Inhibition Of Steroidogenesis Research Articles

The impact of adrenal tumor multidisciplinary team meetings on clinical outcomes.

Multidisciplinary team meetings (MDMs) to address various clinical problems have become common, especially for cancer care. However, the impact of MDMs on adrenal tumor care has rarely been reported. We organized an endocrine tumor MDM including adrenal tumors in August 2014. The objective of this study was to assess the impact of our adrenal tumor MDMs on patient clinical outcomes. We compared several parameters measuring clinical outcomes before and after MDMs were instituted. The adrenal tumor MDMs included an endocrinologists, urologists, radiologists, pathologists, and residents. We analyzed 128 consecutive cases of functioning adrenal tumors (primary aldosteronism (PA), n = 53; Cushing's syndrome (CS), n = 24; pheochromocytoma (PCC), n = 51) who underwent surgery in Kobe University Hospital from 2008 to 2019, and compared clinical parameters before (n = 68) and after (n = 60) MDMs were instituted. Twenty-one selected cases including PA, CS, PCC, adrenocortical carcinoma, and metastatic adrenal tumor were discussed in the MDM. In the analysis of 128 cases, the difference between pre- and postoperative systolic BP (ΔBP) in patients with PA after MDMs were instituted was smaller compared with those before (p = 0.02). In CS, preoperative steroid synthesis inhibitors were used more often (33 vs. 100%, p < 0.01), postoperative plasma ACTH levels were higher (29.1 vs. 84.5 pg/mL, p < 0.01), and postoperative decrease in systolic BP was milder (p < 0.01) after MDMs were instituted. In PCC, doses of preoperative doxazosin were higher (p < 0.01) after MDMs institution. Operating time, bleeding volume, and cure rate did not differ between each tumor type. These data suggest that instituting MDMs improved the perioperative management of functioning adrenal tumors.

Fatal high-grade skull osteosarcoma 30 years following radiotherapy for Cushing's disease.

SummaryCushing’s disease is a rare disorder characterised by excessive cortisol production as a consequence of a corticotroph pituitary tumour. While the primary treatment is surgical resection, post-operative radiation therapy may be used in cases of ongoing inadequate hormonal control or residual or progressive structural disease. Despite improved outcomes, radiotherapy for pituitary tumours is associated with hypopituitarism, visual deficits and, rarely, secondary malignancies. We describe an unusual case of a 67-year-old female with presumed Cushing’s disease diagnosed at the age of 37, treated with transsphenoidal resection of a pituitary tumour with post-operative external beam radiotherapy (EBRT), ketoconazole for steroidogenesis inhibition, and finally bilateral adrenalectomy for refractory disease. She presented 30 years after her treatment with a witnessed generalised tonic-clonic seizure. Radiological investigations confirmed an extracranial mass infiltrating through the temporal bone and into brain parenchyma. Due to recurrent generalised seizures, the patient was intubated and commenced on dexamethasone and anti-epileptic therapy. Resection of the tumour revealed a high-grade osteoblastic osteosarcoma. Unfortunately, the patient deteriorated in intensive care and suffered a fatal cardiac arrest following a likely aspiration event. We describe the risk factors, prevalence and treatment of radiation-induced osteosarcoma, an exceedingly rare and late complication of pituitary irradiation. To our knowledge, this is the longest reported latency period between pituitary irradiation and the development of an osteosarcoma of the skull.Learning points:Cushing’s disease is treated with transsphenoidal resection as first-line therapy, with radiotherapy used in cases of incomplete resection, disease recurrence or persistent hypercortisolism.The most common long-term adverse outcome of pituitary tumour irradiation is hypopituitarism occurring in 30–60% of patients at 10 years, and less commonly, vision loss and oculomotor nerve palsies, radiation-induced brain tumours and sarcomas.Currently proposed characteristics of radiation-induced osteosarcomas include: the finding of a different histological type to the primary tumour, has developed within or adjacent to the path of the radiation beam, and a latency period of at least 3 years.Treatment of osteosarcoma of the skull include complete surgical excision, followed by systemic chemotherapy and/or radiotherapy.Overall prognosis in radiation-induced sarcoma of bone is poor.Newer techniques such as stereotactic radiosurgery may reduce the incidence of radiation-induced malignancies.

