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Caratteristiche cliniche, storia clinica a lungo termine e rischio di recidiva degli adenomi ipofisari corticotropi silenti
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Cushing's Syndrome: Screening and Diagnosis
No full textEndogenous Cushing's syndrome (CS) is a rare disease, and usually characterized by hypertension, diabetes, obesity, osteoporosis, facial rounding, dorsocervical fat pad, thin skin, purple striae, hirsutism, and mood disorders. Efficient diagnostic and screening strategies lead to the diagnosis of a significantly higher number of cases of CS. As a screening test for CS, the Endocrine Society's Clinical Practice Guidelines recommend a single test with a high diagnostic accuracy, among the 1-mg dexamethasone suppression test (1-mg DST), late night salivary cortisol (LNSC), and 24 h urinary free cortisol (UFC). In normal subjects, administering a higher than physiological dose of glucocorticoids prompts the suppression of cortisol secretion. The 1-mg DST explores this normal feedback reaction from the hypothalamic-pituitary-adrenal axis (HPA). It is a simple dynamic test, usually performed in outpatients. A morning serum cortisol level <50 nmol/L suffices to exclude CS, unless there is a strong clinical suspicion to suggest otherwise. The HPA axis reaches a nadir just after a person has fallen asleep, but its circadian rhythm is impaired in CS patients, who feature higher cortisol values at night, which are easy to measure in saliva (the LNSC assay). Saliva collection is also suitable for outpatients since cortisol is stable at room temperature and the collection device can be mailed to the laboratory for analysis. UFC levels reflect the integrated tissue exposure to free cortisol over 24 h, and thus provide a particular picture of endogenous hypercortisolism. In most cases, high UFC levels coincide with severe hypercortisolism. UFC is used not only to diagnose CS, but also to monitor its response to medical treatment. All screening tests have procedural snares: some drugs can interfere with the DST; false-positive or false-negative LNSC results may be due to an inadequate soaking of the device or to cyclic CS; and in the case of UFC it is important to ensure that patients provide complete urine collections with appropriate total volumes. Measuring cortisol with antibody-based immunoassays can also generate false-positive results due to cross-reactivity between cortisol, cortisone and other metabolites. Structurally-based assays, such as liquid chromatography with tandem mass spectrometry, only measure cortisol and have only recently become available for use in routine clinical practice. This review summarizes the recent literature on the clinical and biochemical aspects of CS diagnostics with a view to helping physicians choose the best screening test for diagnosing endogenous hypercortisolism
La terapia glucocorticoide nei pazienti con shock settico: idrocortisone vs fludrocortisone e idrocortisone
No full textLa gestione perioperatoria delle masse surrenaliche
Full text linkLa gestione pre- e postoperatoria del paziente con lesione surrenalica candidato alla chirurgia richiede una diretta e costante collaborazione tra vari professionisti, formata da un team multidisciplinare. La buona pratica clinica che suggeriamo prevede di intervenire chirurgicamente solo dopo aver definito l’eventuale secrezione, ponendo particolare attenzione ai valori pressori e alla ionemia. Suggeriamo, inoltre, una gestione accorta del rischio di iposurrenalismo post-chirurgico e la prevenzione delle complicanze tromboembolich
Central adrenal insufficiency: open issues regarding diagnosis and glucocorticoid treatment
Full text linkBackground Central adrenal insufficiency (CAI) is characterized by impaired adrenocorticotropin (ACTH) secretion because of a disease or injury to the hypothalamus or the pituitary, leading to a reduced cortisol production. CAI suspicion arises more frequently in patients with pituitary tumors, cranial irradiation/surgery/injury/infections, as well as after exogenous glucocorticoid withdrawal. Nevertheless, a late diagnosis is not uncommon because CAI may present with nonspecific signs or symptoms, as fatigue or hyponatremia. Content The PubMed database was searched (years 1980-2018), using "central adrenal insufficiency" and "ACTH deficiency" as keywords. Subsequently, reference sections of the retrieved articles were searched. Summary