. (12), who reported increased insulin-stimulated glucose uptake in a human immortalized subcutaneous adipocyte line (Chub-S7) after acute exposure to dexamethasone, as well as to hydrocortisone (up to 48 hours, in a dose- and time-dependent manner for the latter), thus proposing that the development of GC-induced obesity was promoted by enhanced adipocyte differentiation. However, it must be noted that although Chub-S7 are not fully differentiated adipocytes, they cannot be considered MSCs. In our study, MSCs showed transient signs of IR at T3. In our opinion, this finding represents a physiologic phenomenon and is in line with previous findings in healthy volunteers who were administered hydrocortisone at two different time points and whose endogenous cortisol production was suppressed by metyrapone and nutrient intake was controlled by means of a continuous glucose infusion (39😞 subjects receiving hydrocortisone in the evening showed a more pronounced delayed hyperglycaemic effect than those taking hydrocortisone in the morning (39). Persistent signs of IR in our MSCs appeared even earlier (from T5, after 30 hours of HCE to GCs) than Gathercole’s Chub-S7 (12😞 the ability of MSCs to develop early documentable and conceptually plausible alterations, which can be tracked even once differentiated, further confirms that they are a reliable model for physiopathology studies. The relationship between insulin and lipolysis is bidirectional: inhibition of lipolysis is mainly due to insulin (24), but different mechanisms have been identified where increased lipolysis is involved in the impairment of insulin sensitivity (25, 40). Boden et al. (41) reported that increasing circulating nonesterified fatty acid (NEFA) levels by lipid infusion induced transient IR. To obtain a clearer picture of the possible mechanisms involved in the development of IR in MSCs, we analyzed the expression of LIPE and ATGL genes at different timepoints. We found that HCE cells showed an initial reduction (T2), followed by a significant increase (T7), in the expression of LIPE and ATGL genes compared to LDE cells. The results from previous works on this topic are partially conflicting: Slavin (42) and Villena (43) found upregulated expression of the LIPE and ATGL genes, respectively, after a short treatment with GCs, but studies examining the effects of prolonged GC administration suggested that the acute induction of systemic lipolysis by GCs was not sustained over time (44). However, in these in vitro studies, cells were never treated with insulin, whose counterregulatory effect on lipolysis could not be highlighted. Notably, diabetic patients with CS show an increased activation of lipolysis due to IR (44). Our results fully reflect this scenario, showing that the lipolytic effects are even more marked once insulin levels fail to compensate for associated IR. LIPE and ATGL gene expression was downregulated at T2, when IR had not yet been reached; at T7, when chronic exposure to high GC levels compromised insulin sensitivity, both lipolysis-related enzymes were overexpressed. Of note, increased expression of LIPE and ATGL genes in the presence of IR was also reported by Sumuano et al. in mature adipocytes (37). Given its ability to decrease the tyrosine kinase activity of the insulin receptor, TNF-α is an important mediator of IR in obesity and type 2 diabetes mellitus (26). IL-6 is notably associated with IR by both sustaining low-grade chronic inflammation (45) and impairing the phosphorylation of insulin receptor and IRS-1 (27). In agreement with these statements, TNF-α and IL-6 expression was lower before IR induction (T2) and higher after prolonged exposure (T7) in HCE cells than in LDE cells, further confirming the importance of preserved circadian GC rhythmicity to prevent the occurrence of metabolic alterations. Conclusions MSCs derived from skin could be a good human model for studying the toxic effects of GCs. Like mature adipocytes, they are responsive to insulin stimulation that promotes glucose uptake via GLUT4 translocation, and their chronic exposure to excessive levels of GCs induces the development of IR. For differentiated cells, impaired lipolysis is observed in MSCs once IR has arisen. Furthermore, MSCs could be a promising model to track the mechanisms involved in GC-induced IR throughout cellular differentiation. Functional analyses will be necessary to elucidate the mechanisms behind these first descriptive results and overcame the actual weakness of this research. In addition, co-cultures with MSCs and mature adipocytes will be performed to investigate the crosstalk between these two cell types. 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 human participants were reviewed and approved by Università Politecnica delle Marche Ethical Committee. The patients/participants provided their written informed consent to participate in this study. Author Contributions Conceptualization, MO and GA. Methodology, MDV and MM. Formal analysis, MDV, VL, and CL. Data curation, GDB and GG. Writing—original draft preparation, MO and MDV. Writing—review and editing, MO, GA, and MM. Supervision, MO and GA. All authors have read and agreed to the published version of the manuscript. Funding This work was supported by 2017HRTZYA_005 project grant. 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. 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Front. Endocrinol. 13:816229. doi: 10.3389/fendo.2022.816229 Received: 16 November 2021; Accepted: 20 January 2022;Published: 24 February 2022. Edited by: Pierre De Meyts, Université Catholique de Louvain, Belgium Reviewed by: Jacqueline Beaudry, University of Toronto, CanadaMałgorzata Małodobra-Mazur, Wroclaw Medical University, Poland Copyright © 2022 Di Vincenzo, Martino, Lariccia, Giancola, Licini, Di Benedetto, Arnaldi and Orciani. 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: Giorgio Arnaldi, g.arnaldi@univpm.it †These authors have contributed equally to this work and share first authorship ‡These authors have contributed equally to this work and share last authorship 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.2022.816229/full

So, these are only seven of the many, many symptoms of Cushing’s. I had those above – and I often felt like I looked like one of those little bearded dwarves. Cushing’s affects every part of the body. It’s not like when I had kidney cancer and only the kidney was affected. Here are some of the many areas affected. Progressive obesity and skin changes Weight gain and fatty tissue deposits, particularly around the midsection and upper back, in the face (moon face) and between the shoulders (buffalo hump). Some symptoms such as sudden weight gain, are caused by excess cortisol. The excess cortisol in the body does not increase protein and carbohydrate metabolism. It slows or nearly disables metabolism function, which can cause weight gain (fat accumulation) in the buttocks, abdomen, cheeks, neck, or upper back. Loss of muscle mass. Some areas of the body, such as the arms and legs, will remain thin. Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms Thinning, fragile skin that bruises easily Slow healing of cuts, insect bites and infections Acne Women with Cushing’s syndrome may experience: Thicker or more visible body and facial hair (hirsutism) Irregular or absent menstrual periods Men with Cushing’s syndrome may experience: Decreased libido Decreased fertility Erectile dysfunction Other signs and symptoms include: Fatigue Muscle weakness Depression, anxiety and irritability Loss of emotional control Cognitive difficulties New or worsened high blood pressure Glucose intolerance that may lead to diabetes Headache Bone loss, leading to fractures over time Hyperlipidemia (elevated lipids – cholesterol – in the blood stream) Recurrent opportunistic or bacterial infections Think you have Cushing’s? Get to a doctor and don’t give up!

April is always Cushing's Awareness Challenge month because Dr. Harvey Cushing was born on April 8th, 1869. Thanks to Robin for this wonderful past logo! I've participated in these 30 days for Cushing's Awareness several times so I'm not quite sure what is left to say this year but I always want to get the word out when I can. As I see it, there have been some strides the diagnosis or treatment of Cushing's since last year. More drug companies are getting involved, more doctors seem to be willing to test, a bit more awareness, maybe. How fitting that this challenge should begin on April Fool's Day. So much of Cushing's Syndrome/Disease makes us Cushies seem like we're the April Fool. Maybe, just maybe, it's the doctors who are the April Fools... Doctors tell us Cushing's is too rare - you couldn't possibly have it. April Fools! All you have to do is exercise and diet. You'll feel better. April Fools! Those bruises on your legs? You're just clumsy. April Fools! Sorry you're growing all that hair on your chin. That happens as you age, you know. April Fools! Did you say you sleep all day? You're just lazy. If you exercised more, you'd have more energy. April Fools! You don't have stretch marks. April Fools! You have stretch marks but they are the wrong [color/length/direction] April Fools! The hump on the back of your neck is from your poor posture. April Fools! Your MRI didn't show a tumor. You couldn't have Cushing's. April Fools! This is all in your mind. Take this prescription for antidepressants and go home. April Fools! If you have this one surgery, your life will get back to normal within a few months. April Fools! What? You had transsphenoidal surgery for Cushing's? You wasted your time and money. April Fools! I am the doctor. I know everything. Do not try to find out any information online. You could not have Cushing's. It's too rare... April FOOL! All this reminds me of a wonderful video a message board member posted a while ago: https://youtu.be/GRaDr3cPAmE So now - who is the April Fool? It wasn't me. Don't let it be you, either!

The LINC 4 study demonstrated superiority of Isturisa® (osilodrostat) over placebo in achieving cortisol normalisation during the 12-week, double-blind, randomised phase (77% vs 8%, P<0.0001). Isturisa provided rapid and sustained control of cortisol secretion in the majority of patients throughout the 48-week core phase of the study. PUTEAUX, France, March 29, 2022--(BUSINESS WIRE)--Recordati Rare Diseases announce today the publication of positive results from the Phase III LINC 4 study of Isturisa in The Journal of Clinical Endocrinology & Metabolism.1 These data reinforce Isturisa as an effective and well-tolerated oral therapy for patients with Cushing’s disease. Isturisa is indicated in the EU for the treatment of adult patients with endogenous Cushing’s syndrome,2 a rare and debilitating condition of hypercortisolism that is most commonly caused by a pituitary adenoma (Cushing’s disease).3 The LINC 4 study augments the efficacy and safety data for Isturisa in patients with Cushing’s disease, confirming the results from the Phase III LINC 3 study. This study in 73 adults is the first Phase III study of a medical treatment in patients with Cushing’s disease to include an upfront, randomised, double-blind, placebo-controlled period during which 48 patients received Isturisa and 25 received placebo for the first 12 weeks, followed by an open-label period during which all patients received Isturisa until week 48; thereafter, patients could enter an optional extension phase. Key findings published in the manuscript entitled ‘Randomised trial of osilodrostat for the treatment of Cushing’s disease’ include:1 LINC 4 met the primary endpoint: Isturisa was significantly superior to placebo at normalising mUFC at the end of a 12-week randomised, double-blind period (77% vs 8%; P<0.0001). Effects of Isturisa were rapid. Over one-quarter of patients randomised to Isturisa achieved normal mUFC as early week 2 and 58% achieved control by week 5. The key secondary endpoint was also met, with 81% of all patients in the study having normal mUFC at week 36. Improvements in cardiovascular and metabolic parameters of Cushing’s disease, including blood pressure and blood glucose metabolism, were seen by week 12 and were maintained throughout the study. Physical features of hypercortisolism improved during Isturisa treatment, including fat pads, facial rubor, striae, and muscle wasting. Improvements were observed by week 12, with continued improvement throughout the study to week 48. Patient-reported QoL scores (CushingQoL and Beck Depression Inventory) also improved during Isturisa treatment. Isturisa was well tolerated in the majority of patients, with no unexpected adverse events (AEs). The most common AEs overall were decreased appetite, arthralgia, fatigue and nausea. "These results show convincingly that osilodrostat is an effective treatment for Cushing’s disease," said Peter J. Snyder MD, Professor of Medicine at the University of Pennsylvania. "Osilodrostat rapidly lowered cortisol excretion to normal in most patients with Cushing’s disease and maintained normal levels throughout the core phase of the study. Importantly, this normalisation was accompanied by improvements in cardiovascular and metabolic parameters, which increase morbidity and mortality in Cushing’s disease." "These compelling data build on the positive Phase III LINC 3 study, published in The Lancet Diabetes & Endocrinology in 2020,4 demonstrating that Isturisa enables most patients with Cushing’s disease to gain rapid control of their cortisol levels, which in turn provides relief from a host of undesirable symptoms," said Alberto Pedroncelli, Clinical Development & Medical Affairs Lead, Global Endocrinology, Recordati AG. "Recordati Rare Diseases is committed to improving the lives of patients with this rare, debilitating and life-threatening condition. I would like to thank everyone who has contributed to LINC 4 and the LINC clinical programme." "I had Cushing's disease for 8 years without being diagnosed," said Thérèse Fournier from L'association "Surrénales". "I was trapped in a vicious circle of missed diagnoses and worsening physical and psychological symptoms that became life-threatening. I lost everything – my job, my house, my partner, my friends – I was isolated. When I finally received my diagnosis, I was relieved because I knew the truth. Since my surgery, I have been learning to live again, enjoying the moments that make a life. I am still on the path to remission, but I feel deeply happy, even if I carry this journey that nobody can understand." About Cushing’s syndrome Cushing’s syndrome is a rare disorder caused by chronic exposure to excess levels of cortisol from either an exogenous (eg medication) or an endogenous source.5 Cushing’s disease is the most common cause of endogenous Cushing’s syndrome and arises as a result of excess secretion of adrenocorticotropic hormone from a pituitary adenoma, a tumour of the pituitary gland.5,6 There is often a delay in diagnosing Cushing’s syndrome, which consequently leads to a delay in treating patients.7 Patients who are exposed to excess levels of cortisol for a prolonged period have increased comorbidities associated with the cardiovascular and metabolic systems, which consequently reduce QoL and increase the risk of mortality.3,6 To alleviate the clinical signs associated with excess cortisol exposure, the primary treatment goal in Cushing’s syndrome is to reduce cortisol levels to normal.8 About LINC 4 LINC 4 is a multicentre, randomised, double-blind, 48-week study with an initial 12-week placebo-controlled period to evaluate the safety and efficacy of Isturisa® in patients with Cushing’s disease. The LINC 4 study enrolled patients with persistent or recurrent Cushing’s disease or those with de novo disease who were ineligible for surgery; 73 randomised patients were treated with Isturisa® (n=48) or placebo (n=25).1 The primary endpoint of the study is the proportion of randomised patients with a complete response (mUFC ≤ULN) at the end of the placebo-controlled period (week 12). The key secondary endpoint is the proportion of patients with an mUFC ≤ULN at week 36.1,9 About Isturisa® Isturisa® is an oral inhibitor of 11β-hydroxylase (CYP11B1), which catalyses the final step of cortisol synthesis in the adrenal glands.2 Isturisa® is available as 1 mg, 5 mg and 10 mg film-coated tablets.2 Isturisa® is approved for the treatment of adult patients with endogenous Cushing’s syndrome in the EU and is now available in France, Germany, Greece and Austria.2 Isturisa® was granted marketing authorisation by the European Commission on 9 January 2020. For detailed recommendations on the appropriate use of this product, please consult the summary of product characteristics.2 References 1. Gadelha M, Bex M, Feelders RA et al. Randomised trial of osilodrostat for the treatment of Cushing's disease. J Clin Endocrinol Metab 2022; dgac178, https://doi.org/10.1210/clinem/dgac178. 2. Isturisa® summary of product characteristics. May 2020. 3. Ferriere A, Tabarin A. Cushing's syndrome: Treatment and new therapeutic approaches. Best Pract Res Clin Endocrinol Metab 2020;34:101381. 4. Pivonello R, Fleseriu M, Newell-Price J et al. Efficacy and safety of osilodrostat in patients with Cushing's disease (LINC 3): a multicentre phase III study with a double-blind, randomised withdrawal phase. Lancet Diabetes Endocrinol 2020;8:748-61. 5. Lacroix A, Feelders RA, Stratakis CA et al. Cushing's syndrome. Lancet 2015;386:913-27. 6. Pivonello R, Isidori AM, De Martino MC et al. Complications of Cushing's syndrome: state of the art. Lancet Diabetes Endocrinol 2016;4:611-29. 7. Rubinstein G, Osswald A, Hoster E et al. Time to diagnosis in Cushing's syndrome: A meta-analysis based on 5367 patients. J Clin Endocrinol Metab 2020;105:dgz136. 8. Nieman LK, Biller BM, Findling JW et al. Treatment of Cushing's syndrome: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2015;100:2807-31. 9. ClinicalTrials.gov. NCT02697734; available at https://clinicaltrials.gov/ct2/show/NCT02697734 (accessed March 2021). Recordati Rare Diseases, the company’s EMEA headquarters are located in Puteaux, France, with global headquarter offices in Milan, Italy. For a full list of products, please click here: www.recordatirarediseases.com/products. Recordati, established in 1926, is an international pharmaceutical group, listed on the Italian Stock Exchange (Reuters RECI.MI, Bloomberg REC IM, ISIN IT 0003828271), with a total staff of more than 4,300, dedicated to the research, development, manufacturing and marketing of pharmaceuticals. Headquartered in Milan, Italy, Recordati has operations in Europe, Russia and the other C.I.S. countries, Ukraine, Turkey, North Africa, the United States of America, Canada, Mexico, some South American countries, Japan and Australia. An efficient field force of medical representatives promotes a wide range of innovative pharmaceuticals, both proprietary and under license, in several therapeutic areas including a specialized business dedicated to treatments for rare diseases. Recordati is a partner of choice for new product licenses for its territories. Recordati is committed to the research and development of new specialties with a focus on treatments for rare diseases. Consolidated revenue for 2021 was € 1,580.1 million, operating income was € 490.2 million and net income was € 386.0 million. For further information: Recordati website: www.recordatirarediseases.com This document contains forward-looking statements relating to future events and future operating, economic and financial results of the Recordati group. By their nature, forward-looking statements involve risk and uncertainty because they depend on the occurrence of future events and circumstances. Actual results may therefore differ materially from those forecast as a result of a variety of reasons, most of which are beyond the Recordati group’s control. The information on the pharmaceutical specialties and other products of the Recordati group contained in this document is intended solely as information on the Recordati group’s activities and therefore, as such, it is not intended as medical scientific indication or recommendation, nor as advertising. View source version on businesswire.com: https://www.businesswire.com/news/home/20220325005169/en/ Contacts Celine Plisson, MD Medical Affairs Director Telephone: +33(0)147739463 Email: PLISSON.C@recordati.com Related Quotes Symbol Last Price Change % Change REC Emles Real Estate Credit ETF 22.89 +0.13 +0.57% TRENDING 1. Oil Climbs After Two-Day Drop as Investors Assess Ukraine Talks 2. Stocks Fall, Oil Rises as Russia Concerns Return: Markets Wrap 3. Truckmaker MAN to shorten hours of up to 11,000 workers on Ukraine crisis 4. UPDATE 1-Sri Lanka suffers long power cuts as currency shortage makes fuel scarce 5. German inflation rises more than expected in March From https://finance.yahoo.com/news/recordati-rare-diseases-announce-publication-070000542.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAABds3nKexRHBGxK9BEM1W93vciZ-QM8hw9-QOcCELZxkbW8U7OfcYw-GBd_tvRaS9mnjvRvdhI1sQaBD2jkR6yvqhUZsHw6f7CfO78LaGvdTRWhjaIy7b5IcPvPpOCGzR0Ex1_8t1TFNqxMkSr7OmIxfDflflXrh4cHI8Ze3okeU