Low-Molecular-Weight Ligands of Luteinizing Hormone Receptor with the Activity of Antagonists

Currently, a search for selective antagonists of luteinizing hormone (LH) receptor, which are required to suppress the steroidogenesis in hormone-dependent tumors and to prevent the ovarian hyperstimulation syndrome, is carried out. One approach to tackle this problem is the development of low-molecular-weight antagonists of the allosteric site of this receptor, which is located in its transmembrane domain. The aim of this work was to develop the heterocyclic compounds, the derivatives of thieno[2,3-d]pyrimidine (TP31), pyrimido[4,5,6-de][1,6]naphthyridine (PP10), and pyrido[3,4-d]pyrimidine (PP17), and to study their ability to affect the functional activity of the LH receptor in the in vitro and in vivo conditions. It was shown that TP31 at micromolar concentrations suppressed stimulating effects of human chorionic gonadotropin (hCG) and TP03, an allosteric agonist of the LH receptor, on the adenylyl cyclase activity in rat testicular membranes; its effect was most pronounced in relation to the stimulating effects of TP03. This was due to a higher selectivity of the TP31 antagonist with respect to the cAMP-dependent signaling cascades, predominantly activated by TP03 and realized through Gs proteins. PP17 inhibited stimulatory effects of hCG and TP03 on the adenylyl cyclase activity to a similar extent but was less active compared to TP31. Upon intratesticular (10 mg/kg) or intraperitoneal (45 mg/kg) administration to male rats, TP31 and PP17 decreased the baseline plasma level of testosterone and inhibited the testosterone production stimulated by hCG (100 IU/rat); the inhibitory effect of TP31 was much more pronounced than that of PP17. PP10 exhibited a weaker antagonistic activity than TP31 and PP17 in the in vitro and in vivo conditions. The data obtained indicated that TP31, the most active functional antagonist among the studied compounds, binded to the allosteric site of the LH receptor, made it less accessible to allosteric agonists and impairs the hormonal signal transduction through the LH receptor. This suggests the prospects of the development of TP31-based inhibitors of LH-dependent pathways and steroidogenesis.

Approach to patients with bilateral adrenal incidentalomas.

The current review provides a summary on the most recent developments regarding the cause, work-up and management of bilateral adrenal incidentalomas (BAI). The recent ENS@T/ESE guidelines provide comprehensive directions on the evaluation and management of patients with adrenal incidentalomas with special focus on those with bilateral tumours. Intraadrenal ACTH synthesis that may locally stimulate cortisol secretion challenging the traditionally used term 'ACTH-independent'. Inactivating mutations of a new tumour suppressor gene, armadillo repeat containing 5 (ARMC5), are implicated in a number of patients, especially those with multiple macronodules (bilateral macronodular hyperplasia) and evidence of hypercortisolism. Loss-of-function mutations of the glucocorticoid receptor gene (NR3C1) consist a new possible genetic cause of BAIs. Regarding management an increasing number of studies provide data on the benefits and safety of unilateral rather than bilateral adrenalectomy. There is also emerging data on the beneficial use of steroidogenesis inhibitors in a dosing schedule that aims to mimic the normal cortisol rhythm with promising short-term results, but the long-term clinical benefits of this approach remain to be demonstrated. The diagnostic approach consists of imaging and hormonal evaluation. Imaging characterization should be done separately for each lesion. Hormonal evaluation includes testing for primary aldosteronism, pheochromocytoma and evaluation for autonomous cortisol secretion, using the 1-mg overnight dexamethasone suppression test. Midnight cortisol or 24-h urinary-free cortisol may aid in establishing the degree of cortisol excess. In patients with hypercortisolism ACTH levels should be measured to establish ACTH-independency. The appropriate management of BAI associated with cortisol excess remains controversial. Bilateral adrenalectomy results in lifetime steroid dependency and is better reserved only for patients with overt and severe hypercortisolism. Unilateral adrenalectomy might be considered in selected patients. Medical therapy is not an established approach yet but it may be considered when control of hypercortisolism is desired, but surgery is not an option.

Environmental contaminants and male infertility: Effects and mechanisms.

The escalating prevalence of male infertility and decreasing trend in sperm quality have been correlated with rapid industrialisation and the associated discharge of an excess of synthetic substances into the environment. Humans are inevitably exposed to these ubiquitously distributed environmental contaminants, which possess the ability to intervene with the growth and function of male reproductive organs. Several epidemiological reports have correlated the blood and seminal levels of environmental contaminants with poor sperm quality. Numerous in vivo and in vitro studies have been conducted to investigate the effect of various environmental contaminants on spermatogenesis, steroidogenesis, Sertoli cells, blood-testis barrier, epididymis and sperm functions. The reported reprotoxic effects include alterations in the spermatogenic cycle, increased germ cell apoptosis, inhibition of steroidogenesis, decreased Leydig cell viability, impairment of Sertoli cell structure and function, altered expression of steroid receptors, increased permeability of blood-testis barrier, induction of peroxidative and epigenetic alterations in spermatozoa resulting in poor sperm quality and function. In light of recent scientific reports, this review discusses the effects of environmental contaminants on the male reproductive function and the possible mechanisms of action.

