Urinary Free Cortisol Excretion Research Articles

Cushing's disease with twin pregnancy and diabetes mellitus: a case report and literature review.

A 38-year-old Japanese woman with a history of abnormal thyroid function of non-autoimmune origin, pituitary endocrine tumor, and untreated diabetes mellitus was referred to our outpatient clinic when she became pregnant with twins. Physical findings consistent with Cushing's syndrome (CS) were absent at the time of presentation. Although baseline plasma adrenocorticotropic hormone, serum cortisol, and 24-hour urinary free cortisol excretion levels were above the upper limits of normal non-pregnant reference ranges, we could not exclude a physiological increase associated with pregnancy. No medical or surgical intervention for hypercortisolism was performed during pregnancy. Spontaneous vaginal delivery resulted in the normal delivery of live twins. A diagnosis of Cushing's disease (CD) was established when papery skin developed postpartum. Transsphenoidal surgery was performed and the hypercortisolism partially resolved post-operatively. The patient's abnormal thyroid function also resolved. Pregnancy in women with endogenous CS is rare, with less than 300 cases reported. Most reported cases of CS during pregnancy are of adrenal origin. Only two cases of twin pregnancies with CD have been reported. Therefore, we reported the third case of CD in a twin pregnancy and reviewed the diagnostic and therapeutic challenges associated with CD during pregnancy.

PS-C21-3: URINARY FREE CORTISOL EXCRETION AS A MARKER OF DECREASED BONE DENSITY IN PATIENTS WITH ADRENAL CUSHING'S SYNDROME

Objective: Patients with adrenal Cushing's syndrome (CS) have a poor prognosis due to the autonomous hypersecretion of endogenous cortisol from the adrenal gland. Although several clinical examinations have been developed to manifest the autonomous hypersecretion of endogenous cortisol in this syndrome, it is unknown which parameter of cortisol overproduction is best associated with adrenal cortisol content and the bone and vascular complications of this syndrome. Therefore, the present study was undertaken to evaluate the parameter(s) associated with adrenal cortisol content in patients with adrenal CS, as well as to assess the associations between these parameters and the vascular and bone complications of this syndrome. Design and method: Patients with CS who were over 18 years old and had undergone adrenalectomy for this syndrome were enrolled in this study. Patients who were pregnant, had an allergy to iodine, or who were receiving medications that may interfere with the evaluation of 131I-adosterol single-photon emission computed tomography (SPECT) /computed tomography (CT) were excluded. Those taking medications that may interfere with the evaluation for the diagnosis of CS were also excluded. Relationships between office blood pressure and pulse rate, urinary examinations, blood examinations, endocrinological examinations, CT and 131I-adosterol SPECT/CT data, bone density, physiological function tests, and adrenal cortisol concentration/content were examined. In addition, relationships between the parameter associated with adrenal cortisol concentration/content and complications of CS were investigated. Results: Cardiovascular factors, except for diastolic blood pressure, failed to show an association with adrenal cortisol content. 24-h urinary free cortisol excretion (ρ = 0.893, P = 0.007) and plasma cortisol levels after the 1 mg (ρ = 0.857, P = 0.014) or 8 mg (ρ = 0.900, P = 0.037) overnight dexamethasone suppression test, but not plasma cortisol levels in the morning or at late night or indices of 131I-adosterol SPECT/CT, were significantly and positively associated with adrenal cortisol content. 24-h urinary free cortisol excretion, and not plasma cortisol levels after the 1 or 8 mg overnight dexamethasone suppression test was significantly and negatively associated with lumbar spine bone density (lumbar spine T-score, ρ = -0.883, P = 0.009; lumbar spine Z-score, ρ = -0.883, P = 0.009). Conclusions: 24-h urinary free cortisol excretion is best associated with a decrease in bone density via increased adrenal cortisol overproduction and suggested that it could be used as a marker for osteoporosis in these patients.