Rie Hagiwara Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan Kazunori Kageyama Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan Yasumasa Iwasaki Suzuka University of Medical Science, Suzuka 510-0293, Japan Kanako Niioka Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan Makoto Daimon Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan Keywords: Cushing’s disease, Adrenocorticotropic hormone, Proopiomelanocortin, Corticotroph tumor, Histone deacetylase https://doi.org/10.1507/endocrj.EJ21-0778 Abstract Cushing’s disease is an endocrine disorder characterized by hypercortisolism, mainly caused by autonomous production of ACTH from pituitary adenomas. Autonomous ACTH secretion results in excess cortisol production from the adrenal glands, and corticotroph adenoma cells disrupt the normal cortisol feedback mechanism. Pan-histone deacetylase (HDAC) inhibitors inhibit cell proliferation and ACTH production in AtT-20 corticotroph tumor cells. A selective HDAC6 inhibitor has been known to exert antitumor effects and reduce adverse effects related to the inhibition of other HDACs. The current study demonstrated that the potent and selective HDAC6 inhibitor tubastatin A has inhibitory effects on proopiomelanocortin (Pomc) and pituitary tumor-transforming gene 1 (Pttg1) mRNA expression, involved in cell proliferation. The phosphorylated Akt/Akt protein levels were increased after treatment with tubastatin A. Therefore, the proliferation of corticotroph cells may be regulated through the Akt-Pttg1 pathway. Dexamethasone treatment also decreased the Pomc mRNA level. Combined tubastatin A and dexamethasone treatment showed additive effects on the Pomc mRNA level. Thus, tubastatin A may have applications in the treatment of Cushing’s disease. Access the PDF at https://www.jstage.jst.go.jp/article/endocrj/advpub/0/advpub_EJ21-0778/_pdf/-char/en

https://doi.org/10.1016/j.ajoc.2022.101455 Abstract Purpose To report the clinical course of a patient with central serous chorioretinopathy (CSCR) secondary to subclinical hypercortisolism before and after adrenalectomy. Observations A 50-year-old female patient with multifocal, chronic CSCR was found to have an adrenal incidentaloma and was diagnosed with subclinical hypercortisolism. Patient elected to undergo minimally-invasive adrenalectomy and presented at 3 months after surgery without subretinal fluid. Conclusions and Importance Subclinical Cushing's Syndrome (SCS) may present an underrecognized risk factor for developing chronic CSCR. Further investigation is needed to determine the threshold of visual comorbidity that may influence surgical management. Keywords Central serous chorioretinopathy Subclinical Cushing's syndrome Hypercortisolism Adrenalectomy Retina Surgical intervention 1. Introduction Central serous chorioretinopathy (CSCR) is characterized by accumulation of fluid in the subretinal or sub-RPE space, often with consequential visual impairment. Chronic CSCR has been reported as a manifestation of hypercortisolism due to Cushing's syndrome and subclinical hypercortisolism.1,2 However, the latter is often underrecognized owing to its inherently subtle nature and the optimal threshold for intervention based on associated comorbidities remains unclear. Herein we report the clinical course of a patient with CSCR secondary to subclinical hypercortisolism before and after adrenalectomy. 2. Case report A 50-year-old female presented with blurred, discolored spots in the right eye for several months. Her past medical history included mild hypertension treated with amlodipine. Past ocular and family history were noncontributory. On exam, Snellen visual acuity was 20/50 OD, 20/25 OS. Her pupils, intraocular pressure, and anterior segment exam were within normal limits. Dilated fundus exam revealed bilateral, multifocal areas of subretinal fluid and mottled pigmentary changes (Fig. 1A). Optical coherence tomography confirmed areas of subretinal fluid and other areas of outer retinal atrophy (Fig. 1B). Fundus autofluorescence revealed areas of hyperautofluorescence that highlighted the fundoscopic findings (Fig. 1C). Fluorescein angiography showed multifocal areas of expansile dot leakage (Fig. 1D). Altogether these findings were consistent with multifocal, chronic CSCR. Download : Download high-res image (1MB) Download : Download full-size image Fig. 1. Multimodal imaging of bilateral multifocal central serous chorioretinopathy. Fundus photographs reveal multifocal subretinal fluid and pigmentary changes (Fig. 1A). Optical coherence tomography demonstrates subretinal fluid and outer retinal atrophy (Fig. 1B). Areas of hyperautofluorescence highlight the fundoscopic findings of subretinal fluid (Fig. 1C). Fluorescein angiography showing multiple areas of expansile dot leakage (Fig. 1D). On further clinical follow-up, an adrenal incidentaloma (AI) was detected when the patient underwent imaging for back pain. Subsequently she saw an endocrinologist; she had a normal serum cortisol, but low ACTH and an abnormal dexamethasone suppression test. This led to a diagnosis of subclinical hypercortisolism and provided a reason for her hypertension and chronic CSCR. Since the blur and relative scotomata interfered with her daily activities, she elected to try eplerenone, which yielded a moderate but suboptimal therapeutic response at 50 mg daily. While contemplating photodynamic therapy, in discussion with her endocrinologist, the patient opted to undergo minimally-invasive adrenalectomy. At last follow-up 3 months after surgery and 6 years after her initial presentation, she has been off eplerenone and without subretinal fluid (Fig. 2). Download : Download high-res image (1MB) Download : Download full-size image Fig. 2. Optical coherence tomography imaging at presentation and at last follow-up 3 months after adrenalectomy. There is a significant improvement in subretinal fluid in both eyes, though outer retinal irregularity remains. 3. Discussion CSCR has previously been associated with many risk factors including exposure to excess steroid. A recent study analyzing a nationally representative dataset of 35,000 patients found that patients with CSCR had a higher odds of Cushing's syndrome (OR 2.19, 95% CI 1.33 to 3.59, p = 0.002) than exposure to exogenous steroids (OR 1.14, 95% CI 1.09 to 1.19, p < 0.001)1 Our case highlights the importance of thorough medication reconciliation and careful consideration of comorbid conditions in patients with chronic CSCR. In recent years, subtle endogenous hypercortisolism, termed subclinical Cushing's syndrome (SCS), has been of particular interest in the endocrinology literature because it can be a challenging diagnosis and the most appropriate management remains controversial.3 In general, SCS is comprised of: 1) the presence of an adrenal incidentaloma or mass, 2) biochemical confirmation of cortisol excess, and 3) no classic phenotypic manifestations of Cushing's syndrome.4 Since adrenal incidentaloma has an estimated prevalence of 1–8% of the population,5 it is quite possible that SCS is an underrecognized risk factor for CSCR. SCS may potentiate metabolic syndrome and osteoporosis; studies have found that surgical resection of adrenal incidentalomas improve weight, blood pressure, and glucose control. Consequently, some authors recommend those with SCS-associated comorbidities be considered for resection.6 An important consideration in these patients is how visual comorbidity factors into intervention. In our patient's case, the recurrent CSCR, hypertension, and increased risk of metabolic syndrome were sufficient reasons to elect to have surgery. 4. Conclusion In summary, SCS is a condition of subtle cortisol dysregulation that may represent an underrecognized risk factor for chronic CSCR. Further investigation is needed to determine the threshold of visual comorbidity that may influence surgical management. Patient consent Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient. Acknowledgments and Disclosures Grant support was from the J. Arch McNamara Retina Research Fund. The following authors have no financial disclosures: RRS, AS, AC All authors attest that they meet the current ICMJE criteria for Authorship. No other contributions to acknowledge. References 1 M. Zhou, S.J. Bakri, S. Pershing Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population Br J Ophthalmol, 103 (12) (2019), pp. 1784-1788, 10.1136/bjophthalmol-2018-313050 View PDF View Record in ScopusGoogle Scholar 2 S.N. Appa Subclinical hypercortisolism in central serous chorioretinopathy Retin Cases Brief Rep, 8 (4) (2014), pp. 310-313, 10.1097/ICB.0000000000000036 View PDF View Record in ScopusGoogle Scholar 3 I. Chiodini, A. Albani, A.G. Ambrogio, et al. Six controversial issues on subclinical Cushing's syndrome Endocrine, 56 (2) (2017), pp. 262-266, 10.1007/s12020-016-1017-3 View PDF View Record in ScopusGoogle Scholar 4 M.A. Zeiger, G.B. Thompson, Q.-Y. Duh, et al. American association of clinical endocrinologists and American association of endocrine surgeons medical guidelines for the management of adrenal incidentalomas: executive summary of recommendations Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol, 15 (5) (2009), pp. 450-453, 10.4158/EP.15.5.450 ArticleDownload PDFGoogle Scholar 5 M. Terzolo, A. Stigliano, I. Chiodini, et al. AME position statement on adrenal incidentaloma Eur J Endocrinol, 164 (6) (2011), pp. 851-870, 10.1530/EJE-10-1147 View PDF View Record in ScopusGoogle Scholar 6 L.B. Hsieh, E. Mackinney, T.S. Wang When to intervene for subclinical cushing's syndrome Surg Clin North Am, 99 (4) (2019), pp. 747-758, 10.1016/j.suc.2019.04.011 ArticleDownload PDFView Record in ScopusGoogle Scholar © 2022 The Authors. Published by Elsevier Inc. From https://www.sciencedirect.com/science/article/pii/S2451993622002018?via%3Dihub#!

Sorry guys - I just report the information as I get it I'm in the same "remission boat". This study was done in Sweden so maybe if we stay away from there it will all be good? BTW - welcome, Jazzy - sorry this was your first post.

An analysis of nationwide data from Sweden provides an overview of the increased risk of death associated with Cushing's disease was present even after biochemical remission. New data from an analysis of patient data over nearly 30 years suggests the increased risk of mortality associated with Cushing’s disease persists even after treatment. A 4:1 matched analysis comparing data from 371 patients with Cushing’s disease with 1484 matched controls, indicated risk of mortality was 5-fold greater among those not in remission compared to matched controls, but even those in remission at the last follow-up were at a 50% greater risk of mortality compared to controls. “To our knowledge, this is the first study that investigated mortality in an unselected cohort of patients treated for Cushing’s disease and followed up in comparison to mortality in matched controls. The mortality rate was more than doubled in patients with Cushing’s disease, and not being in remission was a strong predictor of premature death,” wrote investigators. With a lack of consensus surrounding the impact of biochemical remission on life expectancy in patients with Cushing’s disease, a team of investigators from multiple institutions in Sweden designed their study with the intent of assessing this association with mortality in a time-to-event analysis of an unselected nationwide Cushing’s disease cohort. Using the Swedish Pituitary Registry, investigators identified 371 patients with Cushing’s disease for inclusion in their analysis. The Swedish Pituitary Register is a nationwide registry that collected data on the majority of Swedish patients with Cushing’s disease. For the current study, investigators included all patients with Cushing’s disease from the register diagnosed between May 1991-September 2018 and followed these patients until the date of death, date of emigration, or December 26, 2018. From the register, investigators obtained data related to date of diagnosis, age, sex, treatment, and biochemical remission status evaluations. The median age at diagnosis was 44 (IQR, 32-56) years and the median follow-up was 10.6 (IQR, 5.7-18) years. The remissions rates for the study cohort were 80%, 92%, 96%, 91%, and 97% at the 1-, 5-, 10-, 15- and 20-year follow-ups, respectively. These patients were matched in a 4:1 based on age, sex, and residential area at the diagnosis data, yielding a cohort of 1484 matched controls. Upon analysis, the overall risk of mortality was greater among those with Cushing’s disease compared to the matched controls (HR, 2.1 [95% CI, 1.5-2.8]). Investigators pointed out increased risk was observed among patients in remission at the last follow-up (n=303; HR, 1.5 [95% CI, 1.02-2.2]), those in remission after a single pituitary surgery (n=177; HR, 1.7 [95% CI, 1.03-2.8]), and those not in remission (n=31; HR, 5.6 [95% CI, 2.7-11.6]). Additionally, results indicated cardiovascular disease and infections were the most overrepresented cases of death, accounting for 32 and 12 of the 66 total instances of mortality. “The findings of the present study confirm and complement previous findings of increased overall mortality in Cushing’s disease patients, having a more than doubled HR for death compared to matched controls. Most importantly, an increased HR persisted among patients who had been successfully treated and reached a Cushing’s disease biochemical cure,” investigators added. This study, “Increased mortality persists after treatment of Cushing’s disease: A matched nationwide cohort study,” was published in the Journal of the Endocrine Society. From https://www.endocrinologynetwork.com/view/medicaid-expansion-under-aca-may-have-reduced-rate-of-major-diabetes-related-amputations

Researchers published the study covered in this summary on Research Square as a preprint that has not yet been peer reviewed. Key Takeaways Among women who underwent pituitary surgery to treat Cushing disease subsequent pregnancy had no apparent effect on Cushing disease recurrence, in a single-center review of 113 women treated over a 30-year period. Why This Matters No single factor predicts the recurrence of Cushing disease during long-term follow-up of patients who have undergone pituitary surgery. This is the first study to assess the effect of pregnancy on Cushing disease recurrence in a group of reproductive-age women who initially showed post-surgical remission. Study Design Retrospective study of 355 patients with confirmed Cushing disease who were admitted to a single tertiary hospital in Brazil between 1990 and 2020. All patients had transsphenoidal surgery, with a minimum follow-up of 6 months and median follow-up of 83 months. Remission occurred in 246 of these patients. The current analysis focused on 113 of the patients who achieved remission, were women, were 45 years old or younger at time of surgery (median 32 years old), and had information available on their obstetric history. Ninety-one of these women (81%) did not become pregnant after their surgery, and 22 (19%) became pregnant after surgery. Key Results Among the 113 women in the main analysis 43 (38%) had a Cushing disease recurrence, a median of 48 months after their pituitary surgery. Following surgery, 11 women in each of the two subgroups (recurrence, no recurrence) became pregnant. Although the subgroup with recurrence had a higher incidence of pregnancy (11/43; 26%) compared with those with no recurrence (11/70; 16%) Kaplan-Meier analysis showed that survival free of Cushing disease recurrence was similar and not significantly different in the women with a postsurgical pregnancy and those who did not become pregnant (P=.531). The review also showed that, of the women who became pregnant, several obstetrical measures were similar between patients who had a recurrence and those who remained in remission, including number of pregnancies per patient, maternal weight gain, type of delivery (normal or cesarean), delivery time (term or premature), neonatal weight, and neonatal size. The review also showed roughly similar rates of maternal and fetal complications in these two subgroups of women who became pregnant. Limitations The study was retrospective and included a relatively small number of patients. The authors collected information on obstetric history for some patients by telephone or email contacts. Disclosures The study received no commercial funding. None of the authors had disclosures. This is a summary of a preprint research study , " Pregnancy After Pituitary Surgery Does Not Influence the Recurrence of Cushing's Disease, " written by researchers at the Sao Paulo (Brazil) University Faculty of Medicine on Research Square provided to you by Medscape. This study has not yet been peer reviewed. The full text of the study can be found on researchsquare.com.