SAT-213 Parotid Carcinoma Ex Pleomorphic Adenoma Can Produce Ectopic ACTH Too

Background: Ectopic ACTH syndrome accounts for about 14% of Cushing syndrome cases. Small cell lung cancer is the most common cause. A few case reports described ectopic ACTH syndrome in patients with parotid acinic cell carcinoma. Parotid carcinoma ex pleomorphic adenoma is a malignant transformation within a pleomorphic adenoma, which is mostly adenocarcinoma not otherwise specified, but other subtypes can occur. Clinical Case: A 41-year old man with parotid cancer and hypothyroidism was admitted to the hospital for hypokalemia (2.1 mmol/L, n: 3.5-5 mmol/L). Parotid cancer was diagnosed a year before admission. At that time, he underwent left parotidectomy, and pathology showed carcinoma ex pleomorphic adenoma with areas of acinic cell carcinoma. Despite chemoradiation, he was diagnosed with metastasis in the lungs, for which pembrolizumab was started. Over the two months prior to admission, he gained 20 lb, and developed lower extremity weakness, acne, erectile dysfunction and loss of libido. He was also diagnosed with hypertension and started to have mild hypokalemia. Suspecting hyperaldosteronism, oncology team ordered labs just prior to admission, which showed the hypokalemia of 2.1 mmol/L, hypernatremia (147 mmol/L, n: 133-143 mmol/L), normal aldosterone and renin, and high cortisol (59.12 mcg/dL, n: 3-22 mcg/dL) and ACTH (121 pg/mL, n: 9-50 pg/mL).In the hospital, potassium was slowly improving despite aggressive replacement, and blood pressure was still elevated despite increasing his lisinopril dose. Screening for Cushing syndrome revealed an abnormal 1 mg dexamethasone suppression test (cortisol 51.9 mcg/dL, n: <1.8 mcg/dL), and high 24-hour urinary free cortisol (6495 mcg/24h, n: 3.5-45 mcg/24h) and midnight salivary cortisol (2610 ng/dL and 4250 ng/dL, n: <100 ng/dL). Cortisol was not suppressed after 8 mg dexamethasone (cortisol 47.85 mcg/dL, pretest cortisol 48.73 mcg/dL) pointing toward ectopic ACTH syndrome. Spironolactone was started and titrated up to 100 mg BID with better control of hypertension and normalization of potassium. Ketoconazole was started at 200 mg TID and increased gradually as outpatient to 400 mg TID within three weeks. A repeat 24-hour urinary free cortisol was done five weeks after ketoconazole was started showing significant improvement (110 mcg/24h, n: 3.5-45 mcg/24h). Potassium requirements remarkably decreased from 80 mEq TID to 40 mEq daily. Of note, chest CT done during hospitalization showed new lung lesions despite treatment with pembrolizumab. Conclusion: This is the first case of ectopic ACTH syndrome to be described in a patient with parotid carcinoma ex pleomorphic adenoma, though areas of acinic cell carcinoma within the tumor can be the source of ACTH. Hypercortisolism due to ectopic ACTH secretion is usually of rapid onset, and can present with severe hypokalemia. Steroid synthesis inhibitors seem to be an effective therapy.

MON-LB039 Acute Paraneoplastic Cushing’s Syndrome in a Patient With Small Cell Lung Cancer and Co-Incidental Adrenal Adenoma: A Case Report

