Disorders Of The

. Adrenal Cortex
 The adrenal cortex produces three classes of Corticosteroid Hormones:

1. Glucocorticoids (e.g., Cortisol),

2. Mineralocorticoids (e.g., Aldosterone), and
3. Adrenal Androgen Precursors (e.g., Dehydroepiandrosterone, DHEA)
(Fig. 342-1).

Glucocorticoids and Mineralocorticoids act through specific nuclear

receptors,

Regulating aspects of the Physiologic Stress Response

As well as Blood Pressure and Electrolyte Homeostasis.
Adrenal Androgen Precursors

Are converted in the gonads and peripheral target cells to sex steroids
That act via nuclear androgen and estrogen receptors.
Adrenal Steroidogenesis
 CYP11A1, side chain cleavage enzyme; CYP17A1, 17 B-hydroxylase/17,20 lyase; POR, P450 oxidoreductase; ADX,
adrenodoxin; HSD3B2, 3 B-hydroxysteroid dehydrogenase type 2; CYP21A2, 21-hydroxylase; CYP11B1, 11 -
hydroxylase; CYP11B2, aldosterone synthase; HSD11B1, 11 B-hydroxysteroid dehydrogenase type 1; HSD11B2, 11 -
hydroxysteroid dehydrogenase type 2; H6PDH, hexose-6-phosphate dehydrogenase; HSD17B, 17 B-hydroxysteroid
dehydrogenase; SRD5A, 5 a-reductase; SULT2A1, DHEA sulfotransferase; DHEA, dehydroepiandrosterone; DHEAS,
dehydroepiandrosterone sulfate; PAPSS2, PAPS synthase type 2.
 Disorders of the adrenal cortex are characterized by

deficiency or excess of one or several of the three major corticosteroid

classes.

Hormone Deficiency can be caused by

1. Inherited Glandular or Enzymatic Disorders or
2. By Destruction of the Pituitary or Adrenal gland by
Autoimmune disorders,
Infection,
Infarction, or
By iatrogenic events such as surgery or hormonal suppression.
 Hormone Excess is usually the result of neoplasia, leading to

1. Increased production of Adrenocorticotropic Hormone (ACTH)

by the Pituitary or Neuroendocrine Cells (Ectopic ACTH), or
2. Increased production of Glucocorticoids or Mineralocorticoids
by Adrenal Nodules.

Adrenal Nodules are increasingly identified incidentally

During abdominal imaging performed for other reasons.

.

Adrenal Anatomy and Development

The Normal Adrenal Glands weigh 6–11 g each.

They are located above the kidneys and have their own blood supply.

Arterial blood flows initially to the subcapsular region and then

meanders from the Outer Cortical Zona Glomerulosa through the
Intermediate Zona Fasciculata to the Inner Zona Reticularis
and eventually to the Adrenal Medulla.

The Right Suprarenal Vein drains directly into the vena cava
while the Left Suprarenal Vein drains into the left renal vein.
Location And Blood Supply
During early embryonic development, the adrenals originate from the
urogenital ridge and then separate from gonads and kidneys about the
6th week of gestation.

Concordant with the time of sexual differentiation (seventh to ninth week

of gestation, see Chap. 349), the adrenal cortex starts to produce cortisol
and the adrenal sex steroid precursor DHEA.

The orphan nuclear receptors SF1 (steroidogenic factor 1) and DAX1

(dosage-sensitive sex reversal gene 1), among others, play a crucial role
during this period of development, as they regulate a multitude of
adrenal genes involved in steroidogenesis.
Structure And Function Of The
Adrenal Glands.
(ACE = angiotensin-converting
enzyme; JGA = juxtaglomerular
apparatus; MR =
mineralocorticoid receptor; β-
LPH = β-lipotrophic hormone, a
fragment of the ACTH precursor
peptide pro-opiomelanocortin which
contains melanocyte-stimulating
.

Regulatory Control of Steroidogenesis

Production of Glucocorticoids and Adrenal Androgens

Is under the control of the Hypothalamic-Pituitary-Adrenal (HPA) Axis,

Whereas Mineralocorticoids

Are regulated by the Renin-Angiotensin-Aldosterone (RAA) System.

Glucocorticoid Synthesis is under inhibitory feedback control by the
hypothalamus and the pituitary (Fig. 342-2).

Hypothalamic release of Corticotropin-Releasing Hormone (CRH)

occurs in response to endogenous or exogenous stress.