Although Dr. Friedman is at the forefront of Cushing’s Disease, he was not invited to be part of the Pituitary Society Consensus Guidelines on Cushing’s Disease published in Lancet Diabetes and Endocrinology in 2021, many of his ideas on Cushing’s Disease that he has been advocating for years were included in the recent guidelines. In this informative webinar, Dr. Friedman will discuss The use of imaging for the diagnosis of Cushing’s Disease The need for multiple testing to diagnose episodic Cushing’s Disease The importance of UFC and salivary cortisol testing The use of medication trial prior to surgery The use of ketoconazole for the medication trial and longer-term treatment Dr. Friedman will also discuss new Cushing’s medications. Sunday • April 3 • 6 PM PST Via Zoom Click here to join the meeting orhttps://us02web.zoom.us/j/4209687343?pwd=amw4UzJLRDhBRXk1cS9ITU02V1pEQT09OR+16699006833,,4209687343#,,,,*111116#Slides will be available on the day of the talk here. You can also click to read the consensus guidelines There will be plenty of time for questions using the chat button. For more information, email us at mail@goodhormonehealth.com

The study covered in this summary was published on Research Square as a preprint and has not yet been peer reviewed. Key Takeaways A study of 78 patients who underwent elective transsphenoidal adenomectomy to remove a pituitary tumor or other lesions within the pituitary fossa at a single center in the UK suggests that postoperative plasma levels of copeptin — a surrogate marker for levels of arginine vasopressin (antidiuretic hormone) — can rule out development of central (neurogenic) diabetes insipidus caused by a deficiency of arginine vasopressin following pituitary surgery. The researchers suggest using as a cutoff a copeptin level of >3.4 pmol/L at postoperative day 1 to rule out diabetes insipidus. Such a cutoff yields the following: A high sensitivity of 91% for ruling out diabetes insipidus. A negative predictive value of 97%. Only 1 of 38 patients with a copeptin value >3.4 pmol/L at day 1 postoperatively developed diabetes insipidus. A low specificity of 55%, meaning that copeptin level is not useful for diagnosing diabetes insipidus Why This Matters An estimated 1% to 67% of patients who undergo pituitary gland surgery develop diabetes insipidus, often soon after surgery, although it is often transient. Diagnosing diabetes insipidus in such patients requires a combination of clinical assessment, the monitoring of fluid balance, and determining plasma and urine sodium and osmolality. Currently, clinical laboratories in the UK do not have assays for arginine vasopressin, which has a short half-life in vivo and is unstable ex vivo, even when frozen, and is affected by delayed or incomplete separation from platelets. Copeptin, an arginine vasopressin precursor, is much more stable and measurable by commercial immunoassays. The findings suggest that patients who have just undergone pituitary gland surgery and are otherwise healthy and meet the copeptin cutoff for ruling out diabetes insipidus could be discharged 24 hours after surgery and that there is no need for additional clinical and biochemical monitoring. This change would ease demands on the healthcare system. Study Design The study reviewed 78 patients who underwent elective transsphenoidal adenomectomy to remove a pituitary tumor from November 2017 to June 2020 at the John Radcliffe Hospital in Oxford, United Kingdom. Patients remained in hospital for a minimum of 48 hours after their surgery. Clinicians collected blood and urine specimens preoperatively and at day 1, day 2, day 8, and week 6 post surgery. The patients were restricted to 2 L of fluid a day postoperatively to prevent masking of biochemical abnormalities through compensatory drinking. Diabetes insipidus was suspected when patients' urine output was >200 mL/h for 3 consecutive hours or >3 L/d plus high plasma sodium (>145 mmol/L) and plasma osmolality (> 295 mosmol/kg) plus inappropriately low urine osmolality. Definitive diagnosis of diabetes insipidus was based on clinical assessment, urine and plasma biochemistry, and need for treatment with desmopressin (1-deamino-8-D-arginine vasopressin). Key Results The median age of the patients was 55, and 53% were men; 92% of the lesions were macroadenomas; the most common histologic type was gonadotroph tumor (47%). Among the 78 patients, 11 (14%) were diagnosed with diabetes insipidus postoperatively and required treatment with desmopressin; of these, seven patients (9%) continued taking desmopressin after 6 weeks (permanent diabetes insipidus), but the other four did not need to take desmopressin for more than a week. Patients who developed diabetes insipidus were younger than other patients (mean age, 46 vs 56), and 8 of the 11 patients who developed diabetes insipidus (73%) were women. Preoperative copeptin levels were similar in the two groups. At day 1, day 8, and 6 weeks postoperatively, copeptin levels were significantly lower in the diabetes insipidus group; there were no significant differences at day 2, largely because of an outlier result. An area under the receiver operating characteristic curve (AUC; C-statistic) analysis showed that on day 1 after surgery, copeptin levels could account for 74.22% of the incident cases of diabetes insipidus (AUC, 0.7422). On postop day 8, the AUC for copeptin was 0.8015, and after 6 weeks, the AUC associated with copeptin was 0.7321. Limitations Blood samples for copeptin tests from patients who underwent pituitary surgery were collected at specified times and were frozen for later analysis; performing the test in real time might alter patient management. The study may have missed peak copeptin levels by not determining copeptin levels sooner after pituitary gland surgery, inasmuch as other researchers have reported better predictive values for diagnosing diabetes insipidus from samples taken 1 hour after extubation or <12 hours after surgery. Disclosures The study did not receive commercial funding. The authors report no relevant financial relationships. This is a summary of a preprint research study, "Post-Operative Copeptin Analysis Predicts Which Patients Do Not Develop Diabetes Insipidus After Pituitary Surgery," by researchers from John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, in the United Kingdom. Preprints from Research Square are provided to you by Medscape. This study has not yet been peer reviewed. The full text of the study can be found on researchsquare.com. Read the article here: https://www.medscape.com/viewarticle/970357#vp_1

Abstract Corticotroph pituitary adenomas commonly cause Cushing’s disease (CD), but some of them are clinically silent. The reason why they do not cause endocrinological symptoms remains unclear. We used data from small RNA sequencing in adenomas causing CD (n = 28) and silent ones (n = 20) to explore the role of miRNA in hormone secretion and clinical status of the tumors. By comparing miRNA profiles, we identified 19 miRNAs differentially expressed in clinically functioning and silent corticotroph adenomas. The analysis of their putative target genes indicates a role of miRNAs in regulation of the corticosteroid receptors expression. Adenomas causing CD have higher expression of hsa-miR-124-3p and hsa-miR-135-5p and lower expression of their target genes NR3C1 and NR3C2. The role of hsa-miR-124-3p in the regulation of NR3C1 was further validated in vitro using AtT-20/D16v-F2 cells. The cells transfected with miR-124-3p mimics showed lower levels of glucocorticoid receptor expression than control cells while the interaction between miR-124-3p and NR3C1 3′ UTR was confirmed using luciferase reporter assay. The results indicate a relatively small difference in miRNA expression between clinically functioning and silent corticotroph pituitary adenomas. High expression of hsa-miR-124-3p in adenomas causing CD plays a role in the regulation of glucocorticoid receptor level and probably in reducing the effect of negative feedback mediated by corticosteroids. Keywords: neuroendocrine pituitary tumors; Cushing’s disease; silent corticotroph adenoma; miRNA; hsa-miR-124-3p; NR3C1; glucocorticoid receptor 1. Introduction Pituitary adenomas (also referred to as pituitary neuroendocrine tumors, PitNETs) represent about 10–20% of intracranial neoplasms in adults. They may originate from different kinds of secretory pituitary cells including corticotroph ACTH-secreting cells. Corticotroph adenomas commonly cause ACTH-dependent Cushing’s disease, but a significant proportion of these tumors are endocrinologically non-functioning and classified as subclinical/silent corticotroph adenomas (SCAs) [1]. CD-causing ACTH tumors are commonly small microadenomas with approximately 50% being smaller than 5 mm, which is challenging for MRI diagnostics [2]. In contrary, SCAs are commonly diagnosed due to neurological symptoms related to tumor mass at the stage of large macroadenomas. Frequently they show invasive growth and increased proliferation index [1]. According to current recommendations, SCAs are now referred to as “high-risk” pituitary adenomas which refers to their fast and invasive growth, high risk of recurrence and resistance to medical therapy [3,4]. They are recognized to be more aggressive than other clinically nonfunctioning pituitary tumors such as those of gonadotroph origin or null-cell adenomas [5]. The mechanism underlying the difference in secretory activity of CD-causing and subclinical tumors is unclear and only a few studies focused on this issue were published. The results indicated a role of the expression levels of particular genes/proteins involved in the regulation of POMC expression and pro-hormone conversion into ACTH as well as genes involved in pituitary differentiation [6,7,8,9,10,11,12,13]. However, it also appears that both active and silent corticotroph adenomas share a similar overall gene expression profile [14,15]. The aim of this study was to compare the profiles of microRNA (miRNA) expression in clinically functioning and silent corticotroph adenomas and to identify miRNAs that play a role in different ACTH secretory activity. 2. Results 2.1. Patients Characteristics The study included 28 patients with CD and 20 patients suffering from SCA. All patients with CD had clear clinical signs and symptoms of hypercortisolism verified according to biochemical criteria including elevated midnight cortisol levels and 24 h urinary free cortisol (UFC). Patients with SCA had no clinical or biochemical signs of hypercortisolism and showed normal levels of midnight cortisol and 24 h UFC. Patients with CD had significantly higher morning serum cortisol levels than patients with SCAs (p = 0.0002) while no significant difference was observed in the morning serum ACTH levels. No difference in cortisol/ACTH ratio was observed between CD and SCA patients. All the adenoma samples were ACTH-positive upon immunohistochemical staining against pituitary hormones (ACTH, GH, TSH, FSH, LH, α-subunit) and had characteristic ultrastructural features of corticotroph adenoma. Forty-one adenomas were positive only for ACTH, while seven ACTH-positive adenomas showed additional moderate/weak immunoreactivity for α-subunit. Increased proliferation assessed by Ki67 index ≥ 3% was observed in a similar proportion of CD and SCA patients, seven tumors causing CD and five SCAs. A higher proportion of sparsely vs. densely granulated adenomas was observed in SCAs than in CD-related adenomas, but the difference did not cross a significance threshold (p = 0.0787). No difference in the proportion of invasive/noninvasive adenomas was observed in clinically functioning and silent corticotroph adenomas. All SCAs were macroadenomas, while tumors causing CD included 17 macroadenomas and 11 microadenomas. No significant differences in preoperative clinical parameters, including 24 h UFC, morning serum ACTH level, morning and midnight serum cortisol level, cortisol/ACTH ratio, were observed between CD patients with micro- and macroadenomas. Irrespectively, a correlation between tumors size and ACTH level (Spearman R= 0.4678; p = 0.0121) and a negative correlation between cortisol/ACTH ratio (Spearman R= −0.4015; p = 0.0342) was observed in CD patients. No correlation was found between the remaining biochemical parameters and tumor size. Overall, the patients’ characteristics are presented in Table 1, while details including both the clinical and histopathological data are shown in Supplementary Table S1. Table 1. Summary of clinical features of patients with Cushing’s disease and silent corticotroph adenomas. 2.2. Identification of miRNAs Differentially Expressed in Corticotroph Adenomas Causing CD and Subclinical Cortiotroph Adenomas NGS data on miRNA expression of 48 corticotroph adenomas from previous investigation were used to compare miRNA expression levels between adenomas causing CD (n = 24) and subclinical corticotroph adenomas (n = 20). Sequencing of small RNA libraries produced approximately 2,497,367 reads per sample, which were mapped to the human genome (hg19) and used for quantification of expression levels of known miRNAs, according to miRBase 22 release. Sequencing reads were annotated to 1917 miRNAs. Measurements of 1902 mature miRNAs expression were included in the analysis, after filtering out the miRNAs with low expression. When miRNA profiles of adenomas causing CD and SCAs were compared, a total of 19 differentially expressed miRNAs were found that met the criteria of adjusted p-value < 0.05. This set included 16 miRNAs with higher expression in tumors causing CD: hsa-miR-129-2-3p, hsa-miR-129-5p, hsa-miR-124-3p, hsa-miR-132-5p, hsa-miR-129-1-3p, hsa-miR-135b-5p, hsa-miR-27a-3p, hsa-miR-10b-5p, hsa-miR-9-3p, hsa-miR-6506-3p, hsa-miR-6864-5p, hsa-let-7b-5p, hsa-miR-670-3p, hsa-miR-22-5p, hsa-miR-346 and hsa-miR-9-5p, Three miRNAs with lower expression in CD patients were found: hsa-miR-1909-3p, hsa-miR-4319 and hsa-miR-181b-3p. Details are presented in Table 2 and Figure 1A,B. Figure 1. MiRNA expression profiling in corticotroph adenomas. (A). Difference in miRNA expression between functioning and silent corticotroph adenomas. Volcano plot showing differentially expressed miRNAs. Significance and fold change thresholds are marked with dashed lines. (B). Heat map representing the expression of differentially expressed miRNAs and clustering the samples of adenomas causing Cushing’s disease (CD) and silent corticotroph adenomas (SCA). (C). The correlation between the expression levels of differentially expressed miRNAs and POMC expression or hormonal laboratory measurements in patients: morning plasma ACTH level, morning and midnight plasma cortisol levels and 24 h urinary free cortisol; * indicate p-value < 0.05; ** indicate p-value < 0.01; *** indicate p-value < 0.001 Table 2. The list of miRNAs differentially expressed in corticotroph pituitary adenomas causing CD and silent corticotroph adenomas. 2.3. The Correlation of miRNA Expression and Patients’ Clinical Data Since the clustering of the tumors based on the expression of differentially expressed miRNAs did not clearly separate functioning and silent adenomas, we determined whether the expression of the identified differentially expressed miRNAs is directly related to the results of patients’ laboratory tests as well as POMC expression, measured in tumor samples with qRT-PCR. For this purpose, Spearman’s correlation was applied to calculate a correlation matrix. We observed a significant positive correlation between 13 miRNAs out of 19 differentially expressed miRNAs and at least one of clinical laboratory parameters: serum ACTH, morning cortisol level, midnight cortisol level or 24 h UFC. For 11 miRNAs, with higher expression in patients with CD a positive correlation was observed, while a negative correlation was observed for 3 miRNAs that have lower expression in patients with CD. Four of the differentially expressed miRNAs, hsa-miR-9-3p, hsa-miR-9-5p, hsa-miR-27a-3p and hsa-miR-6506-3p, are correlated with POMC expression level in tumor tissue. The absolute value of correlation coefficient ranged between 0.31 and 0.55 which indicates a weak/moderate relationship. Details are presented in Figure 1C. 2.4. Funtional Enrichment Analysis of Differentially Expressed miRNAs To investigate the possible functional role of the identified miRNAs with different expression levels in CD tumors and SCAs, we used the information on experimentally validated miRNA targets gathered in the miRtarbase release 8.0 database. High confidence known miRNA targets that were validated with luciferase reporter assay, reported in miRtarbase, were included in the analysis. The enrichment of the genes reported as miRNA targets of our 19 miRNAs of interest was determined with gene set over-representation analysis (GSOA) based on Gene Ontology (GO) Molecular Function and GO Biological Processes. The list of all the genes reported in miRTarbase as validated with reporter gene assay was used as reference. As a result, we found 30 GO Molecular Function terms and 293 GO Biological Processes terms as significantly enriched with genes that are targets of the 19 differentially expressed miRNAs. Top 10 enriched terms were related mainly to steroid hormone activity, regulation of transcription and regulation of stem cell differentiation, as shown in Figure 2. Details are presented in Supplementary Table S2. We paid special attention to the terms that refer to steroid hormone action, i.e., steroid hormone receptor activity (GO:0003707), nuclear receptor activity (GO:0004879), ligand-activated transcription factor activity (GO:0098531), as well as steroid hormone-mediated signaling pathway (GO:0043401) and hormone-mediated signaling pathway (GO:0009755). Importantly, the miRNA target genes that were overrepresented in these terms included NR3C1 and NR3C2 that encode for adrenal hormones glucocorticoid receptor (GR) and mineralocorticoid receptor (MR), respectively. According to the miRtarbase 9.0 database, hsa-miR-124-3p is a negative regulator of NR3C1 gene [16] while both hsa-miR-124-3p and hsa-miR-135b-5p downregulate MR [17]. Figure 2. Gene set over-representation analysis of putative target genes of miRNAs differentially expressed in clinically functioning and silent corticotroph adenomas. Using the PubMed search, we found additional evidence strongly supporting the role of hsa-miR-124-3p in the regulation of NR3C1 [18,19,20,21] as well as the role of hsa-miR-135b-5p in downregulating NR3C2 [22,23]. 