Background: Paraneoplastic Cushing’s syndrome is a rare cause of hypercortisolism associated with high morbidity, especially in patients with small cell lung cancer. Therefore, early diagnosis and treatment are critical. Clinical Case: Herein we present the case of a 58-year-old man who was referred to the endocrinology department, because of refractory hypokalemia (potassium 2.4 mmol/l; RI: 3.4 - 4.5 mmol/l) despite high potassium supplements and spironolactone therapy. History was remarkable for a metabolic syndrome with newly aggravated hypertension and a 60-pack-year smoking history. The patient reported a 20 kg weight gain in 6 weeks and proximal muscle weakness. On examination, he was overweight (BMI 44.8 kg/m²) with bilateral pitting edema. Other features of hypercortisolism such as striae rubrae, facial plethora or ecchymoses, respectively, were not apparent. Initial biochemical tests showed severe hypokalemia and metabolic alkalosis. Night-time salivary cortisol (205 nmol/l; RI: < 2.5 nmol/l), 24-hour urinary free cortisol (> 4357 nmol/24h; RI: 99 - 378 nmol/24h) and serum ACTH (158 ng/l; RI: < 61 ng/l) were markedly elevated. While the MRI of the head demonstrated no pituitary pathology, the CT of thorax and abdomen revealed a pulmonary mass as well as an incidental right adrenal mass. Bronchoscopic biopsy of the pulmonary mass confirmed the suspected diagnosis of ACTH-producing small cell lung cancer. The dignity of the right adrenal mass remained unclear, since the radiologic features per se could not differentiate between adrenal adenoma and metastasis. Chemotherapy with cisplatin/etoposide and inhibition of steroidogenesis with ketoconazole were initiated, which largely controlled the hypercortisolism. Imaging studies after completion of two cycles of chemotherapy showed a tumor response with regression of the pulmonary mass. The right adrenal mass remained stationary under chemotherapy. Thus, an adrenal metastasis could be excluded as potential cause of the adrenal mass, suggesting an incidental adrenal adenoma as the most likely diagnosis. Conclusion: Paraneoplastic Cushing’s syndrome requires high clinical suspicion for early diagnosis, since many of the classical clinical features of hypercortisolism may still be absent, even if the underlying cancer is already advanced. In patients suspected to have Cushing’s syndrome a three-step diagnostic approach is recommended: (1) biochemical confirmation of hypercortisolism, (2) differentiation between ACTH-dependant and -independant hypercortisolism and (3) identification of its source. This approach helps avoiding misdiagnosis in patients who have both an ACTH-producing cancer and an adrenal adenoma [1].

SAT-158 New Data on High Prevalence and Time of Occurrence of New Onset Hypothyroidism Associated with Mitotane Therapy in a Cohort of Adrenocortical Cancer

Context. Mitotane is a steroidogenesis inhibitor and an adrenocorticolytic drug used to treat adrenocortical cancer (ACC). Central hypothyroidism is recognized in mitotane-treated patients and recent data suggested that mitotane could have an inhibitory effect on TSH-secreting cells in the pituitary gland. Moreover, mitotane may lead to induction of thyroid hormone metabolism. Clinical data on hypothyroidism related to mitotane such as prevalence and time of occurrence was described in a limited number of patients. Objective. To better characterize clinically secondary hypothyroidism in patients with ACC treated with mitotane therapy. Methods. We reviewed retrospectively paper charts and electronic records from patients with histologically confirmed diagnosis of ACC evaluated at our center from 1995-2019. We analysed the pattern of TSH and thyroid function, but also mitotane timing and levels at baseline and during treatment of patients under mitotane therapy. Thyroid hormone assessment including TSH, FT4 and FT3 was performed at least every 3 months during follow-up. Results. Our cohort of 104 patients with ACC includes 84 patients that received mitotane therapy. Among them, thyroid function data was incomplete for 39 cases. Complete data was retrieved from 45 patients. Ten out of 45 (22.2%) patients were already known for primary hypothyroidism and were receiving L-T4 replacement before the initiation of mitotane. Two of 45 (4.4%) patients maintained a normal thyroid function during complete follow up (4.5 years) and 33/45 (73.3%) had new onset hypothyroidism requiring levothyroxine treatment. Of these 33 patients, 22 were females and 11 were males, ranging from 22-74 yo with a median of 46 yo. The number of patients with ENSAT stage I, II, III and IV of disease were 1, 8, 11 and 13 respectively. Thyroid profiles were compatible with central hypothyroidism (low T4 with low or inappropriately normal TSH) in 22/33 patients (66.7%). Interestingly, 6/33 patients (18.2%) developed a TSH elevation with a normal lower-limit or low T4 level. The timeline distribution of the occurrence of hypothyroidism was 21.2% (n:7) at <3 months, 15.2% (n:5) between 3-6 months, 21.2% (n:7) between 6-9 months and 15.2% (n:5) between 9-12 months. 9.1% (n:3) occurred within the second year of treatment (between 12-24 months). However, in 5/33 (15.2%) cases, the exact time of new hypothyroidism onset was undetermined. Conclusion. Mitotane therapy is frequently associated with new onset hypothyroidism with a prevalence of 73% in our cohort of exposed patients and is most likely of central etiology. 72.7% of cases occur in the first year of treatment while 9.1% occur in the second year. This study supports the importance of monitoring thyroid function (including a free T4 level) during the complete course of mitotane therapy.

