Seminar

Cushing’s syndrome
Mônica Gadelha, Federico Gatto, Luiz Eduardo Wildemberg, Maria Fleseriu

Endogenous Cushing’s syndrome results from excess glucocorticoid secretion, which leads to a myriad of clinical Lancet 2023; 402: 2237–52
manifestations, comorbidities, and increased mortality despite treatment. Molecular mechanisms and genetic Published Online
alterations associated with different causes of Cushing’s syndrome have been described in the last decade. Imaging November 17, 2023
https://doi.org/10.1016/
modalities and biochemical testing have evolved; however, both the diagnosis and management of Cushing’s
S0140-6736(23)01961-X
syndrome remain challenging. Surgery is the preferred treatment for all causes, but medical therapy has markedly
Endocrine Unit and
advanced, with new drug options becoming available. Nevertheless, several comorbidities remain even after patient Neuroendocrinology Research
remission, which can affect quality of life. Accurate and timely diagnosis and treatment are essential for mitigating Center, Medical School and
chronic complications of excess glucocorticoids and improving patient quality of life. In this Seminar, we aim to Hospital Universitário
Clementino Fraga Filho,
update several important aspects of diagnosis, complications, and treatment of endogenous Cushing’s syndrome of
Universidade Federal do
all causes. Rio de Janeiro, Rio de Janeiro,
Brazil (Prof M Gadelha MD);
Introduction (isolated or part of Carney complex) involve both adrenal Neuroendocrine Unit
(Prof M Gadelha,
Cushing’s syndrome is a chronic and systemic clinical glands and are rare causes of ACTH-independent
L E Wildemberg MD) and
condition caused by long-term and inappropriate exposure Cushing’s syndrome, together with McCune-Albright Molecular Genetics Laboratory
to glucocorticoids;1 Cushing’s syndrome is an ongoing syndrome and bilateral adenomas or carcinomas.12,13 (Prof M Gadelha), Instituto
clinical challenge.2–4 Exogenous use of supraphysiological Isolated Cushing’s syndrome is rarer in children than Estadual do Cérebro
Paulo Niemeyer, Secretaria
doses of glucocorticoids is the most common cause of it is in adults.1 Data from a Danish population-based
Estadual de Saúde,
Cushing’s syndrome, but in this Seminar we will focus on registry of individuals aged 0–20 years reported an Rio de Janeiro, Brazil
endogenous Cushing’s syndrome.1 Mild autonomous incidence of 0∙89 cases (95% CI 0∙63–1∙16) and a (Prof M Gadelha);
cortisol secretion will not be discussed. We highlight the prevalence of 26 cases (18∙9–35∙8) per million people.14 Endocrinology Unit,
Department of Internal
substantial progress in understanding Cushing’s Median age at diagnosis was 13∙8 years (IQR 10∙5–18∙2), Medicine, IRCCS Ospedale
syndrome pathophysiology, including novel findings in with a slight female predominance (58%).14 A male Policlinico San Martino, Genoa,
genetics and epigenetics, complications, and novel predominance has been observed and might exist in Italy (F Gatto MD); Pituitary
pharmacological therapies available for clinical use. infants and young toddlers.1 A corticotropinoma is the Center, Medicine and
Neurological Surgery, Oregon
main cause of Cushing’s syndrome in children (75–80%), Health & Science University,
Epidemiology and aetiology particularly those older than 7 years.14,15 Adrenal causes Portland, OR, USA
The estimated global incidence of Cushing’s syndrome is are more common in patients younger than 7 years.16 (Prof M Fleseriu MD)
1∙8–4∙5 cases per million individuals per year, and its Cyclic Cushing’s syndrome is a challenging condition17,18 Correspondence to:
estimated prevalence is 57–79 cases per million individuals, occurring in 8–19% of individuals with Cushing’s Prof Mônica Gadelha, Endocrine
Unit and Neuroendocrinology
with all causes considered.5,6 The latest registry data report syndrome, according to different definitions.17,19 For cyclic Research Center, Medical School
a female-to-male ratio of 4:1, and a mean age at diagnosis Cushing’s Syndrome, Cushing’s disease is the most and Hospital Universitário
of 44 years (SD 14).7 common cause (>50%), followed by ectopic ACTH Clementino Fraga Filho,
Endogenous Cushing’s syndrome comprises secretion (approximately 25%) and adrenal tumours (10%).17 Universidade Federal
do Rio de Janeiro,
two groups: adrenocorticotropic hormone (ACTH)- Rio de Janeiro 21941–913, Brazil
dependent causes, which make up the majority mgadelha@hucff.ufrj.br
(70–80% of cases), and ACTH-independent causes Search strategy and selection criteria
(figure 1).1,6,7 Cushing’s disease, also known as both We searched MEDLINE from Jan 1, 2015, to March 31, 2023,
corticotroph pituitary adenoma and corticotropinoma, is for articles published in English using the terms “Cushing’s
the most common form of ACTH-dependent Cushing’s syndrome”, “Cushing’s disease”, “ectopic Cushing’s
syndrome (80–90%).4,8 Non-pituitary ACTH-secreting syndrome”, “ACTH-secreting pituitary adenoma”,
tumours (ectopic ACTH secretion) represent 10–20% of “corticotroph tumour”, and “ectopic ACTH secretion” alone
the ACTH-dependent forms.7,9,10 The lung is the most and in combination with the terms “epidemiology”,
frequent site of tumour development, with lung “prevalence”, “incidence”, “genetics”, “epigenetics”,
neuroendocrine tumours accounting for approximately “methylation”, “therapy”, “treatment”, “surgery”, “pituitary”,
25% of cases, followed by small-cell lung cancers, which “radiation therapy”, “radiotherapy”, “medical therapy”,
make up 20% of cases. Other causes include thymic and “preoperative treatment”, “combination therapy”,
pancreatic neuroendocrine tumours, medullary thyroid “adrenalectomy”, “mortality”, “comorbidities”, “quality of
cancers, and pheochromocytomas or paragangliomas.9,10 life”, “assays”, “screening tests”, and “diagnosis”. The relevant
Unilateral adrenal adenomas are the most common references cited in resultant articles were also reviewed. Older
cause of ACTH-independent Cushing’s syndrome (70%), pertinent publications and reviews that provide
and adrenal carcinomas account for the remain­ comprehensive overviews beyond the scope of this Seminar
ing 20–30%.1,11 Bilateral macronodular adreno­ cortical were also included, when appropriate.
disease and bilateral micronodular adrenal hyperplasia

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 Seminar

70–80%

ACTH-independent 20–30% ACTH-dependent

Cushing’s syndrome Cushing’s syndrome

Rare causes Ectopic ACTH-secreting tumours

• Bilateral macronodular adrenocortical disease Age: 40–50 years
• Bilateral micronodular adrenal hyperplasia Female:male=1–2:1
• McCune-Albright syndrome
• Bilateral adenomas or carcinomas

Adrenocortical cancers
Age*: <4 years and 40–60 years
Female:male=1–2:1 and 3:1
10–20%
20–30%

70–80%
80–90%

Unilateral adrenal Corticotroph pituitary adenomas

adenomas (Cushing’s disease)
Age: 35–45 years Age: 30–40 years
Female:male=5–8:1 Female:male=4–5:1

Figure 1: Cushing’s syndrome: causes, and age and sex distribution per cause
Age ranges refer to average age at first diagnosis. ACTH=adrenocorticotropic hormone. *The two peaks in age are due to a bimodal trend.