CRH stimulates the cleavage of the 241–amino acid polypeptide

Pro Opio-melano-cortin (POMC) by Pituitary-specific Prohormone

Convertase,
Yielding Adrenocorticotropic Hormone (ACTH).
ACTH is released by the corticotrope cells of the anterior pituitary and
acts as the pivotal regulator of Cortisol Synthesis,
With additional Short-term Effects on Mineralocorticoid and
Adrenal Androgen Synthesis.

The release of CRH, and subsequently ACTH, occurs in a Pulsatile

Fashion that follows a Circadian Rhythm under the control of the
Hypothalamus, specifically its Suprachiasmatic Nucleus (SCN), with
additional regulation by a complex network of Cell-specific Clock Genes.

Reflecting the pattern of ACTH secretion, Adrenal Cortisol Secretion

exhibits a Distinct Circadian Rhythm, with PEAK LEVELS in the Morning
and LOW LEVELS in the Evening (Fig. 342-3).
Regulation of the Hypothalamic-Pituitary-
Adrenal (HPA) Axis.

CRH, corticotropin-releasing hormone;

ACTH, adrenocorticotropic hormone.
 Physiologic Cortisol Circadian Rhythm.

Circulating Cortisol Concentrations drop under the rhythm-adjusted mean (MESOR) in the early
evening hours, with nadir levels around midnight and a rise in the early morning hours;
Peak levels are observed appx 8:30 A.M. (acrophase).
5-10 Fold

Locus Coeruleus
Circadian Rhythm from Higher
Centers
Hypoglycemia, Hypotension, Surgery,
Fever, Injury
CRH, AVP, Pro-inflammatory
Cytokines (IL1, IL6, TNF)

ACTH from POMC, Secretion

Constant Frequency, Variable
Amplitude
Melanocortin-2 receptor, G Protein
Coupledadenylate Cyclase 
CAMP
Cortisol Feedback: CRH inhibition,
Antagonism to Pitutary
Secretagogues, POMC Synthesis &
ACTH Release Inhibition
Diagnostic tests assessing the HPA axis make use of the fact that it is
regulated by negative feedback.

Glucocorticoid Excess is diagnosed by employing a

Dexamethasone Suppression Test.

Dexamethasone, a potent glucocorticoid, suppresses

CRH/ACTH and, therefore, Endogenous Cortisol.
If Cortisol Production is autonomous (e.g., Adrenal Nodule),

ACTH is already suppressed and dexamethasone has little additional

effect.

If Cortisol Production is driven by an ACTH-producing pituitary

adenoma,

Dexamethasone suppression is ineffective at low doses

But usually induces suppression at high doses.
If Cortisol Production is driven by an ectopic source of ACTH,

The tumors are usually resistant to dexamethasone suppression.

Thus, the Dexamethasone Suppression Test is useful to establish

The diagnosis of Cushing's Syndrome and

To assist with the Differential Diagnosis of Cortisol Excess.
Conversely, to assess Glucocorticoid Deficiency,

ACTH stimulation of Cortisol Production is used.

The ACTH peptide contains 39 amino acids but the first 24 are sufficient
to elicit a physiologic response.

The Standard ACTH Stimulation Test involves

Administration of Cosyntropin (ACTH 1-24), 0.25 mg IM or IV,

And collection of blood samples at 0, 30, and 60 minutes for Cortisol.
A normal response is defined as a Cortisol Level >20mic g/dL or an
increment of >10mic g/dL Over Baseline.

A low-dose (1mic g Cosyntropin IV) version of this test has been

advocated to Avoid Overstimulation of the Adrenal Gland.
Alternatively, an Insulin Tolerance Test (ITT) can be used to assess
adrenal insufficiency.

It involves injection of Insulin to induce Hypoglycemia,

Which represents a Strong Stress Signal that triggers

Hypothalamic CRH release and activation of the entire HPA axis.
The ITT involves

Administration of Regular Insulin 0.1 U/kg IV

(Dose should be lower if Hypopituitarism is likely)

And Collection of blood samples at 0, 30, 60, and 120 Minutes for
Glucose, Cortisol, and Growth Hormone (GH),
If also assessing the GH axis.
Oral or IV glucose is administered after the patient has achieved
Symptomatic Hypoglycemia (Usually Glucose <40 mg/dL).