SUN-211 Active Steroid Hormone Synthesis Renders Adrenocortical Cells Highly Susceptible to Type II Ferroptosis Induction

Context: Cell death in the adrenal cortex is ill understood but of high clinical relevance. Resistance of adrenocortical carcinoma (ACC) to current treatment with mitotane and chemotherapy calls for an improved understanding of adrenal cortical cell death processes. Ferroptosis is an iron-dependent form of regulated cell death which is characterized by polyunsaturated lipids adrenic (AdA) and arachidonic acid (AA) peroxidation. Aim: To address the potential role of ferroptosis in the adrenal gland as a potential treatment target of ACC. Methods: Human ACC cells H295R, CU-ACC1 and 2 were used. Protein expression of key enzymes was determined by western blotting. Lipid peroxidation was quantified with BODIPY 581/591 and cell viability with CellTiterGlo after treatment with known inducers and inhibitors of ferroptosis and steroidogenesis, respectively. Results: Adrenocortical tissues are enriched in AdA and AA and express high levels of genes relevant to ferroptosis, such as glutathione peroxidase 4 (GPX4) and long-chain-fatty-acid CoA ligase 4 (ACSL4). Inhibition of GPX4 with RSL3 led to cell death in H295R, CU-ACC1 and 2 cells at EC50 values of 2.4x10-7, 8.1x10-7 and 1.5x10-8 M, respectively. The steroidogenesis inhibitor ketoconazole completely reversed RSL3 cytotoxicity in all three steroidogenic cell lines by reducing lipid peroxidation. Mitotane induced lipid peroxidation but inhibition of ferroptosis with liproxstatin did not protect mitotane-induced cell death. Conclusion: Adrenocortical cells are highly sensitive to ferroptosis due to active steroidogenesis. Triggering this form of cell death could present future novel treatment options against ACC.

Interplay between glucocorticoids and tumor-infiltrating lymphocytes on the prognosis of adrenocortical carcinoma.

BackgroundAdrenocortical carcinoma (ACC) is a rare endocrine malignancy. Tumor-related glucocorticoid excess is present in ~60% of patients and associated with particularly poor prognosis. Results of first clinical trials using immune checkpoint inhibitors were heterogeneous. Here we characterize tumor-infiltrating T lymphocytes (TILs) in ACC in association with glucocorticoids as potential explanation for resistance to immunotherapy.MethodsWe performed immunofluorescence analysis to visualize tumor-infiltrating T cells (CD3+), T helper cells (CD3+CD4+), cytotoxic T cells (CD3+CD8+) and regulatory T cells (Tregs; CD3+CD4+FoxP3+) in 146 ACC tissue specimens (107 primary tumors, 16 local recurrences, 23 metastases). Quantitative data of immune cell infiltration were correlated with clinical data (including glucocorticoid excess).Results86.3% of ACC specimens showed tumor infiltrating T cells (7.7 cells/high power field (HPF)), including T helper (74.0%, 6.7 cells/HPF), cytotoxic T cells (84.3%, 5.7 cells/HPF) and Tregs (49.3%, 0.8 cells/HPF). The number of TILs was associated with better overall survival (HR for death: 0.47, 95% CI 0.25 to 0.87), which was true for CD4+− and CD8+ subpopulations as well. In localized, non-metastatic ACC, the favorable impact of TILs on overall and recurrence-free survival was manifested even independently of ENSAT (European Network for the Study of Adrenal Tumors) stage, resection status and Ki67 index. T helper cells were negatively correlated with glucocorticoid excess (Phi=−0.290, p=0.009). Patients with glucocorticoid excess and low TILs had a particularly poor overall survival (27 vs. 121 months in patients with TILs without glucocorticoid excess).ConclusionGlucocorticoid excess is associated with T cell depletion and unfavorable prognosis. To reactivate the immune system in ACC by checkpoint inhibitors, an inhibition of adrenal steroidogenesis might be pivotal and should be tested in prospective studies.

Kisspeptin and Testicular Function-Is it Necessary?