Clinical presentation and diagnosis
The clinical picture of Cushing’s syndrome varies
widely from a mild, insidious presentation to a fully
developed severe case, with rapid evolution (ie, a few
months) in disease presentation. A mild disease
presentation is challenging, since signs and symptoms
can overlap with those of other common clinical
conditions, such as metabolic syndrome and polycystic
ovary syndrome (figure 2).3 Early suspicion of
hypercortisolism is essential for diagnosis. Although no
symptom or sign is unique to hypercortisolism, some
features are more useful to discriminate
hypercortisolism from other conditions—eg, purple
striae larger than 1 cm, easy bruising, facial plethora,
proximal muscular weakness, and in children, weight
gain with decreased growth velocity and alteration to
See Online for appendix typical pubertal development.3,7 As there are few
characteristics that are only found in Cushing’s
syndrome, how to determine who needs screening is a
pertinent consideration. Adult patients with unusual
symptoms for their age (eg, osteoporosis in women who
are premenopausal and men younger than 65 years,
hypertension in individuals younger than 40 years of
age), with multiple and progressive symptoms,
particularly symptoms that are more predictive of
Cushing’s syndrome, as mentioned earlier, or individuals
with an adrenal incidentaloma, as well as children with
weight gain and growth impairment, should all be
screened.3 Exogenous glucocorticoid use and non-
neoplastic hypercortisolism (psychiatric disorders,
alcohol abuse, anorexia nervosa, chronic kidney disease,
intense chronic exercise, and central glucocorticoid
resistance) should be ruled out first.20 Three tests are
currently recommended for screening: late night salivary
cortisol, urinary free cortisol, and the overnight 1 mg
dexamethasone suppression test (figure 3; appendix p 1).4
At least two positive tests are necessary for
hypercortisolism confirmation in most patients, and

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A B
Cushing’s syndrome Signs
(main causes) • Central obesity
• Moon face
• Facial plethora
• Acne
• Hirsutism
• Purple striae
• Pubic hair
development*
• Growth impairment*
Central obesity
High cortisol
Acne and hirsutism
Hypertension Glucose metabolism Bone disease
impairment
Comorbidities
Figure 2: Cushing’s syndrome signs, symptoms, and related comorbidities and the effects of transsphenoidal surgery
(A) Different causes of Cushing’s syndrome (left) result in hypercortisolism, which leads to different signs and symptoms (right), as well as various comorbidities
(bottom). (B) A patient with Cushing’s disease before and 12 months after successful transsphenoidal surgery. *Present in childhood or adolescence.
each test has its own peculiarities and limitations.4,21 The
Pituitary Society consensus recommends starting with
late night salivary cortisol, if available, due to its ease of
performance, except for patients with adrenal tumours
or night-shift workers in whom the overnight 1 mg
dexamethasone suppression test is preferred.4 Tests
investigating hair cortisol (and cortisone), an estimate
for long-term exposure to glucocorticoids, are promising,
although their clinical use is currently low.22
After confirming hypercortisolism, ACTH concen­
trations should be measured to differentiate ACTH-
dependent from ACTH-independent causes (figure 3).4
ACTH concentrations that are less than 10 pg/mL
indicate an adrenal cause; adrenal imaging (CT or MRI)
is the next step. The mass lipid content on CT, in
Hounsfield units (HU), is helpful to assess malignancy
risk: lesions with a density of less than or equal to 10 HU
are virtually never malignant, whereas a density of more
than 20 HU presents a sensitivity of 97% (95% CI 94–98)
for malignancy.23 MRI can be used for indeterminate
lesions; chemical shift technique, in which adrenal
adenomas lose signal on out-of-phase versus in-phase
images, whereas malignant lesions and pheochromo­
cytomas do not, can be also used.24
ACTH concentrations of more than 20 pg/mL indicate
ACTH-dependent Cushing’s syndrome, whereas values
of 10–20 pg/mL are indeterminate and necessitate re-
evaluation.3,22 In adrenal Cushing’s syndrome, mildly
elevated cortisol might not lead to suppressed ACTH.
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Seminar
Symptoms Before transsphenoidal surgery
• Decreased libido
• Psychiatric disorders
• Proximal muscle
weakness
• Hair loss
• Menstrual
irregularities
Moon face and facial
plethora
12 months after transsphenoidal surgery
Purple striae
Infections Hypercoagulability
Therefore, in the case of a classic clinical and laboratory
presentation of Cushing’s syndrome with ACTH
concentrations between 10–20 pg/mL, an ACTH-
dependent cause should be considered.1,22 In addition,
some ACTH assays are unreliable in the intermediate
range, showing clearly detectable concentrations in
patients with adrenal disease. Dehydroepiandrosterone
sulphate could also be useful since it is ACTH-stimulated;
low–normal or suppressed dehydroepiandrosterone
sulphate concentrations suggest an adrenal cause.22
The most frequent cause in ACTH-dependent cases is
Cushing’s disease, and the next step after establishing that
the disease is an ACTH-dependent Cushing’s syndrome
is pituitary MRI.22 Macroadenomas (≥10 mm) are found in
10–20% of patients with Cushing’s disease, but
40–50% of patients might not present visible lesions.25 The
3·0 and 7·0 Tesla MRI identifies microadenomas less
than 5 mm in length more frequently than 1·5 Tesla MRI,
but the value of identifying these microadenomas is
currently unclear, as will be discussed later.26 The role of
molecular imaging is yet to be determined.
A macroadenoma in a patient with ACTH-dependent
hypercortisolism confirms a Cushing’s disease diagnosis.
If no lesion or a lesion less than 6 mm in length is
identified, additional investigation is needed, since
adenomas can be found in up to 20% of the general
population. The gold standard to differentiate
Cushing’s disease from ectopic ACTH secretion is
bilateral inferior petrosal sinus sampling (BIPSS).4 In a
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Clinical suspicion of Cushing’s

syndrome

Exclude exogenous glucocorticoid use

and non-neoplastic hypercortisolism

Perform two out of three tests

• Dexamethasone suppression test
• Late night salivary cortisol*
• Urinary free cortisol*

Typical results Altered results Equivocal results

Cushing’s syndrome unlikely Cushing’s syndrome confirmed Repeat tests

ACTH <10 pg/mL ACTH >20 pg/mL ACTH 10–20 pg/mL

Primary adrenal disorder

(adrenal Cushing’s syndrome Adrenal imaging Pituitary MRI Repeat, more likely pituitary
confirmed)

Lesion ≥10 mm Lesion 6–9 mm No lesion or lesion <6 mm

High dose dexamethasone

Cushing’s disease confirmed Controversial, more likely pituitary BIPSS suppression test, CRH, or
desmopressin tests if BIPSS is
not available†

Yes Central:periphery No
ratio ≥2 baseline or ≥3 after
stimulation

Cushing’s disease confirmed EAS investigation

Whole body imaging (CT or MRI); functional imaging

Figure 3: Algorithm for the investigation of Cushing’s syndrome

Dotted arrows indicate no clear consensus on these testing pathways. ACTH=adrenocorticotropic hormone. BIPSS=bilateral inferior petrosal sinus sampling. CRH=corticotropin-releasing hormone.
EAS=ectopic ACTH secretion. *Late night salivary cortisol and urinary free cortisol must be evaluated in at least two samples. †There is no clear consensus on the use of these tests, since they have
lower sensitivity and specificity than BIPSS.