Changes in DNA Methylation of Clock Genes in Obese Adolescents after a Short-Term Body Weight Reduction Program: A Possible Metabolic and Endocrine Chrono-Resynchronization

Circadian rhythms are generated by a series of genes, collectively named clock genes, which act as a self-sustained internal 24 h timing system in the body. Many physiological processes, including metabolism and the endocrine system, are regulated by clock genes in coordination with environmental cues. Loss of the circadian rhythms has been reported to contribute to widespread obesity, particularly in the pediatric population, which is increasingly exposed to chronodisruptors in industrialized society. The aim of the present study was to evaluate the DNA methylation status of seven clock genes, namely clock, arntl, per1-3 and cry1-2, in a cohort of chronobiologically characterized obese adolescents (n: 45: F/M: 28/17; age ± SD: 15.8 ± 1.4 yrs; BMI SDS: 2.94 [2.76; 3.12]) hospitalized for a 3-week multidisciplinary body weight reduction program (BWRP), as well as a series of cardiometabolic outcomes and markers of hypothalamo-pituitary-adrenal (HPA) function. At the end of the intervention, an improvement in body composition was observed (decreases in BMI SDS and fat mass), as well as glucometabolic homeostasis (decreases in glucose, insulin, HOMA-IR and Hb1Ac), lipid profiling (decreases in total cholesterol, LDL-C, triglycerides and NEFA) and cardiovascular function (decreases in systolic and diastolic blood pressures and heart rate). Moreover, the BWRP reduced systemic inflammatory status (i.e., decrease in C-reactive protein) and HPA activity (i.e., decreases in plasma ACTH/cortisol and 24 h urinary-free cortisol excretion). Post-BWRP changes in the methylation levels of clock, cry2 and per2 genes occurred in the entire population, together with hypermethylation of clock and per3 genes in males and in subjects with metabolic syndrome. In contrast to the pre-BWRP data, at the end of the intervention, cardiometabolic parameters, such as fat mass, systolic and diastolic blood pressures, triglycerides and HDL-C, were associated with the methylation status of some clock genes. Finally, BWRP induced changes in clock genes that were associated with markers of HPA function. In conclusion, when administered to a chronodisrupted pediatric obese population, a short-term BWRP is capable of producing beneficial cardiometabolic effects, as well as an epigenetic remodeling of specific clock genes, suggesting the occurrence of a post-BWRP metabolic and endocrine chronoresynchronization, which might represent a "biomolecular" predictor of successful antiobesity intervention.

OR12-1 Activity of Abiraterone Acetate in the management of Cushing syndrome associated to advanced adrenocortical carcinoma: results of the ABACUS trial.

Abstract Background More than 50% of adrenocortical carcinomas (ACC) in adults are associated with cortisol excess that makes tumor management challenging and has a negative impact on patient outcome. Abiraterone acetate (AA) is an irreversible inhibitor of the 17α-hydroxylase/C17, 20-lyase (CYP17 enzyme) that is used in patients with prostate cancer, in whom it leads to suppression of cortisol and androgens. Thus, the drug is potentially useful in the medical treatment of steroid-secreting tumors. The aim of this study was to assess the activity of AA to control cortisol excess in patients with advanced ACC and overt Cushing syndrome. Methods We designed the phase II trial ABACUS (NCT 03145285) whose primary endpoint was normalization of 24-h urinary free cortisol (UFC) excretion within 1 month from treatment start. Inclusion criteria were histologically proven ACC, locally advanced or metastatic disease, and Cushing syndrome confirmed by two 24-h UFC >1.5 times the upper normal limit with suppressed ACTH. No concomitant treatment with mitotane or chemotherapy was allowed for the first 4 weeks of the study. AA was given orally at the daily dose of 1000 mg. Results From 2017 to 2019, we included 17 patients with ACC (2 stage III, 15 stage IV), 13 women (76%), median age 51 years (18-76), of whom 8 have been heavily pretreated and 9 were treatment naïve. In 8 patients, multiple steroid secretion was found. Patients were treated with AA for a median of 17 days (7-163). Median 24-h UFC (measured by gas-mass spectrometry) was 368 μg/24h (121-7422) at baseline and 94 μg/24h (20-1793) at end of treatment (p=0.01). Normalization of 24-h UFC was attained in 8 patients (53%) and a >50% decrement in 11 patients (73%). The median time to effect was 21 days and median 24-h UFC reduction 81.8% (-97.7 - +25.9). Androgen and precursor steroids were also significantly reduced by AA treatment. The median Cushing Syndrome Score was 5.0 (2 - 8) at baseline and 3.5 (1 - 6) at the end of treatment, thus confirming clinical improvement. Blood pressure was significantly reduced and hypokalemia was not observed. In 2 patients, treatment was discontinued for toxicity. Seven patients died of ACC progression during follow-up with an overall survival of 5.4 months (0.5-39.3). Conclusions AA was able to control rapidly cortisol excess in most patients with a good safety profile. The results of this proof-of-concept study show that AA looks promising and may be viewed as an additional weapon to manage Cushing syndrome in patients with ACC. These findings pose the basis for power calculation and implementation of a prospective long-term study to establish AA efficacy in patients with a steroid-secreting ACC. Presentation: Sunday, June 12, 2022 11:00 a.m. - 11:15 a.m.