2.5. Comparison of the Expression of NR3C1 and NR3C2 in Corticotroph Adenomas Causing CD and Silent Adenomas We determined the expression levels of NR3C1 and NR3C2 in corticotroph adenomas with qRT-PCR. We observed a significantly lower expression of both genes in samples from CD patients (n = 24) as compared to SCAs (n = 24); fold change (FC) 0.49 p = 0.0166 and FC 0.37 p = 0.0132, for NR3C1 and NR3C2, respectively. However, the observed difference is rather slight and a notable dispersion of the results was observed (Figure 3). The differences in NR3C1 and NR3C2 expression correspond to the differences in hsa-miR-124-3p and hsa-miR-135b-5p levels. Patients with CD have higher levels of both miRNAs and lower levels of NR3C1 and NR3C2 mRNA (Figure 3). Unfortunately, we did not find a direct correlation between the expression levels of hsa-miR-124-3p and NR3C1 or hsa-miR-135b-5p and NR3C2. Figure 3. The expression levels of NR3C1 and NR3C2 measured with qRT-PCR as well as hsa-miR-124-3p and hsa-miR-135b-5p measured with small RNA sequencing in tumor samples from CD patients and silent corticotroph adenomas; * indicate p-value < 0.05 2.6. Investigtion of miRNA-Related Regulation of NR3C1 In Vitro Transfecting the cultured cells with miRNA mimics is the commonly used approach of in vitro validation of specific miRNA–mRNA interaction. We used mice corticotroph tumor AtT-20/D16v-F2 cells for in vitro experiment and initially verified whether these cells do express Nr3c1 and Nr3c2 genes using deposited RNAseq data from a previous experiment on AtT-20 cells (GSE132324; Gene Expression Omnibus) and qRT-PCR. This showed that the AtT-20/D16v-F2 have relatively high expression of Nr3c1 but do not express Nr3c2. Thus, we focused on the regulatory role of miR-124-3p on Nr3c1 expression. We used miRBase [24] and Targetscan [25] to determine whether miR-124-3p is evolutionarily conserved in humans and mice and whether it targets NR3C1 in both species. It confirmed that miR-124-3p is broadly conserved and it shares the same sequence of mature miRNA in humans and mice. Importantly, GR is among highly rated miR-124-3p predicted targets in both humans and mice and two highly conserved miR-124-3p binding motifs in 3′UTR of this gene were identified in these two species (Figure 4A). Figure 4. Role of mir-124-3p in regulation of glucocorticoid receptor gene. (A). Putative hsa-mir-124-3p target sites in 3′UTR of NR3C1. (B). Reduced expression of Nr3c1 gene expression and glucocorticoid receptor (GR) protein level in AtT-20/D16v-F2 cells treated with hsa-miR-124-3p mimics. (C). Results of luciferase reporter gene assay, showing the interaction between Nr3c1 3′UTR site 2 and mir-124-3p; * indicate p-value < 0.05; ns—not significant. When we transfected AtT-20/D16v-F2 cells with miR-124-3p miRNA mimic and unspecific negative control miRNA mimic, we observed a significant decrease in Nr3c1 expression in cells treated with miR-124-3p miRNA mimic (Figure 4B). It was significantly lower than in cells treated with unspecific miRNA mimic. This difference was also clearly visible at the protein level. The GR level was reduced in cells treated with miR-124-3p miRNA mimic as compared to control (Figure 4B). Two fragments of Nr3c1 3′UTR including each of putative miR-124-3p binding motifs were cloned in plasmid vector into 3′ region of the firefly luciferase gene. AtT-20/D16v-F2 cells were transfected with empty vector, vector with miR-124-3p binding site 1 and vector miR-124-3p binding site 2. Each of the three variants of the cells were cotransfected with miR-124-3p miRNA mimic or unspecific miRNA mimic that served as a negative control. Luminescence was developed 48 h after transfection and detected with microplate reader. As a result, we observed a significant decrease in luminescence in the cells with introduced plasmid with miR-124-3p binding site 2 treated with miR-124-3p mimic as compared to the cells transfected with the same plasmid construct but with control miRNA mimic. This observation confirms the interaction between miR-124-3p and 3′ UTR of Nr3c1 at putative binding site 2 (Figure 4C). The experiment did not confirm an interaction between miR-124-3p and 3′ UTR of Nr3c1 at binding site 1 since no significant difference of luminescence was found in cells transfected with plasmid vector harboring this binding motif treated with miR-124-3p mimic and the same cells treated with negative miRNA mimic (Figure 4C). 3. Discussion Based on the clinical manifestation and biochemical tests results, pituitary corticotroph adenomas can be divided into functioning adenomas causing Cushing’s disease and SCAs. These two subtypes of tumors also differ in terms of some characteristics in MRI [2,26] and pathological features [27]. In contrast to CD-causing adenomas which are commonly small microadenomas, SCAs are diagnosed as macroadenomas due to neurological symptoms related to tumor mass. They are characterized by invasive growth, high risk of recurrence and resistance to medical therapy and are therefore referred to as “high-risk” pituitary adenomas according to current classification [3,4]. In our study, the SCAs were larger than functioning counterparts, as expected. A clear prevalence of women is observed among CD patients according to literature data [28], while it is not observed in patients suffering from SCAs. Our SCA group contained near equal representation of women and men as in previous reports [29,30]; however, some studies indicated female prevalence in SCAs [31]. Comparing functioning and silent corticotroph adenomas, we did not observe difference in patients’ age as well as differences in invasive growth status, ratio of adenomas with increased proliferation index and proportions of sparsely and densely granulated adenomas that may suggest the lack of difference in the tumors’ “aggressiveness”. Importantly, limitations for generalization of our results should be noted. The number of patients included in the analysis is relatively low and the group is not representative of the general population, especially in the case of patients suffering from Cushing’s disease. Since the main goal of our study was a molecular profiling of tumor tissue, we intentionally preselected large adenomas, which allowed us to have enough tissue for DNA/RNA isolation and successful molecular procedures. In our investigation, we observed a negative correlation between cortisol/ACTH ratio and tumor volume in functioning corticotroph adenomas as described previously [32]. However, we did not observe any difference between micro- and macroadenomas causing CD as compared to SCAs (data not shown) as was found in previous studies [12]. The reason why some of corticotroph adenomas exhibit excessive hormone secretion and the others remain clinically silent is unclear and only few attempts have been made to determine the possible molecular mechanism underlying this difference in secretory activity. They were mainly focused on investigating the expression of the selected genes or proteins by comparing subclinical and functioning corticotroph adenomas. These studies indicated different expression levels of prohormone convertase 1/3 POMC, genes encoding somatostatin receptors, corticotropin releasing hormone receptor 1, vasopressin receptor (V1BR), corticosteroid 11-beta-dehydrogenase as well as NEUROD1 and TPIT [6,7,8,9,10,11,12,13]. However, whole transcriptome studies indicated that adenomas causing CD and subclinical corticotroph adenomas share a very common gene expression profile and a very low number of differentially expressed genes can be found by comparing transcriptome of silent and CD-causing ACTH tumors [14,15]. In our study, we determined the miRNA expression profile of 28 clinically functioning adenomas and 20 SCAs with next-generation sequencing of small RNA fraction. This allowed for the quantification of over 1900 miRNA annotated to current version of miRbase database and comparing their expression in two groups of tumor samples. We found a significant difference only in the expression levels of 19 miRNAs, that represent less than 1% of the miRNAs included in the analysis. This result resembles the observation from previous comparison of whole transcriptome profiles in functioning adenomas and SCAs where only 34 differentially expressed genes were found. Generally, both observations indicate a very common molecular profile of corticotroph adenomas, regardless of the functional status. In our study, the expression levels of 13 out of 19 identified differentially expressed miRNAs were also correlated with peripheral ACTH/cortisol levels, further supporting the role of these miRNAs in secretory activity of corticotroph adenomas. The possible role of miRNA in subclinical nature of SCAs was addressed in only one previous study by García-Martínez A et al. [33]. The authors compared the expression of 5 miRNAs in 24 functioning and 23 silent adenomas and observed a difference in hsa-miR-200a and hsa-miR-103 levels [33]. Their results were not confirmed by our investigation since these two miRNAs were not found among differentially expressed miRNAs. In our data, very a similar expression level of hsa-miR-200a was observed in clinically functioning and silent adenomas. In turn, a slightly higher expression of hsa-miR-103a-3p was observed in SCAs as previously reported, but the difference did not cross the significance threshold level. We should note that different methods were used for these two studies and technical and analytical differences could result in this discrepancy. Since miRNAs play a role in gene regulation, their effect should be investigated in the context of the function of targeted genes. The interaction between miRNA and its target mRNA 3′UTR can be predicted with in silico tools. Unfortunately, prediction results can be very difficult to interpret since a huge number of predicted interactions can be found for some miRNAs. For example, when using the Targetescan (http://www.targetscan.org; accessed on 28 February 2022) prediction tool [25], over 4000 target genes were predicted for each hsa-miR-9-3p, hsa-miR-1909-3p, hsa-miR-22-5p and hsa-miR-181b-3p that we found as differentially expressed in CD and SCA. Therefore, to investigate a possible functional relevance of differentially expressed miRNAs we used a database of experimentally validated miRNA targets [34]. Gene set over-representation analysis of miRNA target genes indicated their enrichment in the pathways of steroid hormone nuclear receptors functioning. This result indicates that miRNAs that have different expression levels in CD and SCAs play a role in the regulation of expression of genes involved in steroid hormone signaling at hormone receptor level. It is especially interesting since this group of compounds includes adrenal hormones that play a role in the regulation of the hypothalamic–pituitary–adrenal (HPA) axis. The particular enriched miRNA target genes included NR3C1 and NR3C2 that encode for corticosteroid hormone receptors (GR and MR, respectively). Both receptors are located in the cytoplasm where they bind glucocorticoids. Upon ligand binding, they are translocated to nucleus where they form dimers on DNA at glucocorticoid response elements (GREs). Glucocorticoid and mineralocorticoid receptors directly regulate the expression of target genes and/or influence the expression indirectly through the interaction with other transcription factors [35]. Glucocorticoids play a role in the basic mechanism of negative feedback of HPA axis. They act on hypothalamus, where high cortisol levels reduce secretion of corticotropin-releasing hormone (CRH), thus they directly reduce stimulation of ACTH secretion by anterior pituitary lobe. Glucocorticoids also inhibit the activity of pituitary cells indirectly. Corticotroph cells express GRs and their activation results in the reduction of POMC expression and secretion of ACTH [36,37]. In pituitary corticotroph adenomas, NR3C1 point mutations and loss of heterozygosity in NR3C1 locus were identified [38]. These mutations seem to affect the secretory activity and result in tumor resistance to corticosteroids [39]. Reduced expression of corticosteroid receptors in corticotroph adenomas has been reported in patients with resistance to high doses of dexamethasone [40]. These data indicate a role of GR in secretory activity of clinically functioning corticotroph adenomas. The expression of corticosteroid genes was previously investigated in CD-causing tumors and SCAs and no significant differences were found. However, it is worth noting that a low number of SCA patients was included in these studies: n = 9 [13], n = 8 [11] and n = 2 [41]. According to previously published results, hsa-miR-124-3p is a negative regulator of NR3C1 [16,18,19,20,21]. This was observed in acute lymphoblastic leukemia [19], adipocytes [20] and human embryonic kidney cells [21], where the reduced expression of NR3C1 upon an increase in hsa-miR-124-3p as well as a direct interaction between this miRNA and 3′UTR of GR gene were observed. Some additional clinical observations also suggest the role of hsa-miR-124-3p in the regulation of the response to cortiosteroids in patients with acute-on-chronic liver failure [18] and lymphoblastic leukemia [19]. Hsa-miRNA-124 also mediates corticosteroid resistance in T-cells of sepsis patients through the downregulation of GR [42]. Our analysis of the expression level of NR3C1 in corticotroph adenomas showed that tumors causing CD have lower gene expression and accordingly they exhibit higher levels of hsa-miR-124-3p. Subsequently, the role of hsa-miR-124-3p in NR3C1 downregulation was confirmed in mice AtT-20/D16v-F2 corticotroph cells using miRNA mimics and reporter gene assay. Transfection of AtT-20/D16v-F2 cells with hsa-miR-124-3p mimics resulted in reduced NR3C1 mRNA expression and GR protein level. We also confirmed the interaction between hsa-miR-124-3p and one of two predicted binding motifs in 3′UTR of NR3C1 with luciferase reporter gene assay. Since sequences of hsa-miR-124-3p and target sequence in 3′UTR of NR3C1 mRNA are the same in mice and in humans, we believe that results showing the regulation of the GR-encoding gene in mice AtT-20/D16v-F2 cells are also relevant to humans. Together, the available data indicate that in pituitary corticotrophs, hsa-miR-124-3p downregulates the expression of the GR gene. Since this receptor mediates the response of pituitary cells to cortisol, the expression of hsa-miR-124-3p appears to be an important element in the regulation of secretory activity of corticotroph cells. Based on these results, we can hypothesize that in CD, a high level of hsa-miR-124-3p contributes to lowering of GR expression and in consequence it plays a role in lowering the effect of glucocorticoid feedback on the activity of corticotroph adenoma. Hsa-miR-124-3p and hsa-miR-135b-5p can downregulate the expression level of MR, as proven in model HeLa cells [17]. Expression of both miRNAs is higher in corticotroph adenomas causing CD which corresponds to the lower expression of the NR3C2 gene in these tumors as compared to SCAs. Since the role of the MR receptor expression in pituitary cells is poorly understood, the functional implication of this observation is much less clear than in the case of GR downregulation. MR and GR have similar amino acid sequences, especially in DNA-binding domain, but they differ in affinity to corticosteroids. MR is specific for both mineralocorticoids and glucocorticoids while GR is specific predominantly for glucocorticoids. MRs have much higher affinity for glucocorticoids than GRs and are activated at basal glucocorticoid conditions, while GR occupancy is increased when glucocorticoid levels rise during the circadian peak or stress. Due to these differences, these two receptors play slightly different roles, despite the fact that they share a number of target genes [43]. MR expression is considered more tissue-specific than GR and was reported to be the most prevalent in kidney and adipose tissue but also in the hippocampus and hypothalamus [44]. However, the available databases of human expression pattern such as the Genotype-Tissue Expression project (https://gtexportal.org; accessed on 10 December 2021) or Protein atlas (https://www.proteinatlas.org; accessed on 10 December 2021) indicate that MR is widely expressed in multiple human tissues and organs including the pituitary gland. Unfortunately, a role of MR receptor in pathogenesis of pituitary tumors remains unknown. AtT-20 cells, which are the only available cell line model of corticotroph adenoma, do not express MR receptor, thus the procedure of experimental validation of the role of miRNA in NR3C2 silencing is not applicable. With a lack of experimental data on the exact role of MR, we can only hypothesize that miRNA-mediated silencing of NR3C2 may have the similar effect on HPA axis feedback as silencing of NR3C1. It may enhance ACTH secretion by reducing the direct inhibitory effect of glucocorticoids on neoplastic pituitary corticotrophs. The difference in expression of hsa-miR-124-3p and hsa-miR-135b-5p between subclinical and CD-causing adenomas is not big, thus we suppose that high expression of these miRNAs is not the only cause of difference in ACTH secretion. Presumably this is one of the mechanisms in the regulation of corticotrophs’ secretory activity. The model of miRNA-based corticosteroid receptor regulation does not undermine the role of previously described differences in the expression of convertase 1/3, POMC, somatostatin receptors or corticotropin releasing hormone receptor 1 or genes involved in differentiation of pituitary cells [6,7,8,9,10,11,12,13]. When considering the complex nature of the regulation of ACTH secretion, it can be assumed that multiple mechanisms may be involved in the silent character of subclinical adenomas. The low number of identified differentially expressed miRNAs or genes in silent and clinically functioning adenomas probably results from the intertumoral molecular heterogeneity of SCAs. This is also in line with clinical evidence indicating that some silent corticotroph adenomas can transform into clinically functioning ones while the others remain silent [1]. The misregulation of GR expression or NR3C1 mutation may have important therapeutical implications in CD patients. Non-selective GR antagonist Mifepristone was officially approved for treatment in patients with Cushing’s syndrome [45] while another new GR inhibitor, Relacorilant (CORT125134), is under clinical investigation for its use in this group of patients [46]. The further studies will be required to assess the role of GR abnormalities in response to GR-targeting treatment in CD. In our study, we focused mainly on the role of hsa-miR-124-3p and hsa-miR-135b-5p in the regulation of corticosteroid receptors, but the role of other differentially expressed miRNAs can also be elucidated, based on the function of putative target genes. In the pathways enrichment analysis of the putative targets, molecular functions related to transcriptional regulation were found among the top processes. Interestingly, five miRNAs, i.e., hsa-miR-132-5p, hsa-miR-135b-5p, hsa-miR-27a-3p, hsa-miR-9-3p and hsa-miR-9-5p, were previously reported to downregulate the expression of FOXO1 transcription factor [47,48,49,50,51]. FOXO1 plays an important role in the differentiation of pituitary cells [52] and secretion of gonadotropic hormones [53,54] and prolactin [55]. The role of FOXO1 in pituitary corticotroph cells was not investigated but it was shown to regulate POMC expression in POMC hypothalamic neurons [56]. In POMC, neurons of arcuate nucleus FOXO1 directly suppresses POMC expression. A similar mechanism was also observed in prolactin pituitary adenomas where FOXO1 suppresses the promoter of PRL gene [55]. It is possible that high expression of hsa-miR-132-5p, hsa-miR-135b-5p, hsa-miR-27a-3p, hsa-miR-9-3p and hsa-miR-9-5p in pituitary corticotroph adenomas reduces the level of FOXO1 and eventually contributes to the upregulation of POMC expression. In our data from corticotroph adenomas, we observed the correlation between levels of hsa-miR-9-3p/hsa-miR-9-5 and POMC expression, which also supports this concept, but the exact role of miRNAs in possible FOXO1-related regulation of secretory activity of corticotroph cells requires further functional investigation. 