The role of kisspeptin in stimulating hypothalamic GnRH is undisputed. However, the role of kisspeptin signaling in testicular function is less clear. The testes are essential for male reproduction through their functions of spermatogenesis and steroidogenesis. Our review focused on the current literature investigating the distribution, regulation and effects of kisspeptin and its receptor (KISS1/KISS1R) within the testes of species studied to date. There is substantial evidence of localised KISS1/KISS1R expression and peptide distribution in the testes. However, variability is observed in the testicular cell types expressing KISS1/KISS1R. Evidence is presented for modulation of steroidogenesis and sperm function by kisspeptin signaling. However, the physiological importance of such effects, and whether these are paracrine or endocrine manifestations, remain unclear.

Methionine-enkephalin-treatment suppresses the pituitary-ovary axis in the cichlid fish Oreochromis mossambicus

The involvement of endogenous opioid peptides in regulation of reproductive activity is implicated in a majority of vertebrates. Methionine-enkephalin (M-ENK) is an endogenous opioid peptide neurotransmitter produced in the central nervous system. Although a role for M-ENK in antinociception (pain suppression) and mediation of stress has been suggested, its influence on fish reproduction is not clearly understood. The aim of the present investigation was to determine the role of M-ENK on the reproductive-axis of the female tilapia Oreochromis mossambicus. Treatment of stripped O. mossambicus with 300 μg M-ENK during the ovarian cycle resulted in suppression of luteinizing hormone (LH) secretory activity. This was evidenced by a significant reduction in the area and the intensity of LH immunoreactivity in the proximal pars distalis of the pituitary gland as compared to controls during the prespawning phase. At the ovarian level, the treatment of M-ENK caused a significant increase in the mean number of follicles with chromatin nucleolar (stage I), perinucleolar (stage II) and cortical alveolar stages (Stage III). Although the mean number of early vitellogenic follicles (stage IV) did not significantly differ from that of initial controls and controls, the mean number of late vitellogenic follicles (stage V, preovulatory) and the serum levels of estradiol were significantly lower in M-ENK treated fish compared to those of controls. However, there was a significant increase in the serum levels of cortisol in M-ENK treated fish compared to controls. Together, these results suggest that treatment of M-ENK inhibits the recruitment of follicles at late vitellogenic stage through the suppression of steroidogenesis in the ovary and LH secretory activity at the level of the pituitary gland in fish. Besides, the ability of M-ENK to stimulate serum cortisol levels indicates a role for this peptide in regulation of the hypothalamo-pituitary-interrenal axis in fish.

Recovery of Adrenal Insufficiency Is Frequent After Adjuvant Mitotane Therapy in Patients with Adrenocortical Carcinoma

Mitotane is a steroidogenesis inhibitor and adrenolytic drug used for treatment of adrenocortical cancer (ACC). Mitotane therapy causes adrenal insufficiency requiring glucocorticoid replacement in all patients. However, it is unclear whether chronic therapy with mitotane induces complete destruction of zona fasciculata and whether hypothalamic-pituitary-adrenal (HPA) axis can recover after treatment cessation. Our objective was to assess the HPA axis recovery in a cohort of patients after cessation of adjuvant mitotane therapy for ACC. We retrospectively reviewed patient files with stage I-II-III ACC in two referral centers in Canada and Italy. Data on demographics, tumor characteristics, hormonal profile, and HPA axis were collected. Data from 23 patients with pathologically proven ACC treated with adjuvant mitotane for a minimum of two years were analyzed. Eight patients were males and 15 were females and the median age was 41 years old (range 18 to 73). After mitotane cessation, 18/23 (78.3%) patients achieved a complete HPA axis recovery while 3/23 (13.0%) were unable to tolerate glucocorticoid withdrawal despite having normal hormonal test values and 2/23 (8.7%) never achieved recovery. The mean time interval between mitotane cessation and HPA axis recovery was 2.7 years. A high proportion of patients achieved HPA axis recovery following cessation of mitotane adjuvant therapy. However, complete recovery was often delayed up to 2.5 years and regular assessment of the hormonal profile is required.

Active steroid hormone synthesis renders adrenocortical cells highly susceptible to type II ferroptosis induction