Approach to the Patient: Diagnosis of Cushing Syndrome.

Cushing syndrome results from supraphysiological exposure to glucocorticoids and is associated with significant morbidity and mortality. The pathogenesis includes administration of corticosteroids (exogenous Cushing syndrome) or autonomous cortisol overproduction, whether or not ACTH-dependent (endogenous Cushing syndrome). An early diagnosis of Cushing syndrome is warranted; however, in clinical practice, it is very challenging partly because of resemblance with other common conditions (ie, pseudo-Cushing syndrome). Initial workup should start with excluding local and systemic corticosteroid use. First-line screening tests including the 1-mg dexamethasone suppression test, 24-hour urinary free cortisol excretion, and late-night salivary cortisol measurement should be performed to screen for endogenous Cushing syndrome. Scalp-hair cortisol/cortisone analysis helps in the assessment of long-term glucocorticoid exposure as well as in detection of transient periods of hypercortisolism as observed in cyclical Cushing syndrome. Interpretation of results can be difficult because of individual patient characteristics and hence requires awareness of test limitations. Once endogenous Cushing syndrome is established, measurement of plasma ACTH concentrations differentiates between ACTH-dependent (80%-85%) or ACTH-independent (15%-20%) causes. Further assessment with different imaging modalities and dynamic biochemical testing including bilateral inferior petrosal sinus sampling helps further pinpoint the cause of Cushing's syndrome. In this issue of "Approach to the patient," the diagnostic workup of Cushing syndrome is discussed with answering the questions when to screen, how to screen, and how to differentiate the different causes. In this respect, the latest developments in biochemical and imaging techniques are discussed as well.

Characterisation of the urinary steroid profile of patients with nonfunctioning adrenal incidentalomas: A matched controlled cross-sectional study.

To identify alterations in steroid metabolism in patients with nonfunctioning adrenal incidentalomas (NFAIs) through the analysis of their urinary steroid profile (USP). Cross-sectional study with one study group (NFAIs, cortisol post dexamethasone suppression test [DST] ≤ 1.8 µg/dl [49.7 nmol/L]) and 2 control groups: patients with autonomous cortisol secretion (ACS group, cortisol post-DST > 1.8 µg/dl (49.7 nmol/L) and patients without adrenal tumours (healthy-adrenal group). Twenty-four-hoururine collections for USP measurement (total and free fraction of 51 24 h-urine specimens) were obtained from 73 participants (24 with NFAIs, 24 without AIs, and 25 with ACS). USP was determined by gas chromatography coupled to mass spectrometry. Patients of the three groups were matched according to sex, age (±5 years-old) and body mass index (±5 kg/m2 ). Compared to healthy-adrenal controls, patients with NFAIs had a lower excretion of androgen metabolites (230.5 ± 190.12 vs. 388.7 ± 328.58 µg/24 h, p = .046) and a higher excretion of urinary free cortisol (UFC) (54.3 ± 66.07 vs. 25.4 ± 11.16 µg/24 h, p = .038). UFC was above the reference range in 20.8% of patients in the NFAI, compared to 0% in the healthy-adrenal group (p = .018). Patients with ACS had a higher prevalence of hypertension, dyslipidemia, and diabetes than patients with NFAIs or the control group. A lower excretion of androgen metabolites (218.4 ± 204.24 vs. 231 ± 190 µg/24 h, p = .041) and a nonsignificant higher excretion of glucocorticoid metabolites (2129.6 ± 1195.96 vs. 1550.8 ± 810.03 µg/24 h, p = .180) was found in patients with ACS compared to patients with NFAIs. NFAIs seem to secrete a subtle, yet clinically relevant, excess of glucocorticoids. Future studies are needed to confirm our findings; and to identify metabolic alterations associated with an increased cardiometabolic risk.