4. Materials and Methods 4.1. Patients and Tissue Samples Pituitary tumor samples from 48 patients were collected during transsphenoidal surgery. Formalin-fixed and paraffin-embedded (FFPE) tissue samples, including 28 samples from patients with Cushing’s disease and 20 samples of SCA were used for the study. Diagnosis of hypercortisolism was based on standard hormonal criteria: increased UFC in three 24 h urine collections, disturbances of cortisol circadian rhythm, increased serum cortisol levels accompanied by increased or not suppressed plasma ACTH levels at 8.00 and a lack of suppression of serum cortisol levels to <1.8 µg/dL during an overnight dexamethasone suppression test (1 mg at midnight). The pituitary etiology of Cushing’s disease was confirmed based on the serum cortisol levels or UFC suppression < 50% with a high-dose dexamethasone suppression test (2 mg q.i.d. for 48 h) or a positive result of a corticotrophin-releasing hormone stimulation test (100 mg i.v.) and positive pituitary magnetic resonance imaging. ACTH levels were assessed using IRMA (ELSA-ACTH, CIS Bio International, Gif-sur-Yvette Cedex, France). The analytical sensitivity was 2 pg/mL (reference range: 10–60 pg/mL). Serum cortisol concentrations were determined by the Elecsys 2010 electrochemiluminescence immunoassay (Roche Diagnostics, Mannheim, Germany). Sensitivity of the assay was 0.02 μg/dL (reference range: 6.2–19.4 μg/dL). UFC was determined after extraction (liquid/liquid with dichloromethane) by electrochemiluminescence immunoassay (Elecsys 2010, Roche Diagnostics)—reference range: 4.3–176 μg/24 h. All the tumors underwent detailed histopathological diagnosis including immunohistochemical staining with antibodies against particular pituitary hormones (ACTH, GH, TSH, FSH, LH, α-subunit) and Ki67 as well as ultrastructural analysis with electron microscopy. The SCAs were characterized by the following clinicopathological criteria: positive immunohistochemical staining for ACTH, lack of signs and symptoms of hypercortisolism (Cushing’s syndrome), negative hormonal evaluation and non-compliance with diagnostic criteria of the CD. Macroadenoma was defined as an adenoma with at least one diameter exceeding 10 mm, and the tumor volume was assessed with the diChiro Nelson formula (height × length × width × π/6). Invasive growth of the tumors was evaluated using Knosp grading [57]. Adenomas with Knosp grades 0, 1 and 2 were considered non-invasive, while those with Knosp 3 and 4 were considered invasive. Forty-three patients had a clear history of not using any drugs that control the overproduction of the cortisol or ACTH (ketoconazole, mitotane, metyrapone, osilodrostat, mifepristone, pasireotide) before surgical treatment. The information on preoperative pharmacological treatment was not available for 5 patients. Tumor tissue content of each FFPE sample ranged between 80 and 100% (median 99%), as assessed with histopathological examination. Patients’ characteristics are presented in Table 1 and details on each patient’s data are available in Supplementary Table S1. The study was approved by the local Ethics Committee of Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw, Poland. Each patient provided informed consent for the use of tissue samples for scientific purposes. Total RNA from FFPE samples was purified with RecoverAll™ Total Nucleic Acid Isolation Kit for FFPE tissue (Thermo Fisher Scientific, Waltham, MA, USA) and measured using NanoDrop 2000 (Thermo Fisher Scientific). RNA was stored at −70 °C. 4.2. Micro RNA Expression Profiling For comparing the miRNA expression profiles in CD-causing and clinically silent adenomas, NGS data from our previous investigation of miRNA expression in corticotroph adenomas were used. The dataset is available at Gene Expression Omnibus, accession no GSE166279. Sequencing of small RNA fraction was performed in 48 tumor samples (28 CD patients and 20 SCA patients) with ion semiconductor sequencing technology, as described previously [58]. Briefly, Ion Total RNA-Seq Kit v2 (Thermo Fisher Scientific) was used for sequencing library construction, Ion Xpress™ RNA-Seq Barcode Kit was used for hybridization and ligation of RNA adapters. RNA reverse transcription and subsequent cDNA purification and library size selection were performed using Nucleic Acid Binding Beads and verified using Bioanalyzer 2100 with High Sensitivity DNA Kit (Agilent, Santa Clara, CA, USA). Ion Chef instrument, with Ion PI™ Hi-Q™ Chef Kit (Thermo Fisher Scientific) and Ion Proton sequencer (Thermo Fisher Scientific) were used for library preparation and sequencing, respectively. BamToFastq package was applied for converting unmapped bam files into fastq files. miRDeep2 was applied for read mapping to known human miRNAs (according to miRBase release 22) and reads quantification. Data normalization and differential expression analysis were performed using DESeq2. Filtration for low-expression miRNAs was applied as described previously. FC of expression calculated as the ratio of the normalized read-count value in CD-causing and silent adenomas was used as a measure of expression difference. Adjusted p-value < 0.05 was used as significance threshold. MiRtarbase release 9.0 database [34] was used to identify known miRNA target genes. PANTHER (http://pantherdb.org; accessed on 10 December 2021) [59] was used for gene set over-representation analysis. 4.3. qRT-PCR gene Expression Analysis One microgram of RNA was subjected to reverse transcription with Transcriptor First Strand cDNA Synthesis Kit (Roche Diagnostics). qRT-PCR reaction was carried out in 384-well format using 7900HT Fast Real-Time PCR System (Applied Biosystems, Foster City, CA, USA) and Power SYBR Green PCR Master Mix (Thermo Fisher Scientific) in a volume of 5 μL, containing 2.25 pmol of each primer. The samples were amplified in triplicates. GAPDH was used as reference gene. Delta Ct method was used to calculate the relative expression level. PCR primers’ sequences are presented in Supplementary Table S3. 4.4. Cell Line Culture and miRNA Mimic Transfection AtT-20/D16v-F2 cells were purchased from ATCC collection and cultured in DMEM medium supplemented with 10% FBS, as recommended. MiRCURY LNA miRNA Mimics including hsa-miR-124-3p mimic (YM00471256, Qiagen, Hilden, Germany) and negative control mimic (YM00479902-ADB, Qiagen) were used. AtT-20/D16v-F2 cells were seeded at 5 × 104 per well of a 24-well plate in culture medium and transfected with 50 nM miRNA with 1% (v/v) HiPerFect Transfection Reagent (Qiagen), according to the manufacturer’s instructions. The next day, the culture medium was changed. In total, 48 h after transfection the cells were harvested and subjected to isolation of total RNA with RNeasy Mini Kit (Qiagen). The expression of the putative hsa-miR-124-3p target gene was determined with qRT-PCR. 4.5. Luciferase Reporter Gene Assay Hsa-miR-124-3p target sites in 3′UTR of NR3C1 were determined with Targetscan [25]. Each of two predicted hsa-miR-124-3p target sites were cloned into pmirGLO Dual-Luciferase miRNA Target Expression Vector (Promega, Madison, WI, USA). AtT-20/D16v-F2 cells (2 × 104/well) were seeded onto a 96-well plate in 100 µL culture medium. The next day, the cells were transfected with 100 ng of each plasmid vector, independently using 0.25% (v/v) lipofectamine 3000 (Invitrogen, Carlsbad, CA, USA) in 10 µL of DMEM. The cells were subsequently transfected with either hsa-miR-124-3p mimic (YM00471256, Qiagen) or negative control mimic (YM00479902-ADB, Qiagen) in a final concentration of 50 nM using HiPerfectReagent (Qiagen). Culture medium was changed on the next day. Luciferase activity was measured with One-Glo Luciferase Assay System (Promega) 48 h after transfection. 4.6. Western Blotting Cells were lysed in ice cold RIPA buffer, incubated for 30 min in 4 °C and centrifuged at 12,500× g rpm for 20 min at 4 °C. Samples were resolved using SDS-PAGE and electrotransferred to polyvinylidene fluoride membranes (PVDF) (Thermo Fisher). GR protein was detected with monoclonal anti-Glucocorticoid Receptor antibody (ab183127, Abcam, Cambridge, UK), and secondary anti-rabbit antibody conjugated to HRP (#7074, Cell Signaling, Beverly, MA, USA). Glyceraldehyde-3-Phosphate Dehydrogenase (#MAB374, Millipore, Bedford, MA, USA) detected with mouse HRP-conjugated antibody (#7076 Cell Signaling) served as control. Visualization was performed with SuperSignal West Pico Chemiluminescent Substrate (Thermo Fisher Scientific) and CCD digital imaging system Alliance Mini HD4 (UVItec Limited, Cambridge, UK). 4.7. Statistical Analysis A two-sided Mann–Whitney U-test was used for analysis of continuous variables. The Spearman correlation method was used for correlation analysis. Significance threshold of α = 0.05 was adopted. Data were analyzed using GraphPad Prism 6.07 (GraphPad Software, La Jolla, CA, USA). Hierarchical clustering analysis was carried out with Cluster 3.0, and the results were visualized using TreeView 1.6 software (Stanford University School of Medicine, Stanford, CA, USA). Supplementary Materials The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijms23052867/s1. Author Contributions Conceptualization, M.M. and M.B.; Methodology, M.B. and B.J.M.; Software, J.B.; Formal analysis, P.K., B.J.M. and M.B.; Investigation, B.J.M., P.K., N.R., M.B. and M.P.; Resources, J.K., G.Z., A.S. and T.M.; Data curation, J.B., B.J.M. and M.B.; Writing—original draft preparation, M.B., P.K. and B.J.M.; Writing—review and editing, all the authors; Visualization, M.B. and B.J.M.; Supervision, M.M.; Project administration M.B.; Funding acquisition, M.M. All authors have read and agreed to the published version of the manuscript. Funding This research was funded by National Science Centre, Poland, grant number 2021/05/X/NZ5/01874. Institutional Review Board Statement The study was conducted in accordance with the Declaration of Helsinki, and approved by the local Ethics Committee of Maria Sklodowska-Curie Institute—Oncology Center in Warsaw, Poland; approval no. number 44/2018, date of approval 26 July 2018. Informed Consent Statement Informed consent was obtained from all subjects involved in the study. Data Availability Statement Data from next-generation sequencing of small RNA fraction of 48 corticotroph adenoma samples are available at Gene Expression Omnibus, accession no GSE166279. Conflicts of Interest The authors declare no conflict of interest. References Ben-Shlomo, A.; Cooper, O. Silent Corticotroph Adenomas. Pituitary 2018, 21, 183–193. 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@happygirl - this looks perfect for you with all your videos! If you or anyone else from these boards does this, please let me know Help Rare Patient Voice spread the word to other patients and caregivers about RPV by submitting a short video on your experience with us. Check out the growing group of patients and caregivers who have recorded stories: https://rarepatientvoice.com#sharevoice. As a thank you for recording a video, we will send you a Rarity zebra plushie AND enter you in a raffle to win a $100 Amazon gift card. Follow these steps to record and submit your own video! Step 1: Scan with code below with the camera app from your Apple/Android mobile device or click the link below! https://admin.storyvine.com/app_users/sign_up/Sharing_My_Voice Step 2: Download the Storyvine app from the App Store or Google Play Step 3: Film and upload your video! To thank you for recording a video, we will send you a Rarity zebra plushie AND enter you in a raffle to win a $100 Amazon gift card. Congratulations to Natalie of California, our January 3 raffle winner! Our next raffle will be held in early February.

Abstract Summary The pandemic caused by severe acute respiratory syndrome coronavirus 2 is of an unprecedented magnitude and has made it challenging to properly treat patients with urgent or rare endocrine disorders. Little is known about the risk of coronavirus disease 2019 (COVID-19) in patients with rare endocrine malignancies, such as pituitary carcinoma. We describe the case of a 43-year-old patient with adrenocorticotrophic hormone-secreting pituitary carcinoma who developed a severe COVID-19 infection. He had stabilized Cushing’s disease after multiple lines of treatment and was currently receiving maintenance immunotherapy with nivolumab (240 mg every 2 weeks) and steroidogenesis inhibition with ketoconazole (800 mg daily). On admission, he was urgently intubated for respiratory exhaustion. Supplementation of corticosteroid requirements consisted of high-dose dexamethasone, in analogy with the RECOVERY trial, followed by the reintroduction of ketoconazole under the coverage of a hydrocortisone stress regimen, which was continued at a dose depending on the current level of stress. He had a prolonged and complicated stay at the intensive care unit but was eventually discharged and able to continue his rehabilitation. The case points out that multiple risk factors for severe COVID-19 are present in patients with Cushing’s syndrome. ‘Block-replacement’ therapy with suppression of endogenous steroidogenesis and supplementation of corticosteroid requirements might be preferred in this patient population. Learning points Comorbidities for severe coronavirus disease 2019 (COVID-19) are frequently present in patients with Cushing’s syndrome. ‘Block-replacement’ with suppression of endogenous steroidogenesis and supplementation of corticosteroid requirements might be preferred to reduce the need for biochemical monitoring and avoid adrenal insufficiency. The optimal corticosteroid dose/choice for COVID-19 is unclear, especially in patients with endogenous glucocorticoid excess. First-line surgery vs initial disease control with steroidogenesis inhibitors for Cushing’s disease should be discussed depending on the current healthcare situation. Keywords: Adult; Male; Other; Belgium; Pituitary; Adrenal; Neuroendocrinology; Oncology; Insight into disease pathogenesis or mechanism of therapy; February; 2022 Background The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a significant impact on the health care systems to date. The clinical presentation of coronavirus disease 2019 (COVID-19) is diverse, ranging from asymptomatic illness to respiratory failure requiring admission to the intensive care unit (ICU). Risk factors for severe course include old age, male gender, comorbidities such as arterial hypertension, diabetes mellitus, chronic lung-, heart-, liver- and kidney disease, malignancy, immunodeficiency and pregnancy (1). Little is known about the risk of COVID-19 in patients with rare endocrine malignancies, such as pituitary carcinoma. Case presentation This case concerns a 43-year-old man with adrenocorticotrophic hormone (ACTH)-secreting pituitary carcinoma (with cerebellar and cervical drop metastases) with a severe COVID-19 infection. He had previously received multiple treatment modalities including surgery, radiotherapy, ketoconazole, pasireotide, cabergoline, bilateral (subtotal) adrenalectomy and temozolomide chemotherapy as described elsewhere (2). His most recent therapy was a combination of immune checkpoint inhibitors consisting of ipilimumab (3 mg/kg) and nivolumab (1 mg/kg) (anti-CTLA-4 and anti-PD-1, respectively) every 3 weeks for four cycles, after which maintenance therapy with nivolumab (240 mg) every 2 weeks was continued. Residual endogenous cortisol production was inhibited with ketoconazole 800 mg daily. He had stabilized disease with a decrease in plasma ACTH, urinary free cortisol and stable radiological findings (2). Surgical resection of the left adrenal remnant was planned but was not carried out due to the development of a COVID-19 infection. In March 2021, he consulted our emergency department for severe respiratory complaints. He had been suffering from upper respiratory tract symptoms for one week, with progressive dyspnoea in the last three days. He tested positive for SARS-CoV-2 the day before admission. On examination, his O2 saturation was 72%, with tachypnoea (40/min) and bilateral pulmonary crepitations. His temperature was 37.2°C, blood pressure 124/86 mmHg and pulse rate 112 bpm. High-flow oxygen therapy was initiated but yielded insufficient improvement (O2 saturation of 89% and tachypnoea 35/min). He was urgently intubated for respiratory exhaustion. Investigation Initial investigations showed type 1 respiratory insufficiency with PaO2 of 52.5 mmHg (normal 75–90), PaCO2 of 33.0 mmHg (normal 36–44), pH of 7.47 (normal 7.35–7.45) and a P/F ratio of 65.7 (normal >300). His inflammatory parameters were elevated with C-reactive protein level of 275.7 mg/L (normal <5·0) and white blood cell count of 7.1 × 10⁹ per L with 72.3% neutrophils. His most recent morning plasma ACTH-cortisol level (measured using the Elecsys electrochemiluminescence immunoassays on a Cobas 8000 immunoanalyzer [Roche Diagnostics]) before his admission was 213 ng/L (normal 7.2–63) and 195 µg/L (normal 62–180) respectively, while a repeat measurement 3 weeks after his admission demonstrated increased cortisol levels of 547 µg/L (possibly iatrogenic due to treatment with high-dose hydrocortisone) and a decreased ACTH of 130 ng/L. Treatment On admission, he was started on high-dose dexamethasone therapy for 10 days together with broad-spectrum antibiotics for positive sputum cultures containing Serratia, methicillin-susceptible Staphylococcus aureus and Haemophilus influenzae. Thromboprophylaxis with an intermediate dose of low molecular weight heparin (tinzaparin 14 000 units daily for a body weight of 119 kg) was initiated. A ‘block-replacement’ regimen was adopted with the continuation of ketoconazole (restarted on day 11) in view of his endocrine treatment and the supplementation of hydrocortisone at a dose depending on the current level of stress. The consecutive daily dose of hydrocortisone and ketoconazole is shown in Fig. 1. View Full Size Figure 1 ‘Block-replacement’ therapy with ketoconazole and hydrocortisone/dexamethasone. Dexamethasone 10 mg daily was initially started as COVID-19 treatment, followed by hydrocortisone at a dose consistent with current levels of stress. Ketoconazole was restarted on day 11 and titrated to a dose of 800 mg daily to suppress endogenous glucocorticoid production. Citation: Endocrinology, Diabetes & Metabolism Case Reports 2022, 1; 10.1530/EDM-21-0182 Download Figure Download