Conditions of impaired adrenal function and tissue destruction, such as in Addison’s disease, and treatment resistance of adrenocortical carcinoma (ACC) necessitate improved understanding of the pathophysiology of adrenal cell death. Due to relevant oxidative processes in the adrenal cortex, our study investigated the role of ferroptosis, an iron-dependent cell death mechanism and found high adrenocortical expression of glutathione peroxidase 4 (GPX4) and long-chain-fatty-acid CoA ligase 4 (ACSL4) genes, key factors in the initiation of ferroptosis. By applying MALDI mass spectrometry imaging to normal and neoplastic adrenocortical tissue, we detected high abundance of arachidonic and adrenic acid, two long chain polyunsaturated fatty acids which undergo peroxidation during ferroptosis. In three available adrenal cortex cell models (H295R, CU-ACC1 and CU-ACC-2) a high susceptibility to GPX4 inhibition with RSL3 was documented with EC50 values of 5.7 × 10−8, 8.1 × 10−7 and 2.1 × 10−8 M, respectively, while all non-steroidogenic cells were significantly less sensitive. Complete block of GPX4 activity by RSL3 led to ferroptosis which was completely reversed in adrenal cortex cells by inhibition of steroidogenesis with ketoconazole but not by blocking the final step of cortisol synthesis with metyrapone. Mitotane, the only approved drug for ACC did not induce ferroptosis, despite strong induction of lipid peroxidation in ACC cells. Together, this report is the first to demonstrate extraordinary sensitivity of adrenal cortex cells to ferroptosis dependent on their active steroid synthetic pathways. Mitotane does not induce this form of cell death in ACC cells.

Current management of Cushing's disease.

Cushing's disease (CD) is caused by a pituitary tumour that secretes adrenocorticotropin (ACTH) autonomously, leading to excess cortisol secretion from the adrenal glands. The condition is associated with increased morbidity and mortality that can be mitigated by treatments that result in sustained endocrine remission. Transsphenoidal pituitary surgery (TSS) remains the mainstay of treatment for CD but requires considerable neurosurgical expertise and experience in order to optimize patient outcomes. Up to 90% of patients with microadenomas (tumour below 1cm in largest diameter) and 65% of patients with macroadenomas (tumour at or above 1cm in greatest diameter) achieve endocrine remission after TSS by an experienced surgeon. Patients who are not in remission postoperatively or those who relapse may benefit from undergoing a second pituitary operation. Alternatively, radiation therapy to the sella with interim medical therapy, or bilateral adrenalectomy, can be effective as definitive treatments of CD. Medical therapy is currently adjunctive in most patients with CD and is generally prescribed to patients who are about to receive radiation therapy and will be awaiting its salutary effects to occur. Available treatment options include steroidogenesis inhibitors, centrally acting agents and glucocorticoid receptor antagonists. Several novel agents are in clinical trials and may eventually constitute additional treatment options for this serious condition.

Microglial Pro-Inflammatory and Anti-Inflammatory Phenotypes Are Modulated by Translocator Protein Activation

A key role of the mitochondrial Translocator Protein 18 KDa (TSPO) in neuroinflammation has been recently proposed. However, little is known about TSPO-activated pathways underlying the modulation of reactive microglia. In the present work, the TSPO activation was explored in an in vitro human primary microglia model (immortalized C20 cells) under inflammatory stimulus. Two different approaches were used with the aim to (i) pharmacologically amplify or (ii) silence, by the lentiviral short hairpin RNA, the TSPO physiological function. In the TSPO pharmacological stimulation model, the synthetic steroidogenic selective ligand XBD-173 attenuated the activation of microglia. Indeed, it reduces and increases the release of pro-inflammatory and anti-inflammatory cytokines, respectively. Such ligand-induced effects were abolished when C20 cells were treated with the steroidogenesis inhibitor aminoglutethimide. This suggests a role for neurosteroids in modulating the interleukin production. The highly steroidogenic ligand XBD-173 attenuated the neuroinflammatory response more effectively than the poorly steroidogenic ones, which suggests that the observed modulation on the cytokine release may be influenced by the levels of produced neurosteroids. In the TSPO silencing model, the reduction of TSPO caused a more inflamed phenotype with respect to scrambled cells. Similarly, during the inflammatory response, the TSPO silencing increased and reduced the release of pro-inflammatory and anti-inflammatory cytokines, respectively. In conclusion, the obtained results are in favor of a homeostatic role for TSPO in the context of dynamic balance between anti-inflammatory and pro-inflammatory mediators in the human microglia-mediated inflammatory response. Interestingly, our preliminary results propose that the TSPO expression could be stimulated by NF-κB during activation of the inflammatory response.