Correction: Urinary free cortisol excretion is associated with lumbar bone density in patients with adrenal Cushing’s syndrome

Correction: Urinary free cortisol excretion is associated with lumbar bone density in patients with adrenal Cushing’s syndrome

Urinary free cortisol excretion is associated with lumbar bone density in patients with adrenal Cushing's syndrome.

Patients with adrenal Cushing's syndrome have a poor prognosis due to the autonomous hypersecretion of endogenous cortisol from the adrenal gland. Although several clinical examinations have been developed to manifest the autonomous hypersecretion of endogenous cortisol in this syndrome, it is unknown which parameter of cortisol overproduction is best associated with the adrenal cortisol content and bone and vascular complications of this syndrome. Therefore, the present study was undertaken to evaluate the parameter(s) associated with the adrenal cortisol content in patients with adrenal Cushing's syndrome, as well as to assess the associations between these parameters and the vascular and bone complications of this syndrome. Cardiovascular factors such as blood pressure and pulse rate, glucose metabolism, lipid metabolism, renal function, and indices of arteriosclerosis, except for diastolic blood pressure, failed to show an association with the adrenal cortisol content. Twenty-four-hour urinary free cortisol excretion (ρ = 0.893, P = 0.007) and plasma cortisol levels after the 1-mg (ρ = 0.857, P = 0.014) or 8-mg (ρ = 0.900, P = 0.037) overnight dexamethasone suppression test, but not plasma cortisol levels in the morning or late at night or indices of 131I-adosterol single-photon emission computed tomography-computed tomography, were significantly and positively associated with the adrenal cortisol content. Twenty-four-hour urinary free cortisol excretion, and not plasma cortisol levels after the 1- or 8-mg overnight dexamethasone suppression test, was significantly and negatively associated with lumbar spine bone density (lumbar spine bone mineral density, ρ = -0.786, P = 0.036; lumbar spine T score, ρ = -0.883, P = 0.009; and lumbar spine Z score, ρ = -0.883, P = 0.009). These results indicate that 24-h urinary free cortisol excretion is best associated with a decrease in bone density via increased adrenal cortisol overproduction and suggest that it could be used as a marker for osteoporosis in these patients.

Hypercortisolism on the background of recovery of COVID-19 (сase report)

Damage to the lung tissue is a predominant complication of the viral disease COVID-19. Recently, there have been complications from other organs, including highly vascularized endocrine glands. Regarding the adrenal glands, there are reports of their damage with a decrease in their function. Сhanging the function of the adrenal glands (AG) in patients with or after COVID-19 is important. A few adrenal autopsy studies in patients have revealed vascular thrombosis, cortical lipid degeneration, ischemic necrosis, parenchymal infarcts, and other lesions leading to a decrease in AG function. The central mechanism of adrenal dysfunction through hemorrhage and necrosis of the pituitary gland is also possible. This paper presents a rare case of the development of hypercortisolism in a young woman after recovering from COVID-19. Based on high ACTH levels (157 and 122pg/ml), a negative nocturnal dexamethasone test, and high 24-hour urinary free (daily) cortisol excretion rates, we tentatively suspected Cushing’s disease. Chromogranin A was within the normal range of 21.35 (reference value <100). Other tests showed an elevated dihydrotestosterone level of 780.6 pg/ml (reference values 24–368 pg/ml). The levels of other anterior pituitary hormones tested were within the normal range. According to clinical guidelines, the drug of choice for the short-term treatment of this disease is steroidogenesis inhibitors— ketoconazole. The effectiveness of such a treatment regimen was previously brought to light by others. In our case, ketoconazole was prescribed at a dose of 400 mg 2 times a day and cabergoline (dostinex) at an initial dose of 1 mg per day. Given the low levels of vitamin D in the blood serum, it was recommended to continue taking vitamin D at a dose of 4000 IU per day. It was recommended to control blood laboratory parameters— serum cortisol, ACTH, AST, ALT, electrolytes, 25(OH)D, blood glucose level after 2 months and decide on further tactics for managing the patient.

Measurement of Urinary Free Cortisol and Cortisone by LC-MS/MS.