A normal response is defined as

A Cortisol >20mic g/dL and GH >5.1mic g/L.

The ITT requires careful clinical monitoring and

sequential measurements of glucose.
 It is Contraindicated in patients with

1. Coronary Disease,
2. Cerebrovascular Disease, or
3. Seizure Disorders,

Which has made the Short Cosyntropin Test

The commonly accepted first-line test.
Mineralocorticoid Production is controlled by the RAA Regulatory Cycle,

Which is initiated by the release of renin from the juxtaglomerular cells in

the kidney,
Resulting in cleavage of angiotensinogen to angiotensin I in the liver (Fig.
342-4).

Angiotensin-converting enzyme (ACE) cleaves angiotensin I to angiotensin

II,

Which binds and activates the angiotensin II receptor type 1 (AT1

receptor),
Resulting in Increased Aldosterone Production and Vasoconstriction.
Aldosterone enhances Sodium Retention and Potassium Excretion,

And increases the Arterial Perfusion Pressure,

Which in turn regulates renin release.

Because Mineralocorticoid Synthesis is primarily under the control of

the RAA system,

Hypothalamic-pituitary Damage does not significantly impact

The capacity of the adrenal to synthesize aldosterone.
Similar to the HPA axis, the assessment of the RAA system can be used
for diagnostic purposes.

If Mineralocorticoid Excess is present,

There is a counter-regulatory downregulation of Plasma Renin.

Conversely, in Mineralocorticoid Deficiency,

Plasma renin is markedly increased.
Physiologically, oral or IV Sodium Loading

Results in Suppression of Aldosterone,

A response that is attenuated or absent
In patients with Autonomous Mineralocorticoid Excess.
.

Steroid Hormone Synthesis, Metabolism,

and Action
ACTH effects on adrenal steroidogenesis. ACTH, adrenocorticotropic hormone; ATP, adenosine
triphosphate; CRE, cAMP response element; CREB, cAMP response element binding; MRAP,
MC2R-accessory protein; StAR, steroidogenic acute regulatory [protein].
Prereceptor activation of cortisol and glucocorticoid receptor (GR) action. GRE, glucocorticoid
response elements; HSP, heat shock proteins; NADPH, nicotinamide adenine dinucleotide
phosphate (reduced form).
.

Hyperfunction of the Adrenal Cortex

1. Excess Cortisol is associated with Cushing's Syndrome;

2. Excess Aldosterone causes Aldosteronism; and

3. Excess Adrenal Androgens cause Adrenal Virilism.

These syndromes do not always occur in the "pure" form but may have
overlapping features.
.

Cushing's Syndrome
 Cushing's Syndrome reflects a constellation of Clinical Features that
result from Chronic Exposure to Excess Glucocorticoids of any etiology.

The disorder can be

1. ACTH-dependent (e.g., Pituitary Corticotrope Adenoma, Ectopic

Secretion of ACTH by Nonpituitary Tumor) or
2. ACTH-independent (e.g., Adrenocortical Adenoma, Adrenocortical
Carcinoma, Nodular Adrenal Hyperplasia), as well as
3. Iatrogenic (e.g., Administration of Exogenous Glucocorticoids to Treat
Various Inflammatory Conditions).
The term Cushing's Disease refers specifically to Cushing's Syndrome
caused by a Pituitary Corticotrope Adenoma.
.

Epidemiology
 Cushing's Syndrome is generally considered a rare disease.

It occurs with an incidence of 1–2 per 100,000 population per year.

However, it is debated whether Mild Cortisol Excess may be more

prevalent among patients with several features of Cushing's such as
1. Centripetal Obesity,
2. Type 2 Diabetes, and
3. Osteoporotic Vertebral Fractures,

Recognizing that these are relatively nonspecific

And common in the population.
In the overwhelming majority of patients, Cushing's syndrome is caused
by

An ACTH-producing Corticotrope Adenoma of the Pituitary (Table 342-1),

As initially described by Harvey Cushing in 1912.

Cushing's Disease more frequently affects Women,

With the exception of prepubertal cases,

Where it is more common in boys.

By contrast, Ectopic ACTH Syndrome is more frequently identified in

Men.
Only 10% of patients with Cushing's Syndrome have

A primary, Adrenal Cause of their disease

(e.g., Autonomous Cortisol Excess Independent of ACTH),
And most of these patients are women.