patient with confirmed ACTH-dependent Cushing’s
syndrome and a lesion of length 6–9 mm, pituitary origin
is considered if BIPSS is unavailable (figure 3). A central-
to-periphery ratio of 2 or more at baseline or of 3 or more
after stimulation in the BIPSS is compatible with
Cushing’s disease (appendix p 2).9,27 BIPSS was initially
developed using corticotropin-releasing hormone;
however, due to worldwide unavailability, desmopressin
has replaced corticotropin-releasing hormone and shows
similar performance (appendix p 2).27 BIPSS is safe but
invasive and it is not a widely available procedure.
Dynamic tests, such as the high-dose dexamethasone
suppression test, the corticotropin-releasing hormone
test, and the desmopressin test can be used as an
alternative, although with lower sensitivity and specificity
than BIPSS (appendix p 2).28,29 Solitary use of any of these
dynamic tests is usually not recommended. A
combination of tests, whole body imaging examinations,
or both has been evaluated; however, more studies
are needed.4 Dynamic tests can be used with caution if
BIPSS is not available (figure 3). In the differential
diagnosis of ACTH-dependent Cushing’s syndrome,
[⁶⁸Ga]-(1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic
acid [DOTA])-corticotropin-releasing hormone PET
detected an adenoma in 24 evaluated cases (in six cases,
adenomas measured ≤6mm in length), which coincided
with MRI findings; on the contrary, no pituitary or diffuse
uptake was observed in three ectopic ACTH secretion
cases.30 These findings seem promising, but larger
studies are needed.
If ectopic ACTH secretion is suspected, a whole-
body thin slice CT scan is performed, followed by
[⁶⁸Ga]-DOTA-Phe1-Tyr3-octreotide (DOTA-TOC) or
[¹⁸F]fluorodeoxyglucose PET or CT if no tumour is

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identified.22 In a meta-analysis, [⁶⁸Ga]-DOTA-TOC
showed an overall sensitivity of 64∙0% (95% CI
53∙1–73∙7).31
Both pituitary and adrenal incidentalomas are
frequently found in the general population, so the
presence of a small lesion does not establish Cushing’s
syndrome; conversely, the absence of a pituitary adenoma
does not exclude a Cushing’s disease diagnosis. Imaging
should only be used after convincing biochemical
hypercortisolism confirmation.
Advances in genetics and epigenetics
ACTH-secreting pituitary adenomas
Corticotropinomas are monoclonal in origin and
mainly sporadic (table 1; appendix pp 3–8).41,50 Somatic
pathogenic variants in the USP8 represent the major
genetic hallmark of corticotropinomas, and have a mean
prevalence of 33% (95% CI 24–42).32–34 The USP8 protein
is a deubiquitinase that prevents lysosomal degradation
of client proteins; cleavage of USP8 due to pathogenic
gene variants results in elevated deubiquitinase activity.32
Increased USP8 activity enhances deubiquitination of
EGFR, leading to increased POMC expression and
ACTH release through sustained EGFR signalling.51
Pangenomic analysis led to the identification of
two corticotropinoma clusters (USP8 mutant and USP8
wild-type adenomas).52 In USP8 wild-type adenomas,
other recurrent pathogenic variants have been described:
activating pathogenic variants in the USP48 gene, loss-of-
function pathogenic variants in the tumour suppressor
gene TP53, and inactivating pathogenic variants in the
glucocorticoid receptor gene NR3C1.35–37,39,53 The
modulation of multiple factors involved in glucocorticoid
receptor regulation (eg, HSP90 and TR4 overexpression)
can also affect physiological glucocorticoid feedback.54
Clinically aggressive corticotropinomas and carcinomas
can have loss-of-function pathogenic variants in the ATRX
gene, with a relatively higher frequency in adenomas
with concomitant TP53 pathogenic variant.36,38,40 Over­
expression of PTTG exerts tumorigenic properties in
corticotroph cells, including cyclin E upregulation, thus
representing a therapeutic target for cyclin-dependent
kinase inhibitors (eg, R-roscovitin).55,56 Germline
mutations in Cushing’s disease are rare (appendix p 2).41,57
Epigenetic analysis of corticotropinomas revealed
hypomethylation of the POMC gene, which is associated
with enhanced promoter activity and POMC over­
expression.58 A novel regulatory region of POMC that
acts as a second promoter, which is highly demethylated
in cortico­tropi­
nomas, partly demethylated in normal
pituitary tissues, and highly methylated in silent
corticotropinomas was identified.59
Ectopic ACTH-secreting tumours
Methylomic and transcriptomic studies have shown that
the POMC promoter is substantially hypomethylated in
ACTH-secreting neuroendocrine tumours of the lung,
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Seminar
thymus, and pancreas, as compared with corresponding
control tissues.60 The upstream POMC promoter has a
binding site for the E2F1 transcription factor, supporting
the role of E2F1 overexpression as a potential mechanism
involved in uncontrolled POMC transcription and
ectopic ACTH secretion.61
Ectopic ACTH-secreting thymic neuroendocrine
tumours, medullary thyroid carcinomas, and pheo­
chromo­ cytomas can present with MEN1 and RET
pathogenic variants in the context of multiple endocrine
neoplasia.1,62
Adrenal adenomas and carcinomas
The protein kinase A (PKA) pathway is involved in
cortisol-producing adenomas. Exome sequencing
revealed activating somatic pathogenic variants in the
PKA catalytic subunit gene (PRKACA) in eight of ten
patients with unilateral cortisol-producing adenomas and
overt Cushing’s syndrome.42 Additional sequencing found
pathogenic variants in the PRKACA gene in 22 (37%) of
59 cortisol-producing adenomas presenting as overt
Cushing’s syndrome, but in none of the adenomas
yielding subclinical Cushing’s syndrome, in aldosterone-
producing, and non-functioning adenomas.42 Other genes
implicated in genesis of cortisol-producing adenomas are
PRKAR1A, CTNNB1, and GNAS (table 1).43–46,63,64
The role of pathogenic variants in the TP53 gene in
adrenal adenomas is controversial, but is probably
involved in the pathogenesis of adrenocortical
carcinomas.47,48 Somatic pathogenic variants of TP53 were
identified in 34 (36%) of 94 patients with adrenocortical
carcinoma, whereas somatic pathogenic variants in the
CTNBB1 gene were found in 18 (19%) of 94 patients
(table 1).48 The TP53 gene could be even more important
in children, among whom germline pathogenic variants
can be found in 50–80% of patients (appendix pp 3–8).65–67
Bilateral macronodular adrenocortical disease
Bilateral macronodular adrenocortical disease, formerly
primary bilateral macronodular adrenocortical hyperplasia,
can be associated with genetic syndromes or be present as
isolated forms, familial, or apparently sporadic cases. The
physiopathology of bilateral macronodular adrenocortical
disease has not been fully elucidated, but several genes are
implicated (appendix pp 3–8).68–72
In most patients with bilateral macronodular
adrenocortical disease (77–87%), adrenocortical cells
express eutopic and ectopic atypical G-protein coupled
receptors, which are associated with steroidogenesis
and can increase cortisol secretion.63,73 However, whether
this aberrant expression is involved in bilateral
macronodular adrenocortical disease pathogenesis or is
secondary to cell proliferation and dedifferentiation is
still unclear.68
A pangenomic study showed that bilateral macro­
nodular adrenocortical disease presents a specific
transcriptomic profile that differentiates it from other
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Chromosomal Protein and biological functions Pathogenic Frequency Clinical characteristics