Monitoring urinary free cortisol (UFC) excretion helps assess adrenal function and is used to screen for endogenous Cushing's syndrome caused by an adrenal or pituitary tumor. While serum cortisol levels fluctuate in response to time of day, stress, and concentrations of cortisol-binding globulin (CBG), a 24-h urine collection measures the cortisol produced over the entire day and does not suffer from as much variability as a serum measurement.We describe here a method of measurement of urinary free cortisol (UFC) and cortisone using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Urine samples, combined with stable isotope-labeled internal standards, are extracted by liquid-liquid extraction using ethyl acetate and hexane. An API 5500 mass spectrometer operated in positive atmospheric pressure chemical ionization (APCI) mode is used for detection.

Cortisol and Phosphate Homeostasis: Cushing's Syndrome Is Associated With Reversible Hypophosphatemia.

ObjectivesThe influence of hypercortisolism on phosphate homeostasis is relatively unknown. A few previous studies have reported on patients with Cushing’s syndrome (CS) with hypophosphatemia in whom serum phosphate normalized after initiation of treatment for CS. We aimed to investigate the prevalence of hypophosphatemia in CS, the association between the degree of hypercortisolism and serum phosphate and the change in serum phosphate after remission of CS. We compared the prevalence of hypophosphatemia in CS with the prevalence in the population-based Rotterdam Study (RS).MethodsPatients diagnosed with CS and treated at the Department of Endocrinology of Erasmus MC in the period of 2002-2020 were included and data was collected on age at diagnosis, sex, serum phosphate, calcium and potassium levels, kidney function and BMI. Using multivariate linear regression, we analyzed the association between 24h urinary free cortisol excretion (UFC) and serum phosphate. Changes in serum phosphate and covariates were tested with a repeated measurement ANOVA, using mean levels of laboratory values for the periods before remission, and 0-14 days and 15-180 days after remission.ResultsHypophosphatemia before treatment was present in 16% of the 99 CS patients with data on serum phosphate, 24h UFC and covariates. In comparison, the prevalence of hypophosphatemia in RS was 2.0-4.2%. Linear regression showed a negative association between the level of UFC and serum phosphate at diagnosis, which remained significant after adjusting for covariates [β -0.002 (95%CI -0.004; -0.0004), p=0.021]. A subset of 24 patients had additional phosphate measurements at 0-14 days and 15-180 days after remission. In this subgroup, serum phosphate significantly increased from 1.03 ± 0.17 mmol/L prior to remission to 1.22 ± 0.25 mmol/L 15-180 days after remission (p = 0.008). BMI decreased after remission [-1.1 kg/m2, (95%CI -2.09 to -0.07), p=0.037]. Other covariates did not show an equivalent change over time.ConclusionIn this retrospective study, we found that 16% of patients with CS had hypophosphatemia. Moreover, serum phosphate was related to the level of cortisoluria and increased after remission of CS. Potential underlying mechanisms related to urinary phosphate excretion and possibly involving FGF23, BMI and parathyroid hormone levels should be further explored.

Dietary sodium intake and cortisol measurements.

To assess the influence of a dietary sodium intake intervention on cortisol measurements within the general population. Cross-over intervention. Six hundred thirty adults without known Cushing syndrome, cardiovascular or renal disease completed a restricted dietary sodium diet (10mmol/d, 230mg/d) followed by cross-over to a liberalized dietary sodium diet (200mmol/d, 4600mg/d). Twenty-four-hour urine collection and biochemical investigations were performed at the end of each dietary intervention. Mean 24-hour urinary free cortisol increased with liberalized sodium intake when compared with restricted sodium intake (178.0±89.7 vs 121.3±65.6nmol/d, P<.001). Nearly all participants (84%) had an increase in the urinary free cortisol following liberalized sodium intake. This translated to a substantial difference in the proportion of participants exceeding categorical thresholds of urinary cortisol on liberalized vs restricted sodium intake: 62% vs 27% for 138nmol/d (50mcg/d), 46% vs 17% for 166nmol/d (60mcg/d), 32% vs 10% for 193nmol/d (70mcg/d), 23% vs 6% for 221nmol/d (80mcg/d), 17% vs 4% for 248nmol/d (90mcg/d). In parallel, there was a small decrease in morning total serum cortisol with liberalized sodium intake (303.0±117.3 vs 326.4±162.5nmol/L, P<.001). Increased dietary sodium intake increases urinary free cortisol excretion and may increase the risk for false-positive results. Variations in dietary sodium intake may influence the interpretations of cortisol measurements performed to evaluate for hypercortisolism.