figure as PowerPoint slide Outcome and follow-up He developed multiple organ involvement, including metabolic acidosis, acute renal failure requiring continuous venovenous hemofiltration, acute coronary syndrome type 2, septic thrombophlebitis of the right jugular vein, and critical illness polyneuropathy. He was readmitted twice to the ICU, for ventilator-associated pneumonia and central line-associated bloodstream infection respectively. He eventually recovered and was discharged from the hospital to continue his rehabilitation. Discussion We describe the case of a patient with severe COVID-19 infection with active Cushing’s disease due to pituitary carcinoma, who was treated with high-dose dexamethasone followed by ‘block-replacement’ therapy with hydrocortisone in combination with off-label use of ketoconazole as a steroidogenesis inhibitor. His hospitalization was prolonged by multiple readmissions to the ICU for infectious causes. Our case illustrates the presence of multiple comorbidities for a severe and complicated course of COVID-19 in a patient with active Cushing’s disease. Dexamethasone was initially chosen as the preferred corticosteroid therapy, in analogy with the RECOVERY trial, in which dexamethasone at a dose of 6mg once daily (oral or i.v.) resulted in lower 28-day mortality in hospitalized patients with COVID-19 requiring oxygen therapy or invasive mechanical ventilation (3). However, the optimal dose/choice of corticosteroid therapy is unclear, especially in a patient population with pre-existing hypercortisolaemia. A similar survival benefit for hydrocortisone compared to dexamethasone has yet to be convincingly demonstrated. This may be explained by differences in anti-inflammatory activity but could also be due to the fact that recent studies with hydrocortisone were stopped early and were underpowered (4, 5). Multiple risk factors for a complicated course of COVID-19 are present in patients with Cushing’s syndrome and might increase morbidity and mortality (6, 7). These include a history of obesity, arterial hypertension and impaired glucose metabolism. Prevention and treatment of these pre-existing comorbidities are essential. Patients with Cushing’s syndrome also have an increased thromboembolic risk, which is further accentuated by the development of severe COVID-19 infection (6, 7). Thromboprophylaxis with low molecular weight heparin is associated with lower mortality in COVID-19 patients with high sepsis‐induced coagulopathy score or high D-dimer levels (8) and is presently widely used in the treatment of severe COVID-19 disease (9). Subsequently, this treatment is indicated in hospitalized COVID-19 patients with Cushing’s syndrome. It is unclear whether therapeutic anticoagulation dosing could provide additional benefits (6, 7). An algorithm based on the International Society on Thrombosis and Hemostasis-Disseminated Intravascular Coagulation score was proposed to evaluate the ideal anticoagulation therapy in severe/critical COVID-19 patients, with an indication for therapeutic low molecular weight heparin dose at a score ≥5 (9). Furthermore, the chronic cortisol excess induces suppression of the innate and adaptive immune response. Patients with Cushing’s syndrome, especially when severe and active, should be considered immunocompromised and have increased susceptibility for viral and other (hospital-acquired) infections. Prophylaxis for Pneumocystis jirovecii with trimethoprim/sulfamethoxazole should therefore be considered (6, 7). Additionally, there is a particular link between the pathophysiology of COVID-19 and Cushing’s syndrome. The SARS-CoV-2 virus (as well as other coronaviruses) enter human cells by binding the ACE2 receptor. The transmembrane serine protease 2 (TMPRSS2), expressed by endothelial cells, is additionally required for the priming of the spike-protein of SARS-CoV-2, leading to viral entry. TMPRSS2 was studied in prostate cancer and found to be regulated by androgen signalling. Consequently, the androgen excess frequently associated with Cushing’s syndrome might be an additional risk factor for contracting COVID-19 via higher TMPRSS2 expression (10), especially in women, in whom the effect of excess androgen would be more noticeable compared to male patients with Cushing’s syndrome. Treating Cushing’s syndrome with a ‘block-replacement’ approach, with suppression of endogenous steroidogenesis and supplementation of corticosteroid requirements, is an approach that should be considered, especially in severe or cyclic disease. The use of this method might decrease the need for monitoring and reduce the occurrence of adrenal insufficiency (7). Our patient was on treatment with ketoconazole, which was interrupted at initial presentation and then restarted under the coverage of a hydrocortisone stress regimen. Ketoconazole was chosen because of its availability. Advantages of ketoconazole over metyrapone include its antifungal activity with the potential for prevention of invasive pulmonary fungal infections, as well as its antiandrogen action (especially in female patients) and subsequent inhibition of TMPRSS2 expression (10). Regular monitoring of the liver function (every month for the first 3 months, at therapy initiation or dose increase) is necessary. Caution is needed due to its inhibition of multiple cytochrome P450 enzymes (including CYP3A4) and subsequently greater risk of drug-drug interactions vs metyrapone (7, 10). Another disadvantage of ketoconazole is the need for oral administration. In our patient, ketoconazole was delivered through a nasogastric tube. i.v. etomidate is an alternative in case of an unavailable enteral route. Finally, as a general point, the first-line treatment of a patient with a novel diagnosis of Cushing’s disease is transsphenoidal surgery. Recent endocrine recommendations pointed out the possibility of initial disease control with steroidogenesis inhibitors in patients without an indication for urgent intervention during a high prevalence of COVID-19 (7). This would allow the optimalization of metabolic parameters; emphasizing that the short-to mid-term prognosis is related to the cortisol excess and not its cause. Surgery could then be postponed until the health situation allows for safe elective surgery (7). This decision depends of course on the evolution of COVID-19 and the healthcare system in each country and should be closely monitored by policymakers and physicians. 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 work 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 and/or clinical images was obtained from the patient. Author contribution statement J M K de Filette is an endocrinologist-in-training and was the main author. All authors were involved in the clinical care of the patient. All authors contributed to the reviewing and editing process and approved the final version of the manuscript. 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by Valentina Guarnotta, Francesca Di Gaudio and Carla Giordano 1 Department of Health Promotion, Maternal-Infantile Care, Excellence Internal and Specialist Medicine “G. D’Alessandro” [PROMISE], Section of Endocrine Disease and Nutrition, University of Palermo, 90127 Palermo, Italy 2 Biochemistry Head CQRC Division (Quality Control and Biochemical Risk), Department of Health Promotion, Maternal-Infantile Care, Excellence Internal and Specialist Medicine “G. D’Alessandro” [PROMISE], University of Palermo, 90127 Palermo, Italy Author to whom correspondence should be addressed. Academic Editor: Edgard Delvin Nutrients 2022, 14(5), 973; https://doi.org/10.3390/nu14050973 Abstract Background: The primary objective of the study was to assess serum 25-hydroxyvitamin D [25(OH)D] values in patients with Cushing’s disease (CD), compared to controls. The secondary objective was to assess the response to a load of 150,000 U of cholecalciferol. Methods: In 50 patients with active CD and 48 controls, we evaluated the anthropometric and biochemical parameters, including insulin sensitivity estimation by the homeostatic model of insulin resistance, Matsuda Index and oral disposition index at baseline and in patients with CD also after 6 weeks of cholecalciferol supplementation. Results: At baseline, patients with CD showed a higher frequency of hypovitaminosis deficiency (p = 0.001) and lower serum 25(OH)D (p < 0.001) than the controls. Six weeks after cholecalciferol treatment, patients with CD had increased serum calcium (p = 0.017), 25(OH)D (p < 0.001), ISI-Matsuda (p = 0.035), oral disposition index (p = 0.045) and decreased serum PTH (p = 0.004) and total cholesterol (p = 0.017) values than at baseline. Multivariate analysis showed that mean urinary free cortisol (mUFC) was independently negatively correlated with serum 25(OH)D in CD. Conclusions: Serum 25(OH)D levels are lower in patients with CD compared to the controls. Vitamin D deficiency is correlated with mUFC and values of mUFC > 240 nmol/24 h are associated with hypovitaminosis D. Cholecalciferol supplementation had a positive impact on insulin sensitivity and lipids. Keywords: glucocorticoid; hypercortisolism; 25-hydroxyvitamin D; cholecalciferol 1. Introduction Vitamin D is the precursor of a hormone with pleiotropic effects. Its deficiency has been largely investigated and shown to be associated with many complications including diabetes mellitus, adrenal insufficiency, cardiovascular disease, neurological disorders and other endocrinopathies [1,2,3]. Vitamin D, also known as cholecalciferol, is first formed in the skin by the photolysis of 7-dehydrocholesterol and after hydroxylated in the liver to 25-hydroxyvitamin D [25(OH)D]. It is further transformed in the kidney into 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) (calcitriol) that is the active form [4]. Cushing’s disease (CD) is characterized by a cortisol excess due to autonomous pituitary ACTH secretion. Patients with CD show many comorbidities such as cardiovascular disease, metabolic disease, diabetes mellitus, metabolic syndrome, dyslipidemia, obesity, osteoporosis/osteopenia and infections that contribute to increasing the mortality risk for these patients [5,6,7,8,9,10,11]. Indeed, GCs are key regulators of intermediary metabolism promoting hepatic gluconeogenesis and glycogenosis and on lipid metabolism favouring the deposition of fat to the upper trunk and the face [12]. They stimulate water diuresis, glomerular filtration rate and renal plasma flow and these effects result in arterial hypertension and atherosclerosis. GCs reduce bone remodelling, augment urinary calcium excretion and decrease the intestinal calcium absorption. In addition, they act on immune and hematological systems inhibiting the secretion of interleukins and increasing the red blood cell count, respectively [12]. An interesting relationship exists between glucocorticoids (GCs) and vitamin D values [13,14,15,16]. Indeed, exogenous steroid therapy has been reported to be associated with vitamin deficiency [13]. The mechanism by which GCs reduce 25(OH)D levels is not direct, but indirect, regulating vitamin D receptor expression in many tissues and cells [17,18]. Some authors have shown that treatment with dexamethasone in mice was associated with a decrease in 1α-hydroxylase which is involved in the conversion from 25(OH)D3 to the active metabolite 1,25(OH)2D3 and an increase in 24-hydroxylase, able to break down the active form of calcitriol, in inactive, reducing circulating 25(OH)D levels [19]. In a clinical setting, controversial data have been reported on GCs effects on serum 1,25(OH)2D concentrations [20,21,22,23]. A likely reason for these discrepancies might be the marked heterogeneity of the studied groups. Some of these studies were performed in humans [23,24,25,26], and others in animal models [27,28], but only a few studies were conducted in subjects with endogenous hypercortisolism. Low serum 25(OH)D levels have significant skeletal and extra-skeletal consequences such as myopathy, high risk of fractures and also affect the immune system and metabolism. All of these systems are impaired in patients with hypercortisolism and a vitamin D deficiency may provide a further aggravation of CD comorbidities. Indeed, it may cause a reduced intestinal calcium absorption resulting in secondary hypocalcemia and hyperparathyroidism leading to a bone demineralization. Its deficiency can contribute to obesity and metabolic syndrome due to the lack of antiadipogenic effect of vitamin D and to cardiovascular disease by a deregulation of the renin–angiotensin–aldosterone system, cardiac contractility and increase in cytokine release [29]. In the end, vitamin D deficiency causes impaired insulin sensitivity and immune system [30]. The discrepancies that emerge in the above-mentioned studies suggest a need to investigate the role of 25(OH)D in patients with CD. Therefore, the primary objective of the study was to evaluate serum 25(OH)D levels in patients with CD, compared to a control group matched for age, BMI and gender, and search for a possible correlation with the degree of hypercortisolism. The secondary objective was to evaluate the response to a course of 150,000 U of cholecalciferol on metabolic and hormonal parameters 6 weeks after the administration in patients with CD. 2. Materials and Methods 2.1. Subjects and Study Design Fifty patients with active CD, 43 of them women (86%) and 7 of them men (20%) (mean age 50.9 ± 17.4 years; mean duration of disease 32.5 ± 22.4 years), followed from January 2016 to December 2020, by the Endocrinology of the University of Palermo, were included in the current study. Clinical practice guidelines and a recent consensus statement were used to diagnose CD [31,32]. We recruited a control group matched for age, BMI and gender in the same temporal period. It was composed of 48 patients, 33 women (82.5%) and 7 men (17.5%) (mean age 48.5 ± 13.4 years) were evaluated by our team for a suspicion not biochemically confirmed of Cushing’s syndrome (CS). In all patients, we evaluated phenotypic characteristics including moon face, facial rubor, dorsal fat pad or buffalo hump, defined as a fatty tissue deposit between the shoulders, purple striae, defined as wide, reddish-purple streaks, and myopathy defined as muscle weakness at the proximal level. We also assessed cardiovascular, metabolic and bone comorbidities. The diagnosis of metabolic syndrome was based on National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) criteria, while the diagnosis of diabetes mellitus and prediabetes were based on the American Diabetes Association (ADA, Arlington, VA, USA) criteria [33,34]. Among patients with diabetes mellitus (18 out of 50), 16 were treated with metformin alone, while 2 were treated with a combination of metformin and GLP-1 agonist receptors. Metformin and GLP-1 agonist receptors were discontinued 24 h and 2 weeks before metabolic evaluations, respectively, to avoid any interference with metabolic parameters. Diabetic patients were on good metabolic control (HbA1c ≤ 7%). Both CD patients and the controls were naïve to cholecalciferol. In CD and the controls, BMI and waist circumference (WC), fasting serum lipids (total cholesterol (TC), HDL cholesterol, LDL cholesterol and triglycerides (TG), HbA1c, glycaemia, insulinaemia, albumin corrected calcium, phosphorus and parathyroid hormone (PTH) were assessed. To avoid seasonal influences, serum 25(OH)D levels were only assayed between winter and spring seasons (November–April). We evaluated urinary free cortisol (UFC) as the mean of three 24 h urine collections (mUFC), cortisol after a low dose of dexamethasone suppression test and plasma ACTH. We defined patients with mild hypercortisolism when mUFC levels not exceeding twice the upper limit of normal (ULN), moderate hypercortisolism by a level of mUFC more than 2 to 5 times the ULN and severe hypercortisolism by a mUFC level more than 5 times the ULN, as previously reported [35]. As defined by the Endocrine Society guidelines, we considered 25(OH)D deficiency for values < 20 ng/mL (50 nmol/L), insufficiency as levels of 20–30 ng/mL (50–75 nmol/L) and sufficiency for values ≥ 30 ng/mL (≥75 nmol/L) [36]. In addition, severe 25(OH)D deficiency was defined by levels < 10 ng/mL (<25 nmol/L) [37]. As markers of insulin sensitivity, we calculated the homeostatic model of insulin resistance (HOMA2-IR) [38], and in 32 patients with CD and in 40 controls who had no previous diagnosis of diabetes, we also evaluated the Matsuda index of insulin sensitivity (ISI-Matsuda) [39], the oral disposition index (DIo) [40] and the area under the curve for insulin (AUC2h insulinemia) and glucose (AUC2h glycaemia). At the baseline visit, we assessed patients’ lifestyle habits: physical activity level, balanced diet (consumption of dairy products, meat, coffee, soft drinks), exposure to ultraviolet (UV) radiation, smoking status and alcohol use. We excluded patients with adrenal-dependent hypercortisolism, pregnancy, taking oral contraceptives, liver or renal disease, cholecalciferol supplementation within 3 months before the study, malabsorption syndrome and exposure to ultraviolet (UV) radiation (solarium and sunscreen usage). Patients with CD received an oral load dose of cholecalciferol of 150,000 UI [41,42] and biochemical parameters (metabolic and hormonal) were assayed 6 weeks after administration. The study protocol was approved by the Ethics Committee of the Policlinico Paolo Giaccone hospital. All patients signed a written informed consent. 2.2. Assays Biochemical parameters were measured by standard methods (Modular P800, Roche, Milan, Italy), as previously reported [9]. Hormonal parameters were measured by electrochemiluminescence immunoassay (ECLIA, Elecsys, Roche, Milan, Italy) following the manufacturer’s instructions, as previously reported [9]. Mean UFC was measured by mass spectrometry, as previously reported [35]. Normal values for hormonal markers were defined as follows: ACTH 2.2–14 pmol/L and UFC 59–378 nmol/24 h. 2.3. Statistical Analysis We used statistical Packages for Social Science SPSS version 19 (SPSS, Inc., Chicago, IL, USA) for data analysis. The normality of quantitative variables was tested with the Shapiro–Wilk test. We calculated mean ± SD for continuous variables and rates and proportions for categorical variables. The differences between paired continuous variables (CD vs. controls) were analysed using one-way ANOVA. We used univariate Pearson correlation to evaluate the relations with the outcome parameters. For those variables which were significant at univariate correlation, we performed multiple linear regression analysis to identify independent predictors of the dependent variable 25(OH)D. A p-value of 0.05 was considered statistically significant. A receiver operating characteristic (ROC) analysis was performed to investigate the diagnostic ability of significantly associated risk factors to predict 25(OH)D deficiency. The ROC curve is plotted as sensitivity versus 1-specificity. The area under the ROC curve (AUC) was estimated to measure the overall performance of the predictive factors for serum 25(OH)D deficiency. 