Overall, the Medical Use of Glucocorticoids

For immunosuppression, or for the treatment of inflammatory disorders,

Is the most common cause of Cushing's Syndrome.
.

Etiology
In at least 90% of patients with Cushing's Disease,

ACTH excess is caused by a Corticotrope Pituitary Microadenoma,

often only a few millimeters in diameter.

Pituitary Macroadenomas (i.e. tumors >1 cm in size),

Are found in only 5–10% of patients.

Pituitary Corticotrope Adenomas usually occur Sporadically,

But very rarely can be found in the context of
Multiple Endocrine Neoplasia Type 1 (MEN1).
Ectopic ACTH Production

Is predominantly caused by Occult Carcinoid Tumors,

Most frequently in the Lung, but also in Thymus or Pancreas.

Because of their small size, these tumors are often difficult to locate.

Advanced Small Cell Lung Cancer can cause ectopic ACTH production.
In rare cases, ectopic ACTH production has been found to originate from

Medullary Thyroid Carcinoma or Pheochromocytoma,

The latter co-secreting Catecholamines and ACTH.
The majority of patients with ACTH-independent Cortisol Excess

Harbor a Cortisol-producing Adrenal Adenoma.

Adrenocortical Carcinomas may also cause ACTH-independent disease

And are often large,

With excess production of Several Corticosteroid Classes.
 A rare but notable cause of adrenal cortisol excess is

ACTH-Independent Macronodular Hyperplasia (AIMAH),

Generally characterized by ectopic expression of receptors
Not usually found in the adrenal, including receptors for
1. Luteinizing Hormone,
2. Vasopressin,
3. Serotonin,
4. Interleukin-1, or
5. Gastric Inhibitory Peptide (GIP), the cause of food-dependent
Cushing's.
 Activation of these receptors results in upregulation of PKA signaling,
As physiologically occurs with ACTH,
With a subsequent increase in cortisol production.

Mutations in a regulatory subunit of PKA (PRKAR1A) are found

In patients with Primary Pigmented Nodular Adrenal Disease (PPNAD)
As part of Carney's Complex,
An autosomal dominant multiple neoplasia condition associated with
1. Cardiac myxomas,
2. Hyperlentiginosis,
3. Sertoli's cell tumors, and
4. PPNAD.
 PPNAD can present as micronodular or macronodular hyperplasia, or
both.

Another rare cause of ACTH-independent Cushing's is

McCune-Albright Syndrome, also associated with

1. Polyostotic Fibrous Dysplasia,

2. Unilateral Café-au-lait Spots, and
3. Precocious Puberty.
McCune-Albright syndrome is caused by

Activating mutations in GNAS-1 (guanine nucleotide binding protein

alpha stimulating activity polypeptide 1),
And such mutations have also been found in bilateral macronodular
hyperplasia
Without other McCune-Albright features.
.

Clinical Manifestations
Glucocorticoids affect almost all cells of the body and thus signs of
cortisol excess impact Multiple Physiologic Systems (Table 342-2),
With Upregulation of Gluconeogenesis, Lipolysis, and Protein
Catabolism causing the most prominent features.

In addition, Excess Glucocorticoid Secretion

Overcomes the ability of 11B-HSD2 to Rapidly Inactivate Cortisol to
Cortisone in the kidney,
Thereby Exerting Mineralocorticoid Actions,
Manifest as Diastolic Hypertension, Hypokalemia, and Edema.
Excess glucocorticoids also interfere with Central Regulatory Systems,

Leading to suppression of Gonadotropins

With subsequent Hypogonadism and Amenorrhea,

And suppression of the Hypothalamic-pituitary-thyroid Axis,

Resulting in Decreased TSH (thyroid-stimulating hormone) Secretion.
The majority of Clinical Signs and Symptoms observed in Cushing's
Syndrome are Relatively Nonspecific and include features such as

Obesity, Diabetes, Diastolic Hypertension, Hirsutism, and Depression

That are commonly found in patients who do not have Cushing's.

Therefore, careful clinical assessment is an important aspect of

evaluating suspected cases.
A diagnosis of Cushing's should be considered

When several clinical features are found in the same patient,

In particular when more specific features are found.
These include Fragility of the Skin,

With easy bruising and broad (>1 cm), Purplish Striae (Fig. 342-8),

And signs of Proximal Myopathy,

Which becomes most obvious when trying to stand up from a chair
without the use of hands or
When Climbing Stairs.