location variant type
Cushing’s disease
USP832-34, 35 15q21.2 USP8, deubiquitinase (well described Gain-of-function 33% More common in female individuals and in younger individuals;
interaction with EGFR) adenomas usually smaller and less invasive than the wild-type
USP4835,36,37 1p36.12 USP48, deubiquitinase (physiological Gain-of-function 13% Smaller adenomas, tendency for higher frequency in female
substrates: H2A and GLI1) individuals (among USP8 wild-type tumours)
TP5335,38 17p13.1 p53; gene acts as tumour suppressor Loss-of-function 12% Aggressive tumour features (larger and invasive lesions, higher Ki67-
positive cells), difficult to manage, poor patient prognosis
NR3C135,39 5q31.3 Glucocorticoid receptor Loss-of-function 6% No peculiar clinical features described (few cases reported); blunted
dexamethasone-induced inhibition of ACTH secretion and cell
proliferation in vitro
BRAF35,36,37 7q34 B-Raf kinase protein; gene has proto- Gain-of-function 7% No differences in tumour size, invasiveness, and surgical outcome
oncogenic activity compared with the wild-type; elevated midnight plasma ACTH; all
data derived from the Chinese cohort
ATRX40 Xq21.1 ATRX transcriptional regulator and Loss-of-function 32% of corticotroph Clinically aggressive tumours and carcinomas (severe
chromatin remodelling protein, maintenance APTs and pituitary hypercortisolism, poor prognosis)
of telomere structure and function carcinomas
GNAS41 20q13.32 α subunit of the stimulatory G protein, Gain-of-function Rare No peculiar clinical features described (few cases)
activation of cAMP pathway
PI3KCA41 3q26.32 PI3K p110α catalytic subunit, activation of Gain-of-function Rare Invasive pituitary adenomas (one single individual reported invasive
AKT pathway corticotrophinoma)
Adrenal adenoma
PRKACA42,43 16p13.12 PKA catalytic subunit α Gain-of-function 37% More severe phenotype than other gene variants; diagnosed at young
age
CTNNB144 3p22.1 β-catenin; involved in cell adhesion and Gain-of-function 22% More frequent in patients with subclinical Cushing’s syndrome than
communication patients with clinical Cushing’s syndrome
GNAS45 20q13.32 α subunit of the stimulatory G protein, Gain-of-function 6% More frequent in female individuals and patients with subclinical
activation of cAMP pathway Cushing’s syndrome than patients with clinical Cushing’s syndrome
PRKAR1A46 17q24.2 PKA regulatory subunit 1 α; gene acts as a Loss-of-function 5% PPNAD-like syndrome
tumour suppressor
Adrenocortical carcinoma
TP5347,48 17p13.1 p53; gene acts as tumour suppressor Loss-of-function 36% Decreased survival rates
CTNNB148 3p22.1 β-catenin; involved in cell adhesion and Gain-of-function 19% Decreased survival rates
communication
Bilateral micronodular adrenal hyperplasia
CTNNB149 3p22.1 β-catenin; involved in cell adhesion and Gain-of-function 11% Found in larger nodules of patients with PPNAD
communication
ACTH=adrenocorticotropic hormone. AKT=serine-threonine kinase 1 (protein kinase B). APT=aggressive pituitary tumour. ATRX=α-thalassemia-mental retardation syndrome X-linked. BRAF=v-raf murine
sarcoma viral oncogene homolog B1. cAMP=cyclic adenosine monophosphate. CTNNB1=beta catenin. EGFR=epidermal growth factor receptor. Gli1=glioma-associated oncogene. GNAS=α subunit of the
stimulatory G protein. Ki67=antigen Kiel 67. H2A=histone H2A. NR3C1=nuclear receptor subfamily 3, group C, member 1. PI3K=phosphoinositide 3-kinase. PI3KCA=PI3K p110α catalytic subunit. PKA=protein
kinase A. PPNAD=primary pigmented nodular adrenocortical disease. PRKACA=protein kinase A catalytic subunit α. PRKAR1A=protein kinase A type I regulatory subunit α. TP53=tumour protein 53.
USP48=ubiquitin-specific protease 48. USP8=ubiquitin-specific protease 8.

Table 1: Main somatic pathogenic variants of genes associated with Cushing’s syndrome

forms of adrenal hyperplasia and adrenal adenomas.74
Bilateral macronodular adrenocortical disease also has
specific methylation, miRNA, and chromosomal
profiles.69,74 The bilateral macronodular adrenocortical
disease cluster is associated with loss-of-function
pathogenic variants in ARMC5.74 This pathogenic variant
was first described in 18 (55%) of 33 patients75 in a
homogeneous subset of patients with severe disease
who had undergone surgery, whereas a group of
heterogeneous patients had lower frequencies (15–25%).70
None of 16 patients with ARMC5 pathogenic variants
had food-dependent Cushing’s syndrome, but nine (28%)
of 32 patients without pathogenic variants did (p=0∙02).72
Food-dependent Cushing’s syndrome is a condition in
which cortisol secretion is stimulated by food intake.
Although the pathogenesis of this condition is not fully
understood, it is probably associated with aberrant
glucose-dependent insulinotropic peptide (GIP) receptor
expression.76,77 Germline pathogenic (or probably patho­
genic) variants in the KDM1A gene were identified in all
17 patients with GIP-dependent bilateral macro­nodular
adrenocortical disease Cushing’s syndrome, whereas no
patients in the control groups had pathogenic variants.78
The loss of the KDM1A protein leads to alterations of
histone methylation, which could result in ectopic GIP
receptor expression in adrenocortical cells and lead to
development of adrenal nodular hyperplasia.70 AMRC5
and KDM1A pathogenic variants are mutually exclusive,
and patients with each mutation present different
phenotypes (appendix pp 3–8).