Serum Visfatin does not seem to be a Useful Marker to Guide Glucocorticoid Substitution in Adrenal Insufficiency.

Primary adrenal insufficiency (Addison's disease, AD) requires lifelong steroid substitution. Excess exogenous glucocorticoids promote abdominal obesity, insulin-glucose imbalance, and hypertension. Reliable markers of the adequate glucocorticoid replacement are lacking. Visfatin is a pro-inflammatory adipokine, with enzymatic activity of nicotinamide phosphoribosyltransferase. It enhances leukocyte function and synthesis of tumour necrosis factor α (TNFα) and interleukin-6 (IL-6). Serum visfatin is elevated in autoimmunity, but also in obesity, insulin resistance, and metabolic syndrome. This study was aimed to investigate whether serum visfatin could guide the glucocorticoid substitution in AD. Biochemical analyses were performed in 96 patients with AD (mean age 43.3±14.9 years) and 91 controls (43.5±12.5 years). Visfatin level was significantly elevated in patients with AD compared to controls (p<0.0001). Higher circulating IL-6 was also detected among subjects with AD (p=0.006). In AD, visfatin level was positively correlated with IL-6 (p=0.014), TNFα (p=0.001), body mass (p=0.015), fasting insulin (p=0.001) and HOMA-IR (p=0.001). No relationship was noticed with daily hydrocortisone (p=0.096) and urinary free cortisol excretion (p=0.499). Only the correlations with IL-6 and fasting insulin survived multiple regression analysis (p=0.049 and p=0.005, respectively). Additionally, positive correlation between visfatin and autoantibodies to 21-hydroxylase was noted (p=0.005). In the control group serum visfatin was correlated with IL-6 (p=0.009) and TNFα (p=0.0002). The current study reveals elevated serum visfatin in autoimmune AD. Visfatin does not seem a useful marker of the glucocorticoid replacement, although it correlates with fasting insulin and pro-inflammatory molecules. Further functional analyses are warranted to elucidate the role of visfatin in autoimmunity.

Isolated ACTH deficiency during single-agent pembrolizumab for squamous cell lung carcinoma: a case report

BackgroundThe programmed cell death 1 (PD-1) inhibitor pembrolizumab is a promising agent for treatment of several different malignancies, but as with all immunotherapy there is a potential risk of immune-related adverse events. Adrenocorticotropic hormone (ACTH) deficiency and hypophysitis have been reported in patients treated with a different PD-1 inhibitor, nivolumab. However, clinical characteristics of these side effects associated with pembrolizumab have yet to be described in detail.Case presentationAn 85-year-old Japanese woman was diagnosed with advanced squamous cell lung cancer. The patient was treated with 200 mg pembrolizumab every three weeks as first-line therapy. Routine examination including thyroid function, complete blood count, serum cortisol and sodium levels before each pembrolizumab infusion had shown no significant changes up to the eighth cycle. However, 8 days after the eighth cycle of single-agent pembrolizumab, she presented with rapidly worsening general fatigue and appetite loss over two days. Laboratory data revealed a low serum cortisol level (0.92 μg/dL) with inappropriately low ACTH (8.3 pg/mL), hyponatremia (122 mmol/L) and hypoglycemia (68 mg/dL). Standard-dose short ACTH testing showed an unsatisfactory cortisol response, indicating adrenal insufficiency. Pituitary magnetic resonance imaging showed diffuse substantial gadolinium enhancement, T2 hyperintensity, loss of pituitary bright spot, but no pituitary enlargement. Serum cortisol and ACTH levels were low throughout the day, and urinary free cortisol excretion fell below the lower normal limit. There was no ACTH and cortisol response in the corticotropin-releasing hormone test, despite significant responses of other anterior pituitary hormones to their corresponding challenge tests. Thus, isolated ACTH deficiency was diagnosed, and hypophysitis was suspected as the etiology. After administration of 15 mg/day hydrocortisone, the patient’s debilitation, hyponatremia, and hypoglycemia swiftly disappeared.ConclusionThis is a case of isolated ACTH deficiency possibly due to hypophysitis in a patient with advanced lung cancer, in whom recent routine examinations had shown unremarkable results. We therefore conclude that isolated ACTH deficiency can suddenly arise during pembrolizumab monotherapy, albeit probably only rarely. Caution should be exercised to make sure that adrenal insufficiency is recognized immediately in order to achieve swift recovery by steroid replacement.

