Adrenal autografts in treatment of Cushing's disease.

Abstract

The accepted treatment for Cushing's syndrome caused by benign or malignant neoplasms of the adrenal cortex is unilateral adrenalectomy with conservation of the contraiateral gland (Sprague, 1953). There is less agree ment, however, on the correct therapy for the majority of patients with this condition, whose syndrome is due to bilateral adrenal hyperplasia. Cushing (1932) envisaged a primary pituitary disorder, and early reports of deep radiotherapy to the pituitary gland were encouraging (Luft, 1946 ; Skrimshire, 1955). Subse quent experience proved less successful (Plotz et al., 1952 ; Cope and Raker, 1955), a clinical remission occurring in only one-quarter of the patients treated. More patients obtained remission after subtotal adrenalectomy (Sprague, 1953 ; Bishop et al, 1954) ; the amount of adrenal tissue removed is critical, however, and the incidence of incomplete remission or relapse is appreciable (Lessof and Bishop, 1956). For this reason there has been an increasing tendency to recommend total bilateral adrenalectomy as the definitive therapy (Sprague et al, 1961). In an attempt to avoid the disadvantage of hormone dependence following this operation, Franksson et al. (1959) described five cases of Cushing's syndrome in which adrenal tissue was implanted into the sartorius muscles at the time of operation. At least three of these patients resumed normal activities without steroid replacement in the post-operative period. In the present paper two cases of Cushing's syndrome in which adrenal autotransplantation has been performed are described. The first patient was found to have a unilateral adrenal carcinoma and the other had bilateral adrenal hyperplasia. Methods Steroid Estimation.?17-Ketosteroids were estimated by the method of Drekter et al. (1952) and the 17 hydroxysteroids by the method of Appleby et al. (1955). To test adrenal responsiveness, urinary steroids were estimated for four days during stimulation with intra muscular zinc corticotrophin 40 units b.i.d., and for three days during and after a 24-hour course of 44 metopirone, 750 mg. six-hourly. In addition, urine steroids were estimated during a six-day course of dexamethasone, 2 mg. and 5 mg. daily. Antibody Studies.?The adrenal tissue was frozen at -20? C. immediately after removal. An extract was prepared by finely slicing the organ after removal of fat, and homogenizing one part in three parts of physio logical saline solution in a Waring blender. The extract was centrifuged at 3,000 r.p.m. and the supernatant used as antigen, diluted to eliminate anti-complementary activity. The technique of the complement fixation was that described by Anderson et al (1957). Tests were performed by incubation at 37? G for one hour and overnight at 4? G Sera from both patients were tested against antigen prepared from their own and each other's adrenal tissue.