Clinical manifestations of Cushing's do not differ substantially among

the different causes of Cushing's.
In Ectopic ACTH Syndrome,

Hyperpigmentation of the Knuckles, Scars, or Skin areas exposed to

Increased Friction can be observed (Fig. 342-8),
And is caused by Stimulatory Effects of Excess ACTH and other POMC
cleavage products on Melanocyte Pigment Production.
Furthermore, patients with Ectopic ACTH Syndrome,

And some with Adrenocortical Carcinoma as the cause of Cushing's,

May have a More Brisk Onset and

Rapid Progression of clinical signs and symptoms.
Clinical Features of Cushing's Syndrome.
A. Note central obesity and broad, purple stretch marks
(B. close-up).
C. Note thin and brittle skin in an elderly patient with
Cushing's.
D. Hyperpigmentation of the knuckles in a patient with
ectopic ACTH excess.
A. Centripetal Obesity
B. Moon Facies
C. Cutanoues Purplish Striae
Patients with Cushing's syndrome can be acutely endangered by
Deep Vein Thrombosis,
With subsequent pulmonary embolism due to a Hypercoagulable State
associated with Cushing's.

The majority of patients also experience Psychiatric Symptoms,

Mostly in the form of Anxiety or Depression,
But Acute Paranoid or Depressive Psychosis may also occur.
Even After Cure, long-term health may be affected by

An increased risk of Cardiovascular Disease and

Osteoporosis with Vertebral Fractures,
Depending on the Duration and degree of exposure to significant
Cortisol Excess.
.

Diagnosis
The most important first step in the management of patients with
suspected Cushing's syndrome is to Establish The Correct Diagnosis.

Most mistakes in clinical management,

leading to unnecessary imaging or surgery,
are made because the diagnostic protocol is not followed

(Fig. 342-9).
This protocol requires Establishing the diagnosis of Cushing's beyond
doubt prior to employing any tests used for the differential diagnosis of
the condition.

In principle, after excluding

Exogenous Glucocorticoid Use as the cause of clinical signs and
symptoms,
Suspected cases should be tested if there are multiple and progressive
features of Cushing's,
Particularly features with a potentially Higher Discriminatory Value.

Exclusion of Cushing's is also indicated in patients with

Incidentally Discovered Adrenal Masses.
The diagnosis of Cushing's syndrome depends on the demonstration of
Increased Cortisol Production and Failure To Suppress Cortisol
Secretion normally when dexamethasone is administered (Chap. 333).

Once the diagnosis is established, further testing is designed to

determine The Etiology (Fig. 336-7 and Table 336-4).
 Evaluating Patients Suspected of Having Cushing's Syndrome.

*A Microadenoma or Macroadenoma may be visualized by Pituitary Magnetic Resonance

Scanning.

• Risk of Carcinoma in Adrenal Tumors 4–6 cm is 6%.

Radiographic clues include tumor heterogeneity and irregular borders (see Fig. 336-8).

17-KS, 17-ketosteroids;
For Initial Screening,

The Overnight Dexamethasone Suppression Test is recommended.

In difficult cases (e.g., in Obese or Depressed Patients),

Measurement of a 24-h Urine Free Cortisol
Can also be used as a screening test.

A level >140 nmol/d (50mic g/d) is suggestive of Cushing's Syndrome.

Sequence of Investigations in Suspected
Spontaneous Cushing's Syndrome
The Definitive Diagnosis is then established by

Failure of Urinary Cortisol to fall to <25 nmol/d (10mic g/d) or of

Plasma Cortisol to fall to <140 nmol/L (5mic g/dL)

After a Standard Low-dose Dexamethasone Suppression Test

(0.5 mg every 6 h for 48 h).

Owing to Circadian Variability,

Plasma Cortisol and, to a certain extent, ACTH Determinations

Are not meaningful when performed in isolation,

But the absence of the Normal Fall of Plasma Cortisol At Midnight

Is consistent with Cushing's Syndrome

Because there is loss of the Diurnal Cortisol Rhythm.
The task of determining The Etiology of Cushing's Syndrome is
Complicated by the fact that
All the available tests Lack Specificity and
By the fact that the tumors producing this syndrome are prone to
Spontaneous and often dramatic changes in hormone secretion
(Periodic Hormonogenesis).