3. Results At baseline, patients with CD had a higher frequency of arterial hypertension (p = 0.009), osteoporosis/osteopenia (p = 0.002), hypercholesterolemia (p = 0.002), diabetes mellitus (p = 0.026), myopathy (p < 0.001), facial rubor (p = 0.005), buffalo hump (p = 0.002) and hypovitaminosis deficiency (p = 0.001) than the controls (Table 1). Table 1. Comorbidities of patients with CD and controls at baseline. By contrast, the controls had a higher frequency of vitamin D sufficiency (p = 0.004). Patients with CD also had higher WC (p = 0.031), PTH (p = 0.003), glycaemia (p = 0.010), HbA1c (p = 0.004), total cholesterol (p < 0.001), LDL cholesterol (p = 0.002), ACTH (p < 0.001), mUFC (p = 0.001), cortisol after a low dose of dexamethasone suppression test (p = 0.001) and lower 25(OH)D (p < 0.001), ISI-Matsuda (p = 0.007) and DIo (p = 0.003) than the controls (Table 2). Table 2. Anthropometric and biochemical parameters of patients with CD and controls at baseline. Six weeks after cholecalciferol treatment, patients with CD showed increased serum calcium (p = 0.017), 25(OH)D (p < 0.001), ISI-Matsuda (p = 0.035), DIo (p = 0.045) and a decrease in PTH (p = 0.004) and total cholesterol (p = 0.017) levels than at baseline (Table 3). Table 3. Anthropometric and biochemical parameters at baseline and 6 weeks after cholecalciferol supplementation in patients with CD. Considering the degree of hypercortisolism, in patients with severe hypercortisolism we observed 25(OH)D deficiency in 73.1% of cases (53.8% of them had a severe deficiency), insufficiency in 12.5% of cases and sufficiency in 6.3% of cases. In patients with moderate hypercortisolism, we observed 25(OH)D deficiency in 64.7% of cases (29% of them had a severe deficiency), insufficiency in 23.5% of cases and sufficiency in 11.8% of cases. In patients with mild hypercortisolism, we observed deficiency in 52.9% of cases (20% of them had a severe deficiency), insufficiency in 41.1% of cases and sufficiency in 6% of cases. At univariate correlation, in patients with CD at baseline, serum 25(OH)D was inversely correlated with glycaemia (r = −0.385, p = 0.019), HbA1c (r = −0.391, p = 0.017), WC (r = −0.373, p = 0.023), mUFC (r = −0.466, p = 0.033) and cortisol after a low dose of dexamethasone suppression test (r = −0.299, p = 0.049) (Table 4). In the controls, at baseline, 25(OH)D was inversely correlated with WC (r = −0.130, p = 0.042) (Table 4). Table 4. Correlation of serum 25-hydroxyvitamin D [25(OH)D] levels at baseline in patients with Cushing’s disease and controls. Multivariate analysis showed that mUFC was independently inversely associated with 25(OH)D (p = 0.010) in patients with CD (Figure 1). In the controls, no significant associations were found. Figure 1. Independent variables associated with serum 25(OH)D in patients with active CD at multivariate analysis. mUFC: mean urinary free cortisol. The ROC analysis showed that a cut-off of mUFC > 240 nmol/24 h was associated with 25(OH)D deficiency with a specificity of 100% and a sensitivity of 56.9%, AUC 0.803 (Figure 2). Figure 2. 25(OH)D status and mUFC. ROC curve showed that a cut-off of mUFC > 240 nmol/24 h could be associated with 25(OH)D deficiency. Statistical analysis was performed using the chi-square test and receiver operator characteristic (ROC) curve analysis. 4. Discussion The present study shows that patients with active CD have lower serum 25(OH)D values than the controls and that serum 25(OH)D levels are inversely correlated with mUFC in CD. In addition, a cholecalciferol load is associated after 6 weeks from the administration with an improvement of serum 25(OH)D and glycometabolic and lipid parameters in patients with CD. Furthermore, we found that higher values of mUFC than 240 nmol/24 h are predictive of 25(OH)D deficiency. The degree of hypercortisolism evaluated by UFC levels is a useful parameter to quantify the “amount” of cortisol secretion, even though it is not sufficiently exhaustive to assess the aggressiveness of the disease [35]. Indeed, a combination of several factors, including the degree of hypercortisolism, but also the duration of the disease, age and other individual predisposing factors, contribute to the aggressiveness of the disease. Long-standing studies were conducted on vitamin D levels in patients with CD. Patients with CD, with and without osteopenia, were compared before and after oral calcium load showing that serum 1,25 (OH)2D3 plasma levels were higher in subjects with osteopenia than in those without it, likely due to a secondary increase in PTH levels as an effect of hypercortisolism [19]. Another study investigated the effect of hypercortisolism and eucortisolism, showing a reduction in serum 25(OH)D levels, but not in 1,25 (OH)2D3 in patients with hypercortisolism. By contrast, two other studies found normal serum 25(OH)D values in patients with CD [23,24]. However, all the above-mentioned studies were conducted on a small sample of patients. Recently, a meta-analysis conducted on the studies that evaluated serum 25(OH)D levels in patients treated with GCs reported lower serum 25(OH)D levels in these patients compared to healthy subjects [16]. A hypothetical reason was that patients with CD had low 24-hydroxylase levels than the controls, causing an alteration of vitamin D catabolism. An interesting in vitro study in NCI-H295R cells found that treatment with 1,25(OH)2D3 decreased corticosterone secretion without affecting cortisol levels [43]. As expected, in the current study, we showed that treatment with cholecalciferol is associated with an improvement in insulin sensitivity and total cholesterol values in patients with CD. Indeed, cholecalciferol supplementation has been reported to be associated with improved peripheral insulin sensitivity and secretion in patients at high risk of diabetes or with type 2 diabetes [44]. A recent meta-analysis on 41 randomized controlled studies showed a significant improvement in total cholesterol levels after cholecalciferol supplementation. In addition, this improvement was more pronounced in patients with vitamin D deficiency [45,46]. A recent study compared the metabolism of vitamin D in patients with CD and controls after cholecalciferol treatment, showing that patients with CD had a higher 25(OH)D/24,25(OH)2D ratio than healthy controls, likely due to a decrease in 24-hydroxylase activity. The authors concluded that this alteration of vitamin D catabolism might have an influence on the effectiveness of cholecalciferol therapy in CD [47]. There are some limitations in the current study. First, the study is not randomized. Second, the dose of cholecalciferol administered is the same independently of the baseline serum 25(OH)D values. Third, we did not register the intake of milk and dairy products of the patients included in the study. In conclusion, serum 25(OH)D levels are lower in subjects with active CD compared to controls matched for age, BMI and gender. Vitamin D deficiency is correlated with mUFC and values of mUFC > 240 nmol/24 h are predictive of 25(OH)D deficiency. In addition, cholecalciferol supplementation has a positive impact on insulin sensitivity and lipids and therefore should be considered part of the treatment of patients with CD at diagnosis, in order to improve the comorbidities. However, further studies are needed to evaluate a possible effect of cholecalciferol supplementation on the aggressiveness of CD. Author Contributions Conceptualization, V.G. and F.D.G.; methodology, V.G.; software, V.G.; validation, V.G., F.D.G. and C.G.; formal analysis, V.G.; investigation, V.G.; resources, F.D.G.; data curation, V.G.; writing—original draft preparation, V.G.; writing—review and editing, V.G.; visualization, V.G.; supervision, C.G.; project administration, C.G.; funding acquisition, C.G. 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Each month, The Clinical Advisor makes one new clinical feature available ahead of print. Don’t forget to take the poll. The results will be published in the next month’s issue. A 35-year-old woman is seen in the outpatient clinic for evaluation of an incidental pituitary macroadenoma. Her medical history is significant for hypertension, diabetes, hyperlipidemia, polycystic ovary syndrome, and obesity. She initially presented to the emergency department (ED) a week ago after an episode of right visual field changes that she described as waviness in her right eye and right hemibody sensory changes without motor deficits. While in the ED, she underwent a full workup for possible stroke, which was negative. Magnetic resonance imaging (MRI) of her brain without contrast revealed a 12-mm pituitary lesion; a repeat MRI with contrast was then ordered (Figure). No serum hormonal panel was available for review from ED records. Figure. Magnetic resonance imaging of the case patient. Left image: sagittal view. Right image: coronal view with contrast. Credit: Melissa Wasilenko, MSN, RN Upon further questioning of her medical history during the clinic visit, the patient notes that a few years ago she was attempting to become pregnant and was evaluated by her gynecologist for amenorrhea. At that time, she reportedly completed an endocrine laboratory workup that showed a slightly elevated prolactin level between 30 and 40 ng/mL (normal level in nonpregnant women, <30 ng/mL). Per the patient, the minimal elevation was not enough to concern the gynecologist and no MRI was ordered at that time. Her gynecologist recommended that she lose weight. Her menses returned to normal with weight loss. With a history of disrupted menstrual cycles, infertility, and patient reported elevated prolactin level, there is high suspicion for endocrine disruption. A complete pituitary panel is ordered again to examine the current hormone function considering the recent MRI findings. This revealed a prolactin of 33.7 ng/ml, and all other hormonal levels were within normal limits. Because the patient reports multiple episodes of visual disturbances and the size of the pituitary adenoma on MRI, a neuro-ophthalmology referral is initiated for visual field testing and to determine if the pituitary macroadenoma is causing mass effect and compressing the optic nerve. The neuro-ophthalmologist found she had no visual field defect from her adenoma on visual field testing and believed that her visual disturbances were probably migraine in nature. Discussion Pituitary gland tumors are usually found incidentally on imaging studies obtained for other reasons or in workup of patients with abnormal endocrine hormone levels (both decreased and increased levels) or with symptoms of mass effect from the lesions.1 These tumors are typically benign in nature; cases with malignancy are extremely rare.1 The exact pathophysiology of pituitary adenomas remains unknown but is thought to be linked to heredity, hormonal influences, and genetic mutations.1 Pituitary tumors are commonly found in adults between the ages of 35 and 60 years of age.2,3 The estimated prevalence of pituitary adenomas varies widely by study and findings are typically based on autopsy and radiology data. Surveillance, Epidemiology, and End Results (SEER) Program data from 2004 to 2018 show an incidence rate of pituitary adenomas and pituitary incidentalomas of 4.28 ± 0.04 and 1.53 ± 0.02 per 100,000 population.4 Pituitary tumors have been found in 14.4% of unselected autopsy cases and 22.5% of radiology tests.1 The SEER data suggest that incidence rates are similar among women and men but are higher among women in early life and higher among males in later life.5 Rates of prolactinomas (prolactin-secreting tumors) and corticotropinomas (adrenocorticotropic hormone-secreting tumors; Cushing disease) are higher in women than men.6 Earlier SEER data showed a significantly higher incidence of pituitary adenomas in Black individuals compared with other racial/ethnic groups; several factors may account for this discrepancy such as the higher stroke rate in this population, which leads to a greater likelihood for brain imaging that detects incident pituitary tumors.5 Incidental findings of pituitary adenoma may be found during workup related to hormonal dysfunction (amenorrhea, galactorrhea, fertility disorders, sexual dysfunction), noticeable vision change, new-onset headaches, or imaging performed for other diagnostic purposes.7 Pituitary Types Pituitary tumor types are differentiated by location, size, and functional status. Pituitary tumors commonly arise from the anterior portion of the gland (adenohypophysis) and rarely from the posterior portion (neurohypophysis).2 Both adenohypophyseal and neurohypophyseal tumors are commonly benign and slow-growing.1 Malignant pituitary tumors account for less than 1% of pituitary lesions and are usually metastases from breast and lung cancers.3 Adenohypophyseal carcinoma is rare, with less than 140 reported cases.2 Pituitary tumors are categorized by the size1,2: Microadenomas (<10 mm) Macroadenomas (>10 mm to 40 mm) Giant adenomas (>40 mm) Pituitary adenomas are further classified as functioning (hormone-secreting) or nonfunctioning (nonsecreting).1,6 If the adenoma is functioning, hormone levels will be found in excess. If the levels are within normal limits, a nonfunctioning pituitary adenoma is suspected. Functioning Tumors Approximately 65% of all pituitary adenomas are functioning tumors.2 Functioning pituitary adenomas present in various ways depending on which hormone is involved and the level of hormone secretion. Prolactinomas are the most common type of functioning adenomas followed by growth hormone-secreting and adrenocorticotropic hormone-secreting pituitary tumors. Adenomas secreting thyrotropin and follicle-stimulating hormone are less commonly found.2 Clinical features of functional pituitary adenomas are outlined in Table 1.2.8 Table 1. Clinical Features and Laboratory Findings of Functioning Pituitary Adenomas Nonfunctioning Tumors Approximately 20% to 30% of pituitary adenomas are nonfunctional.3 These tumors may go undiagnosed for years until the mass of the tumor starts to effect surrounding structures and causing secondary symptoms such as compression of the optic chiasm causing vision impairments. Nonfunctioning pituitary adenomas and prolactinomas (functioning) are the 2 most common types of pituitary adenomas.2,3 The consulting clinician must understand the difference in pathology of these 2 types of lesions, what diagnostic test to order, how to interpret the test results, and which specialty to refer the patient to best on the initial workup findings. Initial Workup Proper baseline workup should be initiated before referring patients with incidental pituitary adenoma to a specialist. The initial workup includes imaging, blood work to determine if the pituitary adenoma is causing hormonal dysfunction, and neuro-ophthalmology referral for visual field testing to determine if the optic nerve/chiasm is impacted. Imaging The most accurate diagnostic modality of pituitary gland pathology is MRI with and without contrast. The MRI should focus on the hypothalamic-pituitary area and include contrasted imaging to evaluate the soft tissue within the intracranial structure.9 The coronal and sagittal views are the best to display the pituitary gland width and height and identify abnormalities.9 The MRI provides a detailed evaluation of the pituitary gland related to adjacent structures within the skull, which helps to detect microalterations of the pituitary gland.10 If a pituitary adenoma is an incidental finding on another imaging modality (such as a computed tomography scan or MRI without contrast), an MRI with and without contrast that focuses on the pituitary gland should be obtained. Pituitary Laboratory Panel A complete pituitary panel workup should be obtained including prolactin, thyrotropin, free thyroxine, cortisol (fasting), adrenocorticotropic hormone, insulinlike growth factor 1, growth hormone, follicle-stimulating hormone, luteinizing hormone, estradiol in women, and total testosterone in males.1 Tests should be completed in the morning while fasting for the most accurate results. For instance, normally cortisol levels drop during fasting unless there is abnormality. Table 2 below shows normal laboratory ranges for a complete pituitary panel. Serum prolactin levels can slightly increase in response to changes in sleep, meals, and exercise; emotional distress; psychiatric medications; and oral estrogens. If the initial prolactin level is borderline high (21-40 ng/mL), the test should be repeated. Normal levels are higher in women than in men. Microadenomas may cause slight elevations in prolactin level (ie, <200 ng/mL), while macroadenomas are likely to cause greater elevations (ie, >200 ng/mL).1 Patients with giant prolactinomas typically present with prolactin levels ranging from 1000 ng/mL to 100,000 ng/mL.11 Perimetry Pituitary adenomas may cause ophthalmologic manifestations ranging from impaired visual field to diplopia because of upward displacement of the optic chiasm. The optic chiasm is located above the pituitary gland and a pituitary tumor that grows superiorly can cause compression in this area.12 Optic chiasm compression from a pituitary adenoma commonly causes bitemporal hemianopsia.2 If the tumor volume is promptly reduced by surgical resection or medication (in the case of prolactinomas), initial vision changes due to compression may be reversible.12 Baseline and routine follow-up perimetry are important in patients with pituitary adenoma, as symptoms of optic chiasm compression may go unnoticed by patients as visual field deficits often develop gradually. Also, post-treatment perimetry assessments can be used to compare the initial testing to evaluate reversible visual field deficits. It is recommended that patients with pituitary adenomas (both function and nonfunctiong) receive neuro-ophthalmologic evaluations twice a year to ensure no visual changes have occurred.12 Referral to a Specialist Management of pituitary adenomas requires a multidisciplinary team of specialists including endocrinologists, neurosurgeons, and neuro-ophthalmologists. The type of adenoma governs which specialist patients with incidental adenoma should see first. Patients with functioning pituitary adenomas should be referred to an endocrinologist before a neurosurgeon. The most prevalent functioning adenomas, prolactinoma, are initially treated with dopamine agonist medications.1,6 A patient with prolactinoma would only need to see a neurosurgeon if they have a macroadenoma that is not responsive or only partially responsive to dopamine agonists therapy or is causing vision deficits related to compression of the optic chiasm.2 Patients with nonfunctioning pituitary adenomas should first be referred to a neurosurgeon to discuss surgical options versus observation. The recommended treatment for patients with nonfunctioning adenomas and clinical features of mass effect (ie, visual deficits) is surgery.1,6 If the patient is asymptomatic with no signs of visual field deficits, the neurosurgery team may recommend continued surveillance with serial imaging and serial perimetry screenings.12 The patient in the case was found to have a nonfunctioning pituitary adenoma (prolactin was 33.7 ng/mL). Neuro-ophthalmology did not find any visual field defect upon initial assessment; the patient decided to continue observation with serial imaging (MRI) and serial neuro-ophthalmology assessments. Serial imaging with MRI brain revealed slow but real progression of the pituitary macroadenoma (12 mm initially; 13 mm 6 months later; and 14 mm 1 year from initial MRI findings). Although the patient still did not have any visual field defects per the neuro-ophthalmology reassessments, the documented growth on MRI over a short period of time was enough to make the patient more amendable to surgical resection. The patient underwent trans-sphenoidal resection of the pituitary lesion approximately 16 months after discovery of the tumor. Conclusion A thorough workup including laboratory testing, imaging, and vision field testing is the foundation of an effective referral process for pituitary adenomas and guides which specialist is consulted first. If patients are referred before initial workup is completed, delays in care, unnecessary specialty visits, and increased overall health care costs may occur. Melissa Wasilenko, MSN, RN, is a registered nurse at Lyerly Neurosurgery in Jacksonville, Florida. She is currently pursuing a doctorate in nursing practice with a focus in family medicine at the University of North Florida in Jacksonville. References 1. Russ S, Anastasopoulou C, Shafiq I. Pituitary adenoma. 