Adrenal venous sampling in patients with ACTH-independent hypercortisolism

PurposeTo study the usefulness of adrenal venous sampling (AVS) in distinguishing unilateral from bilateral cortisol production in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions, or morphologically normal adrenal glands.MethodsA retrospective analysis of ten consecutive patients with ACTH-independent hypercortisolism who underwent AVS at our institution between 2009 and 2017. Unilateral dominant cortisol production was defined as a side-to-side cortisol/aldosterone lateralization ratio >2.ResultsFour of ten patients had overt Cushing’s syndrome. Of these, two had bilateral adrenal lesions on computed tomography and two had normal adrenal glands. One of the two patients with bilateral adrenal lesions had, based on the AVS, a unilateral dominant cortisol production. Following unilateral adrenalectomy the patient developed adrenal insufficiency. The other three patients were considered to have bilateral cortisol production and underwent bilateral adrenalectomy. Six patients had a mild autonomous cortisol secretion and bilateral adrenal lesions. Based on AVS, one patient was considered to have unilateral dominant cortisol production, underwent unilateral adrenalectomy and developed transient adrenal insufficiency postoperatively.ConclusionsAVS may contribute to appropriate treatment in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions. In our series, AVS was helpful in the decision-making of two out of ten patients, avoiding chronic treatment with steroidogenesis inhibitors, or inappropriate bilateral adrenalectomy.

Hunting for new anesthetics

Existing anesthetics in clinical use have side effects that can make the drugs dangerous for vulnerable populations, such as the very young and the very old. These side effects include drops in blood pressure and inhibition of steroid biosynthesis. Anesthesiologists know how to mitigate those side effects, but drugs without them would be safer and easier to use. A team led by Edward J. Bertaccini of Stanford University School of Medicine and the VA Palo Alto Health Care System has identified a class of compounds that could lead to a new family of anesthetics without the side effects (Proc. Natl. Acad. Sci. U.S.A. 2019, DOI: 10.1073/pnas.1822076116). Through a series of modeling studies, one of which involved finding compounds that could bind strongly to the γ-aminobutyric acid (GABA) type A receptor, the researchers identified N-aryl pyrroles as a class of molecules to pursue. They searched compound databases for molecules with that

Cabergoline in severe ectopic or occult Cushing's syndrome.

Cabergoline has been shown to have some effect in the treatment of moderate Cushing's disease, but its effectiveness in Cushing's syndrome of ectopic or occult origin remains to be investigated. In this case series, cabergoline was used in combination with steroidogenesis inhibitors in nine patients with severe Cushing's syndrome of ectopic or occult origin. Cabergoline's effectiveness enabled rapid withdrawal of the steroidogenesis inhibitors and long-term control of the hypercortisolism in three of the cases. In the literature, we found only 11 cases of ectopic or occult Cushing's syndrome treated with dopamine receptor agonists, alone or in combination. Yet of these 11 cases, 10 responded. Although limited, the existing experience highlights the potential value of cabergoline in the treatment of ectopic or occult Cushing's syndrome.

Cyproterone acetate or spironolactone in lowering testosterone concentrations for transgender individuals receiving oestradiol therapy.

BackgroundOestradiol with or without an anti-androgen (cyproterone acetate or spironolactone) is commonly prescribed in transfeminine individuals who have not had orchidectomy; however, there is no evidence to guide optimal treatment choice.ObjectiveWe aimed to compare add-on cyproterone acetate versus spironolactone in lowering endogenous testosterone concentrations in transfeminine individuals.DesignRetrospective cross-sectional study.MethodsWe analysed 114 transfeminine individuals who had been on oestradiol therapy for >6 months in two gender clinics in Melbourne, Australia. Total testosterone concentrations were compared between three groups; oestradiol alone (n = 21), oestradiol plus cyproterone acetate (n = 21) and oestradiol plus spironolactone (n = 38). Secondary outcomes included serum oestradiol concentration, oestradiol valerate dose, blood pressure, serum potassium, urea and creatinine.ResultsMedian age was 27.0 years (22.5–45.1) and median duration of hormone therapy was 1.5 years (0.9–2.6), which was not different between groups. On univariate analysis, the cyproterone group had significantly lower total testosterone concentrations (0.8 nmol/L (0.6–1.20)) compared with the spironolactone group (2.0 nmol/L (0.9–9.4), P = 0.037) and oestradiol alone group (10.5 nmol/L (4.9–17.2), P < 0.001), which remained significant (P = 0.005) after adjustments for oestradiol concentration, dose and age. Serum urea was higher in the spironolactone group compared with the cyproterone group. No differences were observed in total daily oestradiol dose, blood pressure, serum oestradiol, potassium or creatinine.ConclusionsThe cyproterone group achieved serum total testosterone concentrations in the female reference range. As spironolactone may cause feminisation without inhibition of steroidogenesis, it is unclear which anti-androgen is more effective at feminisation. Further prospective studies are required.