No test has a specificity >95%,

And it may be necessary to use a Combination of Tests
To arrive at the correct diagnosis.
Sequence of Investigations in Suspected
Spontaneous Cushing's Syndrome
Plasma ACTH Levels can be useful in distinguishing the various causes
of Cushing's Syndrome,
Particularly in separating ACTH-dependent from ACTH-independent
causes.

In general, measurement of plasma ACTH is useful

In the diagnosis of ACTH-independent Etiologies of the syndrome,

Since most Adrenal Tumors cause low or undetectable ACTH levels
[<2 pmol/L (10 pg/mL)].
Furthermore, ACTH-secreting Pituitary Macroadenomas and ACTH-
producing Nonendocrine Tumors usually result in Elevated ACTH
Levels.

In the Ectopic ACTH Syndrome,

ACTH levels may be elevated to >110 pmol/L (500 pg/mL),

And in most patients the level is >40 pmol/L (200 pg/mL).
In Cushing's Syndrome as the result of a
Microadenoma or Pituitary-hypothalamic Dysfunction,

ACTH levels range from 6–30 pmol/L (30–150 pg/mL)

[normal, <14 pmol/L (<60 pg/mL)],

With half of values falling in the normal range.

 However, the main problem with the use of ACTH levels in the
Differential Diagnosis of Cushing's Syndrome is that

ACTH Levels may be Similar in individuals with

1. Hypothalamic-pituitary Dysfunction,
2. Pituitary Microadenomas,
3. Ectopic CRH Production, and
4. Ectopic ACTH Production (Especially Carcinoid Tumors)

(Table 336-4).
A useful Step to Distinguish Patients with an

ACTH-secreting Pituitary Microadenoma or

Hypothalamic-pituitary Dysfunction

From those with other forms of Cushing's Syndrome is

To determine the Response of Cortisol Output to administration of

High-dose Dexamethasone (2 mg every 6 h for 2 days).

An alternative 8-mg, overnight high-dose dexamethasone test has been
developed;
however, this test has a lower sensitivity and specificity than the
standard test.
When the diagnosis of Cushing's Syndrome is Clear-cut

On the basis of Baseline Urinary and Plasma Assays,

The High-dose Dexamethasone Suppression Test may be used

Without performing the Preliminary Low-dose Suppression Test.

The High-dose Suppression Test provides close to 100% Specificity

If the criterion used is Suppression of Urinary Free Cortisol by >90%.

Occasionally, in individuals with Bilateral Nodular Hyperplasia and/or

Ectopic CRH Production,
Steroid Output is also suppressed.
 Failure Of Low- and High-dose Dexamethasone Administration to
Suppress Cortisol Production (Table 336-4)

Can occur in patients with Adrenal Hyperplasia secondary to an

1. ACTH-secreting Pituitary Macroadenoma or an
ACTH-producing Tumor of Nonendocrine Origin

2. And in those with Adrenal Neoplasms.

Because of these difficulties, Several Additional Tests have been
advocated,

Such as the Metyrapone and CRH Infusion Tests.

The rationale underlying these tests is that

Steroid hypersecretion by an adrenal tumor or the ectopic production of

ACTH
Will suppress the Hypothalamic-pituitary Axis
So that inhibition of pituitary ACTH release can be demonstrated by
either test.
Thus, most patients with Pituitary-hypothalamic Dysfunction and/or a
Microadenoma have an increase in steroid or ACTH secretion
In response to Metyrapone or CRH administration,

Whereas most patients with Ectopic ACTH-producing Tumors do not.

Most Pituitary Macroadenomas also respond to CRH,

but their response to metyrapone is variable.

However, false-positive and false-negative CRH tests can occur in

patients with ectopic ACTH and pituitary tumors.
 The main diagnostic dilemma in Cushing's syndrome is to distinguish
those instances due to Microadenomas of the Pituitary from those due to
Ectopic Sources (e.g., Carcinoids or Pheochromocytoma)
that produce CRH and/or ACTH.

The Clinical Manifestations are Similar unless the Ectopic Tumor

produces other symptoms, Such as
1. Diarrhea and Flushing from a Carcinoid Tumor or
2. Episodic Hypertension from a Pheochromocytoma.
Sometimes, one can distinguish between Ectopic and Pituitary ACTH
Production by using Metyrapone or CRH Tests, as noted above.

In these situations, CT of the Pituitary Gland is usually Normal.