2021 Jul 18. In: StatPearls. StatPearls Publishing; 2022 Jan–. Updated July 18, 2021. 2. Greenberg MS. Tumors of non-neural origin. In: Handbook of Neurosurgery, 9th ed. Thieme Medical Publishers: 2019; 1655-1755 3. Yeung M, Tahir F. The pathology of the pituitary, parathyroids, thyroid and adrenal glands. Surgery. 2020;38(12):747-757. 4. Watanabe G, Choi SY, Adamson DC. Pituitary incidentalomas in the United States: a national database estimate. World Neurosurg. 2021:S1878-8750(21)01780-0. doi:10.1016/j.wneu.2021.11.079 5. McDowell BD, Wallace RB, Carnahan RM, Chrischilles EA, Lynch CF, Schlechte JA. Demographic differences in incidence for pituitary adenoma. Pituitary. 2011;14(1):23-30. doi:10.1007/s11102-010-0253-4 6. Molitch ME. Diagnosis and treatment of pituitary adenomas: a review. JAMA. 2017;317(5):516-524. doi:10.1001/jama.2016.19699 7. Yao S, Lin P, Vera M, et al. Hormone levels are related to functional compensation in prolactinomas: a resting-state fMRI study. J Neurol Sci. 2020;411:116720. doi:10.1016/j.jns.2020.116720 8. Beck-Peccoz P, Persani L, Lania A. Thyrotropin-secreting pituitary adenoma. In: Feingold KR, Anawalt B, Boyce A, et al, ed. Endotext. MDText.com, Inc.; 2019. 9. Yadav P, Singhal S, Chauhan S, Harit S. MRI evaluation of size and shape of normal pituitary gland: age and sex related changes. J Clin Diagnostic Research. 2017;11(12):1-4. doi:10.7860/JCDR/2017/31034.10933 10. Varrassi M, Cobianchi Bellisari F, Bruno F, et al. High-resolution magnetic resonance imaging at 3T of pituitary gland: advantages and pitfalls. Gland Surg. 2019;8(Suppl 3):S208-S215. doi:10.21037/gs.2019.06.08 11. Shimon I. Giant prolactinomas. Neuroendocrinology. 2019;109(1):51-56. doi:10.1159/000495184 12. Vié AL, Raverot G. Modern neuro-ophthalmological evaluation of patients with pituitary disorders. Best Pract Res Clin Endocrinol Metab. 2019;33(2):101279. doi:10.1016/j.beem.2019.05.003 From the March/April 2022 Issue of Clinical Advisor

https://doi.org/10.1002/ccr3.5337 Abstract A 50-year-old woman with adrenal Cushing's syndrome and chronic hepatitis C developed an acute exacerbation of chronic hepatitis C before adrenectomy. After administration of glecaprevir/pibrentasvir was started, her transaminase levels normalized promptly and a rapid virological response also was achieved. Laparoscopic left adrenectomy was then performed safely. 1 INTRODUCTION Reports of reactivation of hepatitis C virus (HCV) and acute exacerbation of chronic hepatitis C associated with immunosuppressive therapy and cancer drug therapy are rarer than for hepatitis B virus (HBV) but have been made occasionally. In HBV infection, viral reactivation and acute hepatitis caused by an excess of endogenous cortisol due to Cushing's syndrome have been reported, but no acute exacerbation of chronic hepatitis C has been reported so far. Here, we report a case of acute exacerbation of chronic hepatitis C during the course of adrenal Cushing's syndrome. 2 CASE REPORT A woman in her 50s underwent a CT scan at a nearby hospital to investigate treatment-resistant hypertension and was found to have a left adrenal mass. Her blood tests showed low ACTH and HCV antibody positivity, and she was referred to our hospital because she was suspected of having Cushing's syndrome and chronic hepatitis C. There is nothing special to note about her medical or family history. She had never smoked and drank very little. Her physical findings on admission were 164.5 cm tall, 92.6 kg in weight, and a BMI of 34.2 kg/m2. Her blood pressure was 179 / 73 mmHg, pulse 64 /min (rhythmic), body temperature 36.8°C, and respiratory rate 12 /min. She had findings of central obesity, moon face, buffalo hump, and red skin stretch marks. Her blood test findings (Table 1) showed an increase in ALT, HCV antibody positivity, and an HCV RNA concentration of 4.1 log IU/mL. The virus was genotype 2. Cortisol was within the reference range, but ACTH was as low, less than 1.5 pg/mL. Her bedtime cortisol level was 7.07 μg/dL, which was above her reference of 5 μg/dL, suggesting the loss of diurnal variation in cortisol secretion. Testing showed the amount of cortisol by 24-hour urine collection was 62.1 μg/day, and this level of cortisol secretion was maintained. In an overnight low-dose dexamethasone suppression test, cortisol after loading was 6.61 μg/dL, which exceeded 5 μg/dL, suggesting that cortisol was autonomously secreted. Her contrast-enhanced CT scan (Figure 1) revealed a tumor with a major axis of about 30 mm in her left adrenal gland. MRI scans showed mild hyperintensity in the “in phase” (Figure 2A) and decreased signal in the “out of phase” (Figure 2B), suggesting her adrenal mass was an adenoma. Based on the above test results, she was diagnosed with chronic hepatitis C and adrenal Cushing's syndrome. She agreed to receive treatment with direct acting antiviral agents (DAAs) after resection of the left adrenal tumor. However, two months later, she had liver dysfunction with AST 116 U/L and ALT 213 U/L (Figure 3). HBV DNA was undetectable at the time of liver injury, but the HCV RNA concentration increased to 6.4 logIU/mL. Therefore, an acute exacerbation of chronic hepatitis C was suspected, and a percutaneous liver biopsy was performed. The biopsy revealed an inflammatory cell infiltration, mostly composed of lymphocytes and plasma cells and mainly in the portal vein area (Figure 4). Fibrosis and interface hepatitis were also observed, and spotty necrosis was evident in the hepatic lobule. No clear fat deposits were found in the hepatocytes, ruling out NASH or NAFLD. According to the New Inuyama classification, hepatitis equivalent to A2-3/F1-2 was considered. Because HBV DNA was not detected, no new drug was used, and no cause of liver damage, such as biliary atresia, was found; the patient was diagnosed with liver damage due to reactivation of HCV, with acute exacerbation of chronic hepatitis C. The treatment policy was changed, in order to treat hepatitis C before the left adrenal resection, and administration of glecaprevir/pibrentasvir was started. A blood test two weeks after the start of treatment confirmed normalization of AST and ALT, and a rapid virological response was achieved (Figure 3). Subsequently, HCV RNA remained negative, no liver damage was observed, and laparoscopic left adrenectomy was safely performed nine months after the initial diagnosis. The pathological findings were adrenal adenoma, and no atrophy was observed in the attached normal adrenal cortical gland. After the operation, hypertension improved and weight loss was obtained (92.6 kg (BMI: 34.2 kg/m2) before the operation, but 77.0 kg (BMI: 28.5 kg/m2) one year after the operation). ACTH increased, and the adrenal Cushing's syndrome was considered to have been cured. Regarding HCV infection, the sustained virological response has been maintained to date, more than 2 years after the completion of DAA therapy, and the follow-up continues. TABLE 1. Laboratory data on admission Hematology Chemistry WBC 6100 /μL TP 8.2 g/dL DHEA-S 48 /μL RBC 526 x 104 /μL Alb 3.4 g/dL PRA 0.7 ng/mL/h Hb 15.8 g/dL T-Bil 0.3 mg/dL ALD 189 pg/mL Ht 49.1 % AST 33 U/L PLT 25.5 x 104 /μL ALT 46 U/L Serological tests LDH 201 U/L CRP <0.10 mg/dL ALP 292 U/L HBsAg (-) γ-GTP 77 U/L anti-HBs (-) Coagulation BUN 13 mg/dL anti-HBc (+) PT 126.1 % Cr 0.63 mg/dL HBeAg (-) APTT 27.5 sec HbA1c 6.2 % anti-HBe (+) Cortisol 7.46 μg/dL anti-HCV (+) ACTH <1.5 pg/mL FBS 82 mg/dL Genetic tests Na 138 mmol/L HBV DNA Undetectable Cl 105 mmol/L HCV RNA 4.1 LogIU/Ml K 3.6 mmol/L HCV genotype 2 Ca 9.0 mg/dL Abbreviations: Hematology: WBC, white blood cells; RBC, red blood cells; Hb, hemoglobin; Ht, hematocrit; PLT, platelets. Coagulation: PT, prothrombin time; APTT, activated partial thromboplastin time. Chemistry: TP, total protein; Alb, albumin; T-Bil, total bilirubin; AST, aspartate transaminase; ALT, alanine aminotransferase; LDH, lactate dehydrogenase; ALP, alkaline phosphatase; γGTP, γ-glutamyl transpeptidase; BUN, blood urea nitrogen; Cr, creatinine; HbA1c, Hemoglobin A1c; FBS, fasting blood sugar; Na, sodium; Cl, chlorine; K, potassium; Ca, calcium; DHEA-S, dehydroepiandrosterone sulfate; PRA, plasma renin activity; ALD, aldosterone. Serological tests: CRP, C-reactive protein; HBsAg, hepatitis B surface antigen; anti-HBs, hepatitis B surface antibody; anti-HBc, hepatitis B core antibody; HBeAg, hepatitis B e antigen; anti-HBe, hepatitis B e antibody; anti-HCV, hepatitis C virus antibody. Genetic tests: HBV DNA, hepatitis B virus deoxyribonucleic acid; HCV RNA, hepatitis C virus ribonucleic acid. FIGURE 1 Open in figure viewerPowerPoint Contrast-enhanced CT examination. Contrast-enhanced CT examination revealed a tumor (arrow) with a major axis of about 30 mm in the left adrenal gland FIGURE 2 Open in figure viewerPowerPoint MRI image of the adrenal lesion. MRI showed mild hyperintensity in the "in phase" (A) and decreased signal in the "out of phase" (B), suggesting adrenocortical adenoma (arrow) FIGURE 3 Open in figure viewerPowerPoint Changes in serum transaminase and HCV RNA levels. All showed rapid improvement by administration of direct acting antivirals. ALT: alanine aminotransferase, AST: aspartate transaminase, HCV RNA: hepatitis C virus ribonucleic acid FIGURE 4 Open in figure viewerPowerPoint Pathological findings of tissues obtained by percutaneous liver biopsy. Infiltration of inflammatory cells, which was mostly composed of lymphocytes and plasma cells and a small number of neutrophils, was observed mainly in the portal vein area. This was accompanied by fibrous enlargement and interface hepatitis. Although the arrangement of hepatocytes was maintained in the hepatic lobule, spotty necrosis was observed in some parts. No clear fat deposits were found in the hepatocytes, and NASH or NAFLD was a negative finding. According to the New Inuyama classification, hepatitis equivalent to A2-3/F1-2 was considered (a; ×100, b; ×200, scale bar = 500 µm) 3 DISCUSSION Reactivation of HBV can cause serious liver damage. Therefore, it is recommended to check the HBV infection status before starting anticancer chemotherapy or immunotherapy and to continue monitoring for the presence or absence of reactivation thereafter.1, 2 On the other hand, there are fewer reports of the reactivation of HCV, and many aspects of the pathophysiology of HCV reactivation remain unclear. In this case, it is possible that chronic hepatitis C was acutely exacerbated due to endogenous cortisol secretion in Cushing's syndrome. Although the definition of HCV reactivation has not been defined, several studies3-5 have defined an increase of HCVRNA of 1.0 log IU/ml or more as HCV reactivation. In addition, the definition of acute exacerbation of chronic hepatitis C is that ALT increases to more than three times the upper limit of the reference range.3, 4, 6 Mahale et al. reported a retrospective study in which acute exacerbation of chronic hepatitis C due to cancer medication was seen in 11% of 308 patients.3 Torres et al. also reported that, in a prospective study of 100 patients with cancer medication, HCV reactivation was found in 23%.4 Given these reports, HCV reactivation potentially could occur quite frequently. However, Torres et al. reported that only 10% of all patients had acute exacerbations, none of which led to liver failure.4 Such data suggest that HCV reactivation may often be overlooked in actual cases without aggravation. Thus, the frequency of aggravation due to hepatitis virus reactivation is thought to be lower for HCV than for HBV. However, there are some reports of deaths from acute exacerbation of chronic hepatitis C.7-10 In addition, if severe hepatitis develops following viral reactivation, mortality rates have been reported to be similar for HBV and HCV.8, 11 Thus, reactivation of HCV is considered to be a pathological condition that requires caution, similar to HBV. Torres et al. reported that administration of rituximab or corticosteroids is a significant independent risk factor.4 In addition, there are reports of acute exacerbation of chronic hepatitis C due to corticosteroids administered as antiemetics and as immunosuppressive therapy.12-14 Therefore, excess cortisol can reactivate not only HBV but also HCV. The mechanism by which HCV is reactivated with cortisol is assumed to be decreased cell-mediated immunity due to rapid apoptosis of circulating T cells caused by glucocorticoids,4 enhancement of HCV infectivity by upregulation of viral receptor expression on the hepatocyte surface,15 and enhanced viral replication.16 In addition, there is a report that genotype 2 is more common in cases with acute exacerbation of chronic hepatitis C,4, 13 which is consistent with this case. Regarding HBV reactivation due to Cushing's syndrome, three cases of acute exacerbation of chronic hepatitis B have been reported.17-19 It is believed that Cushing's syndrome caused a decrease in cell-mediated immunity and humoral immunity due to an endogenous excess of cortisol, resulting in an acute exacerbation of chronic hepatitis B.13 As described above, because an excess of cortisol can cause reactivation of HCV, it is considered that a decrease in immunocompetence due to Cushing's syndrome, which is an excess of endogenous cortisol, can also cause reactivation of HCV and acute exacerbation of chronic hepatitis. However, as far as we can determine, no cases of Cushing's syndrome causing HCV reactivation or acute exacerbation of chronic hepatitis C have been reported and similar cases may be latent. Among the reports of acute exacerbation of hepatitis B due to adrenal Cushing's syndrome, there is a case in which the liver damage and viral load were improved only by adrenalectomy.17 Therefore, it is also possible that hepatitis C was improved by adrenal resection in this case. However, general anesthesia associated with adrenalectomy and the use of various drugs used for postoperative physical management should be avoided, if possible, in situations where some severe liver damage is present. In addition, reactivation of immunity due to rapid depletion of glucocorticoid, following resection of an adrenal tumor, may lead to exacerbation of liver damage. In this case, the amount of HCV and hepatic transaminase levels were improved rapidly by glecaprevir/pibrentasvir treatment, and the operation could be performed safely. If Cushing's syndrome is complicated by an acute exacerbation of hepatitis C, clinicians should consider including treatment strategies such as in this case. Summarizing the above, when liver damage appears in HCV-infected patients with Cushing's syndrome, it will be necessary to distinguish the acute exacerbation and reactivation of chronic hepatitis C. Treatment with DAAs may then be considered to be effective for reactivation of HCV and acute exacerbation of chronic hepatitis. 4 CONCLUSION We report a case of chronic hepatitis C with acute exacerbation during the course of Cushing's syndrome. At the time of cancer drug therapy and in the state of endogenous and extrinsic corticosteroid excess, it is necessary to pay attention not only to acute exacerbation of chronic hepatitis B but also to hepatitis C. ACKNOWLEDGEMENTS All authors would like to thank the patient and his family for allowing this case study. CONFLICT OF INTEREST The authors have no conflict of interests. AUTHOR CONTRIBUTIONS TO and KM were collected and analyzed the data and wrote and edited the manuscript. KH, ST, HO, KT, KM, and JK were involved in the patient's care and provided advice on the preparation of this case report. ETHICAL APPROVAL This study complied with the standards of the Declaration of Helsinki and the current ethical guidelines. CONSENT Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy. From https://onlinelibrary.wiley.com/doi/10.1002/ccr3.5337

This article was originally published here Front Surg. 2022 Feb 2;8:806855. doi: 10.3389/fsurg.2021.806855. eCollection 2021. ABSTRACT PURPOSE: Currently, endoscopic transsphenoidal surgery (ETS) and microscopic transsphenoidal surgery (MTS) are commonly applied treatments for patients with pituitary adenomas. This meta-analysis was conducted to evaluate the efficacy and safety of ETS and MTS for these patients. METHODS: A computer search of Pubmed, Embase, Cochrane library, Web of Science, and Google Scholar databases was conducted for studies investigating ETS and MTS for patients with pituitary adenomas. The deadline is March 01, 2021. RevMan5.1 software was used to complete this meta-analysis after literature screening, data extraction, and literature quality evaluation. RESULTS: A total of 37 studies including 5,591 patients were included. There was no significant difference in gross tumor removal (GTR) and hormone-excess secretion remission (HES remission) between two groups [RR = 1.10, 95% CI (0.99-1.22), P = 0.07; RR = 1.09, 95% CI (1.00-1.20), P = 0.05]. ETS was associated with lower incidence of diabetes insipidus (DI) [RR = 0.71, 95% CI (0.58-0.87), P = 0.0008], hypothyroidism [RR = 0.64, 95% CI (0.47-0.89), P = 0.007], and septal perforation [RR = 0.32, 95% CI (0.13-0.79), P = 0.01] than those with MTS. CONCLUSION: This meta-analysis indicated that ETS cannot significantly improve GTR and HES remission. However, ETS could reduce the incidence of DI, hypothyroidism, and septal perforation without increasing the rate of other complications. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/prospero/#myprospero, identifier: CRD42021241217. PMID:35187049 | PMC:PMC8847202 | DOI:10.3389/fsurg.2021.806855