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Bilateral micronodular adrenal hyperplasia
Bilateral micronodular adrenal hyperplasia is
characterised by adrenal hyperplasia with nodules
measuring less than 1 cm in length; this condition
includes primary pigmented nodular adrenocortical
disease and isolated micronodular adrenal disease.79
In 258 (73%) of 353 patients with either Carney complex
or pigmented nodular adrenocortical disease, a germline
inactivating pathogenic variant in the PRKAR1A gene
was detected.80 Of 185 families with Carney complex,
114 (62%) had a PRKAR1A pathogenic variant.80
Inactivation of the PRKAR1A gene leads to activation
of the cAMP and PKA, Wnt and β-catenin, and
mTOR pathways, which impairs the cell cycle and cell
migration.63,81 Pigmentation of adrenal nodules occurs due
to autophagy impairment, leading to lipofuscin nodule
deposition.81 In the remaining 30% of patients with Carney
complex, an affected locus on chromo­some 2p16 can be
found.82
Germline pathogenic variants in PDE11A and PDE8B
and somatic CTNNB1 pathogenic variants can also be
found (table 1; appendix pp 3–8).49,83,84
Treatment of Cushing’s syndrome
Cushing’s disease
Pituitary surgery
Transsphenoidal surgery represents the first-line
treatment, except in cases when the patient is not eligible
or declines intervention.2,4 Transsphenoidal surgery
should be performed in specialised pituitary tumour
centres of excellence by an experienced neurosurgeon, as
the highest remission rates are observed in these
settings.85,86 Postoperative morning serum cortisol within
the first 7 days is the most commonly performed test; a
value of less than 55 nmol/L (<2 µg/dL) is predictive for
remission.87,88 A meta-analysis reported an overall
remission rate of 80% (95% CI 77–82) after primary
transsphenoidal surgery, which was higher in
microadenomas (83%, 79–87) versus macroadenomas
(68%, 60–76; figure 2).88 Microscopic surgery has similar
results to the endoscopic approach.89 Delayed remission
occurs in approximately 6% of patients and requires
careful follow-up.90 High remission rates are reported for
microadenomas, without cavernous sinuses invasion,
visible at preoperative MRI, and with a confirmed
histological diagnosis.4,88,91 However, a negative MRI does
not represent a contraindication for surgery.88,92 When
pathological results are negative for ACTH staining,
remission seems to be low in most, but not all studies.87,88
Complication rates are usually low in trans­ sphe­
noidal surgery, particularly when performed by
experienced neurosurgeons.85,86 The most common
complications are transient arginine vasopressin
deficiency (9∙4–21∙7%), new-onset hypopituitarism
(9∙4–11∙2%), cerebrospinal fluid leakage (4–12%), and
permanent arginine vasopressin deficiency (2∙4–
4%).88,89,91 Meningitis (0∙1–1∙9%), bleeding (0∙4–3∙7%),
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Seminar
and venous thrombo­ embolism (1∙2–1∙5%) are not
commonly observed, and visual field defects and cranial
nerve deficits are rare (<1%).88,89,91 Perioperative mortality
is also uncommon (<1%).4,88,89
Patients with Cushing’s disease are expected to
develop hypocortisolism postoperatively if they enter
remission;87,93 they require glucocorticoid replacement
until the hypothalamic-pituitary-adrenal axis is
recovered.4,87,93 Clinical and biochemical evaluation after
3 months and then every 3–6 months is needed.2
Postoperative testing for remaining pituitary function is
also needed, with hormonal replacement initiated as
appropriate.4 The growth hormone axis, which is often
impaired in Cushing’s syndrome, can improve
postoperatively.4
Despite disease remission, recurrence can occur
frequently.4 Mean recurrence rates in meta-analyses
vary from 9∙6% (95% CI 6∙9–12∙7) to 18% (14–22), with
high variability among single studies.4,88,89,91,94 Follow-up
duration affects results, since half of recurrences appear
within the first 5 years; the other half of recurrences
occur up to 36 years postoperatively, thus lifelong
monitoring is needed.4,94 Patients with low or suppressed
postoperative morning serum cortisol concentrations,
who require long-term glucocorticoid replacement
therapy (1–3 years), and have a non-invasive
microadenoma (operated in a specialised centre) have a
low recurrence risk.88,91,95–97 Late night salivary cortisol,
urinary free cortisol, and the overnight 1 mg
dexamethasone suppression test show high specificity,
but lower sensitivity when monitoring for recurrence
versus initial diagnosis.4,98 Late night salivary cortisol is
usually a first test to detect recurrence, whereas urinary
free cortisol seems to be the last test to become
atypical.98–100 Late night salivary cortisol testing should
be performed yearly in patients with a restored
hypothalamus-pituitary-adrenal axis, unless signs and
symptoms suggestive of recurrence prompt an earlier
biochemical assessment.4
In case of recurrence or persistence, a second pituitary
surgery is a valuable option to be considered by a
multidisciplinary team, particularly for patients with
visible tumour remnant.86,94 The mean remission rate
after repeated surgery is 58% (95% CI 50–66), with
enhanced outcomes in patients with recurrences
(80%, 68–90) versus those with persistent disease
(54%, 38–69).88 Surgical and endocrinological compli­
cations are slightly higher for repeated surgery than a
first surgery.87,88,94
Medical and surgical therapy
Medical therapy
Medical therapy is an option for persistent or recurrent
disease after surgery, as a bridge treatment while awaiting
the complete effect of radiotherapy, and as a first-line
therapy in patients with severe hypercortisolism that
requires prompt biochemical control.1,4,101,102
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Commonly used dose Biochemical outcome Main adverse events

Adrenal steroidogenesis inhibitors
Ketoconazole100,102–105 400–1200 mg per day, orally 64–71% UFC normalisation, 15% escape (ie, loss of Hepatotoxicity with increased liver enzymes,
response) in initially responsive patients gastrointestinal disturbances, adrenal insufficiency, skin
rash, hypogonadism, and gynaecomastia
Levoketoconazole106–108 300–1200 mg per day, orally 31–50% UFC normalisation (prospective studies) Gastrointestinal disturbances, headache, hypertension,
adrenal insufficiency, and increased liver enzymes
Metyrapone102,109,110 500 mg–6 g per day, orally 47–71% UFC normalisation, 8% escape in initially Increased androgenic and mineralocorticoid precursors
responsive patients (hirsutism and acne in female individuals, hypertension,
hypokalaemia, oedema), gastrointestinal disturbances,
and adrenal insufficiency
Osilodrostat111–113 2–60 mg per day, orally (lower starting doses 68–77% mUFC normalisation (prospective studies) Gastrointestinal disturbances, adrenal insufficiency,
also used) headache, fatigue and asthenia, and increased androgenic
and mineralocorticoid precursors (hirsutism and acne in
female individuals, hypertension, and hypokalaemia)
Mitotane4,102 500 mg–4 g per day, orally 80% UFC normalisation Gastrointestinal disturbances, dizziness, cognitive
alterations, adrenal insufficiency, and increased liver
enzymes
Etomidate102,114 0·04–0·1 mg/kg per h intravenously for patients Approximately 100% control by serum cortisol Sedation or anaesthesia, adrenal insufficiency, myoclonus,
in the intensive care unit; 0·025 mg/kg per h for nausea, vomiting, and dystonic reactions at doses used for
patients not in the intensive care unit anaesthesia
Pituitary tumour directed agents
Cabergoline115,116 0∙5–7∙0 mg per week, orally 35% UFC normalisation, 22% escape during long-term Nausea, headaches, dizziness, postural hypotension, nasal
treatment congestion, cardiac valvulopathy, and impulse control
disorders
Pasireotide117–120 600 µg or 900 µg twice a day, subcutaneously; or Prospective studies show UFC normalisation of 15% Diarrhoea, cholelithiasis, headache, abdominal pain, and
long-acting release formulation 10 mg or 30 mg (600 mcg), 26% (900 mcg), 42% (10 mg long-acting), hair loss; pasireotide-associated hyperglycaemia in
every 4 weeks, intramuscularly and 41% (30 mg long-acting) approximately 70% of patients
Glucocorticoid receptor antagonist
Mifepristone121 300–1200 mg per day, orally A prospective study has shown that 60% of patients Adrenal insufficiency, endometrial hyperplasia,
improve glucose control, 38% improve blood pressure hypertension, oedema, and hypokalaemia
control, and 87% have clinical improvement
Adapted from Lacroix et al1 and Fleseriu et al.4 mUFC=mean urinary free cortisol. UFC=urinary free cortisol.