Longitudinal Change in Cortisol Levels Across the Adult Life Span.

Cortisol is a key stress hormone implicated in the pathogenesis of many age-related diseases. Longitudinal information on cortisol exposure has been restricted to animal models and a small number of human studies. The purpose of the present study was to quantify longitudinal change in cortisol across the adult life span. We conducted a prospective longitudinal study of 24-hour urinary free cortisol excretion from ages 20 to 90 years and older. Participants were 1,814 men and women from the Baltimore Longitudinal Study of Aging who provided a total of 5,527 urine specimens for analysis. The average duration of longitudinal follow-up was 6.6 years. The primary outcome measure was 24-hour urinary free cortisol to creatinine ratio (UFC/Cr) as determined by liquid chromatography/mass spectrometry. UFC/Cr follows a U-shaped pattern across the life span with decreases in UFC/Cr in the 20s and 30s, relative stability in the 40s and 50s, and increases thereafter. This pattern of change was robust with respect to adjustment for several potential confounding factors. Age-related changes in cortisol exposure raise important questions about the potential protective or exacerbating role of cortisol exposure in predicting medical, physiological, and behavioral outcomes.

Toward a Diagnostic Score in Cushing's Syndrome.

Cushing's syndrome (CS) is a classical rare disease: it is often suspected in patients who do not have the disease; at the same time, it takes a mean of 3 years to diagnose CS in affected individuals. The main reason is the extreme rarity (1–3/million/year) in combination with the lack of a single lead symptom. CS has to be suspected when a combination of signs and symptoms is present, which together make up the characteristic phenotype of cortisol excess. Unusual fat distribution affecting the face, neck, and trunk; skin changes including plethora, acne, hirsutism, livid striae, and easy bruising; and signs of protein catabolism such as thinned and vulnerable skin, osteoporotic fractures, and proximal myopathy indicate the need for biochemical screening for CS. In contrast, common symptoms like hypertension, weight gain, or diabetes also occur quite frequently in the general population and per se do not justify biochemical testing. First-line screening tests include urinary free cortisol excretion, dexamethasone suppression testing, and late-night salivary cortisol measurements. All three tests have overall reasonable sensitivity and specificity, and first-line testing should be selected on the basis of the physiologic conditions of the patient, drug intake, and available laboratory quality control measures. Two normal test results usually exclude the presence of CS. Other tests and laboratory parameters like the high-dose dexamethasone suppression test, plasma ACTH, the CRH test, and the bilateral inferior petrosal sinus sampling are not part of the initial biochemical screening. As a general rule, biochemical screening should only be performed if the pre-test probability for CS is reasonably high. This article provides an overview about the current standard in the diagnosis of CS starting with clinical scores and screenings, the clinical signs, relevant differential diagnoses, the first-line biochemical screening, and ending with a few exceptional cases.

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

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

SUN-397 A Rare Case of Ectopic Adrenocorticotropic Hormone (ACTH) Syndrome Due to Thymic Large Cell Neuroendocrine Carcinoma Presenting as Severe Hypokalemia in a Taiwanese Man