Dynamic tests are needed when morning basal cortisol levels are not sufficient to exclude or to confirm CAI. Short Synacthen Test (SST) is the most used, and Endocrine Society's guidelines recommend a cortisol peak >500 nmol/L to exclude CAI. Despite thresholds, understanding the pretest probability of ACTH deficiency (the clinical background of the patient) is essential because the diagnostic accuracy of SST in case of a negative result is suboptimal. Glucocorticoid replacement therapy, able to replicate cortisol circadian rhythm, is required in patients with CAI; fludrocortisone treatment is not necessary. Short-acting glucocorticoid drugs (hydrocortisone or cortisone acetate) are the most used; lower doses than previously used are nowadays recommended to reduce cortisol-related comorbidities. Promising results have been obtained with modified-release hydrocortisone, especially regarding glucose metabolism in patients with primary adrenal insufficiency. Outlook An accurate clinical diagnosis and a careful individualized therapy are mandatory in patients with CAI
Personalized medical treatment for pituitary adenoma
Full text linkIntroduction and Aim: Pituitary adenomas are common neoplasms, with a reported prevalence of about one case in 1000 subjects. Patients with pituitary adenomas show significant morbidity due to pituitary hormone hypersecretion or deficiencies, mass effects and infiltration of the surrounding tissues. Although trans-sphenoidal surgery and radiotherapy are largely used to treat patients with pituitary adenomas, the overall long-term remission rate is not complete, beside side effects of surgery or brain irradiation. Therefore, medical treatments with pituitary-directed drugs are increasingly used in patients with secreting pituitary adenomas, especially when surgery fails or is not indicated, or awaiting for effects of radiotherapy. Somatostatin analogues (SSA) have been the mainstay of the medical treatment of GH-secreting adenomas, and nowadays are also used to treat ACTH-secreting pituitary adenomas, since these tumours express several types of somatostatin receptors (SSTR), with the prevalence of SSTR type 2 in the GH-secreting PA and of SSTR type 5 in the ACTH-secreting. Regrettably, 50% of patients with GH- secreting and 60% with ACTH- secreting pituitary adenomas do not respond to medical treatment with pituitary-directed drugs, or present only a partial hormonal reduction. Receptor desensitization, internalization and intra-cellular trafficking of SSTR could explain at least partially the lack of response, hence more data and knowledge about these cellular processes are urgently needed. Moreover, pituitary adenomas are not always benignant: some aggressive cases (up to 15-20% in all series) are characterized by rapid regrowth after first surgery, invasion of the surrounding structure, resistance to medical therapy, therefore the term Pituitary Neuroendocrine Tumor (PitNET) should be actually used.
The aims of this PhD project are to describe the role of medical treatment in patients with PitNET, in order to study the efficacy of available compounds; applicate the combination of medical treatment in clinical practice; analyse the differential effects (if existing) of medical treatment compared to surgery (considered the best curative treatment).
Materials and methods: Among our cohort of patients (120 with GH-, 134 with ACTH-, 171 with PRL-, 6 with TSH- secreting PitNET, 150 with non-secreting PitNET), we retrospectively and prospectively analysed clinical, radiological and pathological features of patient. Considering the treatment of aggressive PitNET or patients with Cushing’s Syndrome, we focused our attention to everolimus, temozolomide (TMZ) and metyrapone (MET) treatment. In some case, primary cell culture were used to study the effect of medical treatment.
Results: Regarding medical treatment, we considered the use of everolimus, TMZ, cabergoline and MET.
1. In a patient with tuberous sclerosis complex (TSC) and silent gonadotroph PitNET we tested the efficacy of everolimus, observing a reduction of cell viability after an in vitro treatment of PitNET’s derived primary cells. TSC analysis retrieved no disease-associated variants with the exception of the heterozygous intronic variant c.4006-71C>T found in TSC2: the computational tools predicted a gain of a new splice site with consequent intron retention, not confirmed by an in-vitro analysis of patient’s lymphocyte derived RNA.