Table 2: Summary of medical therapies for Cushing’s syndrome

Steroidogenesis inhibitors showed normalisation of mean urinary free cortisol after

Steroidogenesis inhibitors target the adrenal gland,
blocking one or more enzymes involved in steroido­genesis,
which leads to the production of aldosterone, cortisol, and
testosterone.4,54,102 To date, ketoconazole, levoketoconazole,
metyrapone, osilodrostat, mitotane, and etomidate are the
available drugs in clinical practice used for all causes of
Cushing’s syndrome (table 2; appendix pp 9–10).4,122
Ketoconazole inhibits multiple enzymes in the adrenal
cortex.103,122,123 A meta-analysis including patients with
various causes of Cushing’s syndrome reported a mean
efficacy of 71∙1% (95% CI 51∙6–87∙5) in normalising
cortisol concentrations.104 A retrospective review including
more than 300 patients with Cushing’s disease from five
studies showed the urinary free cortisol normalisation
occurred in a mean of 64∙3% (range 44∙7–92∙9) of patients,
with an escape (ie, loss of response) in a mean of 14∙5%
(7∙1–22∙7) of patients.101 The most common adverse events
include hepatotoxicity, gastrointestinal disturbances,
adrenal insufficiency, and skin rash.101,105,106,123 A decrease in
adrenal and gonadal steroids can occur.101,103
Levoketoconazole also targets multiple enzymes of the
steroidogenesis pathway.107–109 In the prospective phase 3
SONICS trial, 31% of patients with Cushing’s syndrome
6 months of treatment in the maintenance phase.107
Clinical signs and symptoms (acne, hirsutism, and
peripheral oedema), as well as comorbidities (eg, weight
gain, hyperglycaemia, and hyperandrogenism), signi­
ficantly improved.107,109 In the LOGICS trial, at the end of
the randomised withdrawal phase, 50% of patients in the
levoketoconazole group had normalised mean urinary free
cortisol, compared with 5% of the placebo group.108 The
most common adverse events included nausea, headache,
hypertension, and fatigue.107,108
Metyrapone shows preferential inhibitory activity for
11β-hydroxylase.122,123 A review including 120 patients with
Cushing’s disease from six studies showed mean urinary
free cortisol normalisation in a mean of 71%
(range 45∙4–100) of patients, with an escape in a
mean of 7∙8% (0–18∙7) of patients treated for a mean of
8∙7 months;101 a more recent observational study of
31 patients showed urinary free cortisol normalisation in
70% of individuals.110 Lastly, a multicentre prospective
study showed mean urinary free cortisol normalisation in
47% of patients after a 12-week treatment.111
Most patients treated with metyrapone show a rapid-
onset improvement of clinical signs and symptoms.4,123