Background Ectopic ACTH syndrome (EAS) represented 5% of Cushing syndrome. EAS is rapid onset, severe, associated with hypercortisolism related life-threatening infections and hypokalemia. In 60% of cases, the tumor is located in intrathoracic organ (lung, bronchus and thymus). Large cell neuroendocrine tumor of thymus secreting ACTH is a high grade, aggressive, poor prognosis and only few case reports in literature. Here we report a case of thymic LCNEC related EAS, which presented as severe hypokalemia, metabolic alkalosis and muscle weakness. Clinical Case A 71-year-old man presented with 12-kg weight loss, progressive generalized weakness and bilateral legs edema for two months.He has medical histories of hypertension and diabetes mellitus. Physical examination revealed generalized weakness without Cushingoid appearance. Laboratory examination showed metabolic alkalosis and severe hypokalemia (1.7 mmol/L, range 3.4-4.7).Hypokalemia work-up showed high morning ACTH 497 pg/mL (normal <46.0), cortisol 87.8 μg/dL (range 3.7-19.4), and normal limits of other pituitary hormones. Cushing syndrome survey showed lack of ACTH/cortisol circadian rhythm, markedly increased 24h urinary free cortisol excretion on two consecutive days ( 21429, 17061 μg). Low-dose and high-dose dexamethasone suppression tests showed non-suppressible. Ovine corticotrophin-releasing hormone stimulation test and desmopressin (DDAVP) test showed ectopic ACTH source. Pituitary MRI revealed negative findings. Bilateral inferior petrosal sinus sampling showed no central-to-peripheral ACTH gradient. Ectopic ACTH syndrome was impressed. Etomidate continuous infusion was prescribed.Fournier gangrene of left scrotum occurred during hospitalization and antibiotic and surgical treatment were given. Chest CT scan revealed tiny lobulated nodule in left lower lung field and soft tissue nodule in prevascular of mediastium. In-111 Octreoscan revealed several nodular lesions with increased In-111 uptake in the paraortic and prevascular region considering neuroendocrine tumor. Anterior mediastinal tumor excision was performed and histopathological report showed large cell neuroendocrine carcinoma of thymus with mitotic count 13/10 HPF and positive immunohistochemical stain for synaptophysin, chromogranin, DD-56, SSTR2 and ACTH. Sandostain LAR injection was administered afterward. Unfortunately, tumor progression with hypercortisolemia occurred after 6 months . External radiation and systemic chemotherapy were performed later. Clinical Lessons Although rare, Cushing syndrome must be considered in differential diagnosis of hypokalemia like our case, a challenging case of EAS. Early diagnosis and treatment was important to avoid life-threatening infections and metabolic complications. Moreover recurrence free survival with Sandostain LAR alone was only 6 months for LCNEC.

Secretory tumors of the pituitary gland: a clinical biochemistry perspective.

The pituitary gland is responsible for the production and/or secretion of various hormones that play a vital role in regulating endocrine function within the body. Secretory tumors of the anterior pituitary predominantly, pituitary adenomas, collectively account for 10%-25% of central nervous system tumors requiring surgical treatment. The most common secretory tumors are prolactinomas, which can be diagnosed by basal prolactin levels. Acromegaly can be diagnosed by basal insulin growth-like factor 1 levels and the failure of growth hormone (GH) to suppress during an oral glucose tolerance test. Cushing disease can be diagnosed by demonstrating hypercortisolemia evidenced by increased salivary cortisol levels in the evening, increased urine free cortisol excretion and failure of plasma cortisol to suppress following oral dexamethasone given overnight (1.0 mg). We also discuss the diagnosis of the rarer thyroid-stimulating hormone and gonadotrophin secretory tumors. Morbidity is associated with tumor occurrence, clinical sequelae as well as the related medical, surgical and radiological management. This review focuses on the pathogenesis of secretory tumors of the anterior pituitary with emphasis on molecular mechanisms associated with tumorigenesis and the major role of the clinical chemistry laboratory in diagnosis and management of these tumors.

Prognostic markers of remission of cushing's disease after transsphenoidal endoscopic adenomektomii.

Aim. To study the role of prognostic oral high-dose dexamethasone suppression test (HDDST) and pituitary MRI in the prognosis of Cushing’s disease (CD). remission after transsphenoidal endoscopic surgery (TSS). Material and methods. 59 patients with Cushing’s disease (9 men, 50 women, mean age 40 years (15-72) underwent TSS were included. Before the TSS HDDST and pituitary MRI were performed in all cases. Postoperative examination was done one year after surgery. Remission criteria were: combination of normal midnight serum cortisol levels, normal 24 hour urine free cortisol (UFC) excretion and serum cortisol suppression less than 50 nmol/l in 1-mg dexamethasone test or secondary adrenal insufficiency (the need for glucocorticoid replacement). The optimal threshold value of serum cortisol suppression in the HDDST for prediction of CD remission after TSS was calculated by ROC-analysis. Results. One year after surgery CD remission was confirmed in 39 patients, whereas in 20 patients hypercortisolism persisted. The optimal threshold value of serum cortisol suppression in the HDDST for prediction of CD remission after TSS was 72%. Test’s sensitivity and specificity were 82% and 84%, respectively. The probability of wrong prediction was 17% (p=0,0001). In our study, the results of TSS did not correlate with MRI adenoma size.