2. Regarding TMZ in aggressive PitNET, we conducted an Italian survey on 31 patients: 11 patients (35.5%) had reduction of the tumor during TMZ treatment, while 6 patients (19.4%) had progression of disease. Median follow-up after start of TMZ was 18 months. Seven patients presented disease progression. The 2-yr recurrence-free survival was 62% (95% C.I., 34 -99%). Seven patients died of progressive disease. The 2-yr and 4-yr survival rates were 90% (95% C.I., 77-100%) and 56% (95% C.I., 26-85%). Moreover, we treated a patient with a combined cabergoline+TMZ treatment, achieving excellent results.
3. Considering MET in patients with Cushing’s Syndrome, patients were treated with a median dose of 1000 mg for 9 months. UFC and LNSC decreased quickly after the first month of treatment (-67% and -57% from baseline), with sustained UFC normalization up to 12 and 24 months (in 13 and 6 patients, respectively). UFC and LNSC normalized later (after 3-6 months) in patients with severe hypercortisolism (>5-fold baseline UFC). Regarding last visit, 70% and 37% of patients normalized UFC and LNSC, respectively. Body weight reduction (-4kg) was observed after UFC normalization. Severe side-effects were not reported, half female patients complained hirsutism, and blood pressure was not increased.
4. In patients with acromegaly, a significant proportion of patients developed Central Adrenal Insufficiency (CA) over time: while primary or secondary medical treatment did not contribute to the risk of CAI, repeated surgery or radiotherapy affected pituitary-adrenal axis. CAI was diagnosed in 18% of patients (10/57) after surgery, and in 53% (9/17) after radiotherapy (p=0.01).
Considering those aspects related to predict the effects of medical treatment with SSA in acromegaly, we studied the role of AIP-AHR and GIPR pathway. Considering AIP-AHR axis, involved in the detoxification of endocrine disruptors and chemical pollutants, we observed that acromegaly is more biochemically severe and resistant to SSA treatment in patients living in highly polluted areas, especially if they also carry specific AHR and/or AIP gene variants. Moreover, we found a stimulatory effect of IGF-1 on GIP promoter support in GIPR-expressing somatotropinomas, suggesting a novel molecular pathway able to induce GH-secreting PitNET.
Conclusions: In this complex scenario, understanding the physio-pathology of PitNET is the beginning of personalized treatment. In clinical practice, a multidisciplinary team for the management of patients is fundamental, to suggest the correct treatment plan, tailored to the patient
The Pathophysiology and Treatment of Hypertension in Patients With Cushing's Syndrome
Full text linkWhen hypertension, a pathology that is frequently found in the general population, presents in a young patient, secondary causes such as Cushing's syndrome (CS), a rare disease characterized by long-term elevated cortisol levels, should be considered. Present in ~80% of CS patients independently of their age and sex, hypertension is one of the pathology's most prevalent, alarming features. Its severity is principally associated with the duration and intensity of elevated cortisol levels. Prompt diagnosis and rapid initiation of treatment are important for reducing/delaying the consequences of hypercortisolism. Glucocorticoid excess leads to hypertension via a variety of mechanisms including mineralocorticoid mimetic activity, alterations in peripheral and renovascular resistance, and vascular remodeling. As hypertension in CS patients is caused by cortisol excess, treating the underlying pathology generally contributes to reducing blood pressure (BP) levels, although hypertension tends to persist in approximately 30% of cured patients. Surgical removal of the pituitary tumor remains the first-line treatment for both adrenocorticotropin hormone (ACTH) dependent and independent forms of the syndrome. In light of the fact that surgery is not always successful in curing the underlying disease, it is essential that other treatments be considered and prescribed as needed. This article discusses the mechanisms involved in the pathogenesis of CS and the pros and the cons of the various antihypertensive agents that are presently available to treat these patients
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