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Adverse events, which correlate with increases in
mineralocorticoid precursors and adrenal androgens,
include hirsutism and acne in female individuals,
hypokalaemia, oedema, and hypertension.101,103,110,111,123 Other
common complaints include gastrointestinal disturbances,
dizziness, arthralgia, and fatigue.101,103,110,111,123
Osilodrostat also shows preferential inhibitory action on
11β-hydroxylase.122 In a phase 3 study (LINC3), mean
urinary free cortisol normalisation was reported in
68% of patients.112 In the LINC4 study, mean urinary free
cortisol normalisation at week 12 was reported for
77% of patients randomly assigned to the osilodrostat
group.113 A sustained response was reported in the study’s
extension phases for more than 72 weeks.112,113,124 Substantial
improvements in clinical and biochemical variables were
described, together with increases in quality of life and
decreased depression scores.112,113,124 The most common
adverse events include nausea, decreased appetite, fatigue
and asthenia, headache, arthralgia, diarrhoea, and adrenal
insufficiency (this latter event occurs in up to
30% of individuals).112,113,124 Signs and symptoms of adrenal
insufficiency need to be carefully monitored. Hypoka­
laemia and hypertension have also been described, as well
as increased blood testosterone, acne, and hirsutism in
female individuals.112,113,124
Two other adrenal steroidogenesis inhibitors, mitotane
and etomidate, are rarely used for benign Cushing’s
syndrome, whereas they can be useful in very severe
hypercortisolism (table 2; appendix pp 9–10).4
Pituitary targeted treatment
Currently available pituitary-acting drugs for
Cushing’s disease include the dopamine agonist
cabergoline and somatostatin receptor ligand pasireotide
(table 2; appendix pp 9–10).125
Two meta-analyses evaluating cabergoline found similar
results with respect to Cushing’s disease remission: 34%
(95% CI 26–43)115 and 35% (27–43).116 However,
22% of the patients with long-term evaluation had treat­
ment escape.115 The safety profile of cabergoline is
favourable; mild adverse events (mainly orthostatic
hypotension, dizziness, and nausea) occur in 24%
(14∙4–35∙1) of patients.104,115 Potentially serious adverse
events are cardiac valve involvement (patients receiving
weekly doses ≥2 mg need an echocardiogram yearly) and
psychiatric disorders.126,127
Pasireotide was evaluated in a phase 3 study.125 15%
(95% CI 7–22) of patients in the 600 µg group and 26%
(17–36) of patients in the 900 μg group had normalised
mean urinary free cortisol after 6 months of treatment.117
Another phase 3 trial reported that monthly intramuscular
injections of pasireotide long-acting release led to mean
urinary free cortisol normalisation in 41∙9% (30∙5–53∙9)
of patients treated with 10 mg and 40∙8% (29∙7–52∙7) of
patients treated with 30 mg.118 A meta-analysis showed
biochemical control with pasireotide (as individually
assessed) in 44% (30–60) of patients;116 substantial tumour
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Seminar
volume reduction (≥25% as measured by MRI) was
observed in 41∙2% (22∙9–62∙3) of patients.119 Adverse
events include diarrhoea, cholelithiasis, headache,
abdominal pain, and hair loss.126 However, the main
adverse event associated with pasireotide is hyper­
glycaemia,120 occurring in 72–83% of patients.118 Although
frequent, pasireotide-associated hyperglycaemia is mostly
mild and manageable with metformin-based or incretin-
based therapy, or both, with insulin treatment needed in
specific cases.120 USP8-mutated adenomas show increased
somatostatin receptor subtype 5 (SST5) expression,
suggesting a favourable response to pasireotide.128,129
Other drugs, such as R-roscovitine are being investi­
gated in clinical trials (appendix pp 9–10).130
Glucocorticoid receptor antagonist
Mifepristone, the only available glucocorticoid receptor
antagonist, is approved for hyperglycaemia associated with
Cushing’s syndrome; it also blocks the progesterone
receptor.121 Improvements in glucose blood concentration
(>60% in clinical trials) and several other clinical features
are substantial, but there is no biochemical measure for
monitoring efficacy, as cortisol and ACTH concen­trations
are increased during treatment. Mifepristone treatment
can also lead to hypertension and hypokalaemia due to
mineralocorticoid receptor activation by high circulating
cortisol concentration and to endometrial thickness
and vaginal bleeding due to progesterone receptor
blockage.126 Relacorilant, a selective glucocorticoid receptor
modulator with no progesterone receptor activity, is
currently in clinical trials (appendix pp 9–10).131
Glucocorticoid receptor antagonists can be used in patients
with severe Cushing’s syndrome, who are in need of rapid
control of hypercortisolism, or patients who have not
responded to other medical management.121
Radiotherapy
Radiotherapy is an adjuvant treatment for patients with
persistent or recurrent Cushing’s disease, especially when
there is aggressive tumour growth.4,132 Two meta-analyses
found biochemical control rates of 57% (95% CI 51–63) for
stereotactic radiotherapy or radiosurgery and 74% (54–88)
for radiosurgery.133,134 In a multicentre study (255 patients),
gamma-knife radiosurgery induced remission after 5 years
in 68% of patients; early procedures (<3 months after
surgery) increased chances of remission compared with
late procedures (hazard ratio 1∙518, 95% CI 1∙039–2∙218,
p=0∙031).135 Tumour control was observed in 94% of
patients.135 Proton beam, which is less frequently studied,
induced control rates in 65∙8% of patients in three studies.136
The main radiotherapy adverse event is new onset of
hypo­pituitarism in 15–50% of patients; serial pituitary
function testing is therefore required after radiotherapy.137
Other adverse events include visual toxicity, cranial nerve
neuropathy, brain radionecrosis, cerebrovascular events,
neurocognitive impairment, and second brain tumours
(more rare).
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Bilateral adrenalectomy
Bilateral adrenalectomy is effective in almost all patients,
providing immediate and permanent hypercortisolism
resolution. However, due to adrenal insufficiency and life-
long glucocorticoid and mineralocorticoid replacement
therapy, it is often a last-resort treatment.4,138 Bilateral
adrenalectomy can be considered earlier for patients with
severe persistent or recurrent Cushing’s disease who
have not responded to medical treatment or for female
patients who want to become pregnant.4,138
Surgical morbidity (6–31%) and mortality (0–8%) rates
are low, and treatment leads to improvements in
symptoms and comorbidities.138,139 Almost half of the
deaths after bilateral adrenalectomy occur in the first
year, mostly due to cerebrovascular or cardiovascular
disorders and sepsis.139 Management of adrenal
insufficiency and prevention of adrenal crisis is crucial;
preferred treatment is with short-acting hydrocortisone
in divided doses.
Long-term consequences include corticotroph tumour
progression (previously Nelson’s syndrome), which can
occur in 22–53% of patients.140,141 Patients younger
than 35 years with large tumours and substantial ACTH
elevation in the first year after bilateral adrenalectomy had
a higher frequency of tumour progression than those
without these characteristics.140,142 The recommended
surveillance programme is MRI surveillance 3 months
after surgery, followed by MRI surveillance every 12 months
for 3 years, and thereafter yearly clinical surveillance with
MRI performed every 2–4 years (depending on clinical
variables and ACTH concentrations).140
Ectopic ACTH-secreting tumours
Ectopic ACTH secretion is usually associated with severe
hypercortisolism and aggressive or metastatic lesions.9
When the tumour is detectable, without distant metastases
or local invasion, the treatment of choice is complete
primary lesion resection.2,9,143 For occult primary lesions,
wide metastatic spread, and severe hypercortisolism,
therapeutic approaches need to be discussed in a
multidisciplinary team.9,10 Rapid control of hypercortisolism
and treatment of ectopic ACTH secretion-related
comorbidities are the main goals.9 Medical therapy with
steroidogenesis inhibitors, glucocorticoid receptor
blockers, bilateral adrenalectomy, or a combination of
these, can lead to rapid hyper­cortisolism control.9,114 A real-
world study noted a rapid-onset urinary free cortisol
decrease with osilodrostat (normalisation in
>80% of patients).144 Etomidate, administered intra­
venously, with its potent and rapid steroidogenesis
inhibition, can be particularly effective in this setting.145 For
bilateral adrenalectomy, robust data highlight its crucial
role in the management of patients with ectopic ACTH
secretion who have not been cured by primary surgery, are
not eligible for radical intervention, are not adequately
controlled with medical therapy, or a combination of
these.114,146
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The role of tumour-directed medical therapies is
increasing,9,102 as well as the importance of histopathological
characterisation of metastatic or locally invasive tumours.9
Kinase inhibitors, such as selpercatinib and pralsetinib,
can control hypercortisolism in medullary thyroid
cancers.9,102 Somatostatin receptor ligands (octreotide and
lanreotide) and cabergoline have mixed efficacy in ACTH-
secreting neuroendocrine tumours.9,102
Radiofrequency ablation and chemoembolisation, as
well as peptide radionuclide therapy, could represent
additional treatment tools in well defined scenarios.9
Combination medical therapy for Cushing’s syndrome
Patients with Cushing’s syndrome can be simultaneously
treated with more than one drug aimed to reduce cortisol
concentrations (eg, cabergoline and ketoconazole). Since
currently available treatments exert their effects at
different targets (pituitary and adrenal) and the various
steroidogenesis inhibitors show preferential interactions
with different enzymes, combined treatment could have
a potential synergistic effect (appendix pp 11–12).1,102,122
Combination therapy allows lower doses of single
agents, possibly minimising treatment-related adverse
events.102,122
Adrenal Cushing’s syndrome
Minimally invasive surgery is the best treatment for
cortisol-secreting unilateral adenomas. It presents low
morbidity and mortality rates but is dependent on
surgeon experience and is only indicated in lesions less
than or equal to 6 cm in length, with no evidence of
nearby organ infiltration.23,147 Postoperative glucocorticoid
replacement, as patients develop hypocortisolism due to
hypothalamic-pituitary-adrenal axis suppression, is
needed. Mitotane can be used as neo-adjuvant therapy
for advanced or metastatic adrenocortical carcinoma.148
For patients with bilateral disease, although bilateral
adrenalectomy is the standard treatment, unilateral
adrenalectomy is a viable option for some patients.149,150 In
patients with bilateral macronodular adrenocortical
disease, initial remission rate is 93%, with recurrence in
15% of cases, whereas 14% need to undergo contralateral
adrenal gland removal.149 For micronodular bilateral
adrenal hyperplasia, remission rates are lower (65%),
with recurrence in 12% and a need for completion
surgery in 18% of patients.149
Several criteria are used to select the proper adrenal
gland to be removed, such as size on imaging, adrenal
uptake in [¹³¹I]-norcholesterol or [¹²³I]-iodometomidate
scintigraphy, and cortisol gradients using bilateral
adrenal venous sampling,149 but further studies are
needed.
Complications and mortality
Cushing’s syndrome is frequently associated with long-
term comorbidities, and acute complications, adversely
affecting quality of life and survival (figure 2).4 In studies
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analysing both patient and physician questionnaires,
physicians did not accurately estimate the prevalence of
comorbidities.151 Furthermore, treatment of com­
plications, performed mostly by endocrinologists, was
satisfactory for just 63% of patients, highlighting a need
for improvement.
Hypertension is highly prevalent (50–75% of patients)
and seems to be associated with glucocorticoid excess
duration and severity.152 It contributes, together with
dyslipidaemia, diabetes, and hypercoagulability or
thromboembolism events, to augmented cardiovascular
risk.4 In this regard, prevention of cardiovascular disease
requires very stringent therapeutic targets.
Other frequent complications include decreased
bone density, musculoskeletal impairment, psychiatric
alterations, and cortical atrophy; many of these compli­
cations will persist after remission.
Bone disease, although present in most patients with
Cushing’s syndrome, seems to be worse if the syndrome
has an adrenal cause.153 Close monitoring (methods and
timeline) remain controversial, as bone mineral density
improvement could take up to 2 years;153 furthermore,
bone mineral density measurement by dual-energy x-ray
absorptiometry (DEXA) is not always accurate. Reductions
in bone health give a reduced trabecular bone score;
trabecular bone score measurements are more accurate at
predicting vertebral fractures than bone mineral density
measurements.153 Vertebral fractures are seen in more
than 50% of patients with active Cushing’s syndrome and
can be the presenting manifestation of the syndrome,
leading to diagnosis.154 Myopathy could be severe and one
of the last conditions to improve, particularly in patients
with lower IGF-1 concentrations after surgery.155 Patients
with Cushing’s disease and hypopituitarism have even
worse impairments to quality of life,93 and the role of
glucocorticoid withdrawal syndrome in decreased quality
of life after remission is being increasingly recognised.156
Several important factors regarding long-term
comorbidities need to be addressed: can we predict who
will develop the most comorbidities, and why sex-based
comorbidities persist after remission? The sex-based
discrepancy remains unexplained, although different
clinical presentations, perceptions of the disease, coping
strategies, and long-term durations have all been
suggested.157–159 Low baseline urinary free cortisol for
Cushing’s disease and adrenal Cushing’s syndrome
could be associated with a number of long-term
comorbidities,160 possibly due to the extensive exposure to
excess glucocorticoids in milder Cushing’s syndrome.
Delay in diagnosis seems to be a better predictor for
long-term psychiatric morbidity and quality of life
compared with cortisol concentration.157
Improvement or comorbidity resolution after Cushing’s
syndrome remission varies; in one study, diabetes
resolved in 56%, depression in 52%, and hypertension in
36% of patients.160 Dyslipidaemia persists in most
patients (75%).160 Monitoring is essential, as concomitant
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Seminar
medications for comorbidities need to be serially down-
titrated in many patients. Age, BMI, fasting glucose, and
how many comorbidities were present at diagnosis could
predict the number of long-term comorbidities.160 Total,
visceral, and subcutaneous fat, weight, and waist
circumference all decrease after remission, but three-
quarters of patients will still be overweight or obese at
5 years after remission,152 highlighting the need for
additional medication for obesity.
Risk of acute complications is also very high; acute
complications have been reported in 62% of patients with
Cushing’s disease, 40% with adrenal Cushing’s syndrome
(adrenal cancer excluded), and 100% with ectopic ACTH
secretion in a large single-centre study.161 The most
frequent complications in patients with benign Cushing’s
syndrome were infection-related disorders (25%),
thromboembolism (17%), hypokalaemia (13%), hyper­
tensive crises (9%), cardiac arrhythmias (5%), and acute
coronary events (3%).161 In another study, in which the risk
of both arterial and venous thromboembolism was
almost 20%, many patients had more than one event, with
higher risk 30–60 days after surgery than after 60 days.162
Currently, low-molecular-weight heparin or other
treatments (fondaparinux and rarely, direct oral
anticoagulants) should be considered in selected patients
with additional risk factors for thrombosis and in the
perioperative setting if there are no contraindications;
treatment duration remains controversial.4
Systematic prophylaxis for Pneumocystis pneumonia in
patients with Cushing’s syndrome is suggested if urinary
free cortisol is more than 5–10 times the upper limit of
the normal range. Hypokalaemia, catabolic symptoms,
and other possible risk factors should also be considered
when assessing infection risks.163,164
Mortality in Cushing’s syndrome remains elevated. In
a large registry, infectious diseases were the most
common cause of death in patients with Cushing’s disease
or adrenal Cushing’s syndrome and underlying tumour
progression was the most common cause of death for
ectopic ACTH secretion.165 Age and male sex, as well as
myopathy, diabetes, and ectopic ACTH secretion, were
predictors of higher mortality.165
In a large meta-analysis of 3691 patients (excluding those
with adrenal cancer), mortality rates were similar for
different types of Cushing’s syndrome; the overall stan­
dardised mortality rate was 3 for all Cushing’s syndrome
causes, ranging from 3∙3 for adrenal Cushing’s syndrome
to 2∙8 for Cushing’s disease, with some improve­ment in
the past decade.166 In another study, standardised mortality
rates for cardiovascular disease (3∙3) and stroke (3∙0) were
high; the standardised mortality rate related to cardio­
vascular complications was higher in active
Cushing’s disease (9∙5) versus patients in remission (2∙5).167
Future directions and unmet needs
Cushing’s syndrome is still a challenging disease, with
complicated processes for both diagnosis and condition
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management. Improvements in early detection, screening
methods, genetic testing, management of some
complications, and personalised treatment are long
awaited. Two clinical scores have been developed to
attempt to reduce delays in diagnosis, especially for mild
cases, and showed discriminative ability for Cushing’s
syndrome diagnosis of 0∙93 and 0∙84, respectively, as
measured by the area under the curve.168,169 Although they
have high predictive power, a recent validation study (in a
German population) showed poor sensitivity of these
tools.170 The superiority of mass spectrometry over
immunoassays for measurement of cortisol concentrations
has also been controversial.21 Although mass spectrometry
has higher specificity to detect cortisol concentrations,
the diagnostic performance of currently available
immunoassays seems to give similar results (although
reports have given conflicting results). Immunoassay
techniques are easy to handle, widely available, and
available at lower cost.21 Although substantial progress in
elucidating some genetic causes of Cushing’s syndrome
has been made,13 the role of routine genetic testing in
patients with Cushing’s syndrome remains unclear.32
Management of compli­cations varies widely from country
to country and prospective studies are needed to determine
best management practices for several comorbidities,
especially hypercoagulability. Unilateral adrenalectomy
use in bilateral adrenal disease with Cushing’s syndrome
has been expanded, but long-term data are needed. The
role of precision medicine in the management of various
diseases has also been increasing.4 The development of
new drugs targeting specific molecules or pathological
mechanisms, such as EGFR, BRAF, or epigenetic
mechanisms (epidrugs), and investigation of response
biomarkers to existing drugs could change the Cushing’s
syndrome approach from trial and error to a precision
medicine-based approach.171
Conclusions
Cushing’s syndrome is a multisystemic chronic condition
with high morbidity and mortality. Important advances
have been made in the understanding of the genetic and
pathological mechanisms leading to the different causes of
Cushing’s syndrome. Furthermore, substantial progress
has been made in the development of treatment options,
improving the care of patients with Cushing’s syndrome.
However, mortality and morbidity remain high, and
quality of life is lower than that of the general population
despite remission. More research is needed to improve
patient outcomes.
Contributors
FG, LEW, and MF contributed to the literature review and writing of
specific sections of this Seminar. FG and LEW contributed to drafting of
tables and figures. MG was responsible for the integration of various
sections. All authors revised and approved the final version of the Seminar.
Declaration of interests
MG has received funding as principal investigator from Crinetics and
Recordati in the last 3 years, has received personal honoraria for
lectures, consulting, and advisory boards from Crinetics and Recordati,
2248
and is an Associate Editor of The Journal of Clinical Endocrinology and
Metabolism. FG is an Associate Editor of Frontiers in Endocrinology
(Translational Endocrinology), serves on the Executive Committee of the
European Neuroendocrine Association, and has received personal
honoraria for lectures, manuscript writing, and educational events from
Ipsen, Novartis, Pfizer, and Recordati. LEW has received personal
honoraria for lectures from Ipsen and is on the advisory board for
Crinetics. MF has received funding from Crinetics, Recordati, Sparrow,
and Xeris (previously Strongbridge) in the last 3 years as a principal
investigator at the Oregon Health & Science University, has received
personal honoraria for consulting and acting on advisory boards from
Crinetics, HRA Pharma, Recordati, Sparrow, and Xeris (previously
Strongbridge), is Deputy Editor of the European Journal of Endocrinology,
and serves on the board of the Pituitary Society.
Acknowledgments
There was no funding source for this Seminar. Patients provided
informed consent for publication of pictures included in this Seminar.
References
1 Lacroix A, Feelders RA, Stratakis CA, Nieman LK. Cushing’s
syndrome. Lancet 2015; 386: 913–27.
2 Nieman LK, Biller BM, Findling JW, et al. Treatment of Cushing’s
syndrome: an Endocrine Society clinical practice guideline.
J Clin Endocrinol Metab 2015; 100: 2807–31.
3 Nieman LK, Biller BM, Findling JW, et al. The diagnosis of
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