MRI with the enhancing agent Gadolinium may be better than CT for
this purpose
but demonstrates pituitary microadenomas in only half of patients with
Cushing's disease.
Because Microadenomas can be detected in up to 10–20% of individuals
Without Known Pituitary Disease,
a positive imaging study does not prove that the pituitary is the source of
ACTH excess.

In those with Negative Imaging Studies, Selective Petrosal Sinus Venous

Sampling for ACTH is now used in many referral centers.

ACTH levels are measured at Baseline, 2, 5, and 10 min

after ovine CRH (1mic /kg IV) injections.
Peak Petrosal:peripheral ACTH Ratios of >3:1 confirm the presence of a
Pituitary ACTH-secreting Tumor.

In centers where petrosal sinus sampling is performed frequently,

it has proved highly sensitive for distinguishing
pituitary and nonpituitary sources of ACTH excess.

However, the catheterization procedure is technically difficult, and

complications have occurred.
The diagnosis of a Cortisol-producing Adrenal Adenoma is suggested
by

Low ACTH and disproportionate elevations in baseline urine free

cortisol levels
With only modest changes in urinary 17-ketosteroids or plasma DHEA
sulfate.

Adrenal Androgen Secretion is usually reduced in these patients

Owing to the cortisol-induced suppression of ACTH and
Subsequent involution of the Androgen-producing Zona Reticularis.
The diagnosis of Adrenal Carcinoma is suggested by

A Palpable Abdominal Mass and by

Markedly elevated baseline values of both Urine 17-ketosteroids and
Plasma DHEA Sulfate.

Plasma and urine cortisol levels are variably elevated.

Adrenal Carcinoma is usually resistant to

both ACTH stimulation and dexamethasone suppression.
 Elevated Adrenal Androgen Secretion often leads to virilization in the
female.

Estrogen-producing Adrenocortical Carcinoma usually presents with

1. Gynecomastia in Men and
2. Dysfunctional Uterine Bleeding in Women.
These adrenal tumors secrete increased amounts of androstenedione,

Which is converted peripherally to the Estrogens Estrone and Estradiol.

Adrenal carcinomas that produce Cushing's syndrome

Are often associated with elevated levels of the intermediates of steroid

biosynthesis (especially 11B-deoxycortisol),
Suggesting inefficient conversion of the intermediates to the final
product.
This feature also accounts for the characteristic increase in 17-
ketosteroids.

Approximately 20% of Adrenal Carcinomas

are not associated with endocrine syndromes

And are presumed to be Nonfunctioning
or to produce biologically inactive steroid precursors.

In addition, the excessive production of steroids

is not always clinically evident (e.g., Androgens in adult men).
The Immune-adrenal Axis.

Cortisol has Anti-inflammatory Properties that include effects on the Microvasculature, Cellular
Actions, and the Suppression of Inflammatory Cytokines
(The so-called Immune-adrenal Axis).

A Stress such as Sepsis increases adrenal secretion, and cortisol in turn suppresses the immune
response via this system.

–, suppression; +, stimulation;
CRH, corticotropin-releasing hormone;
ACTH, adrenocorticotropic hormone;
IL, interleukin; TNF, tumor necrosis factor; PAF, platelet activating factor.
.

Differential Diagnosis
.

Pseudo-Cushing's
Syndrome
Problems in diagnosis include patients with Obesity, Chronic
Alcoholism, Depression, and Acute Illness of any type.

Extreme Obesity is uncommon in Cushing's Syndrome;

Furthermore, with Exogenous Obesity,
The adiposity is Generalized, Not Truncal.

On adrenocortical testing, abnormalities in patients with exogenous

obesity are usually modest.
 Basal Urine Steroid Excretion Levels in Obese Patients
Are also either Normal or Slightly Elevated,
And the Diurnal Pattern in blood and urine levels is normal.

Patients with Chronic Alcoholism and those with Depression

Share Similar Abnormalities in Steroid Output:

1. Modestly Elevated Urine Cortisol,

2. Blunted Circadian Rhythm of Cortisol Levels, and
3. Resistance to Suppression Using the Overnight Dexamethasone Test.
In contrast to Alcoholic Subjects,
Depressed Patients do not have signs and symptoms of Cushing's
Syndrome.

Following Discontinuation of Alcohol and/or Improvement in the

Emotional Status,
Results of steroid testing usually Return to Normal.

One or more of Three Tests have been used to differentiate

Mild Cushing's Syndrome and Pseudo-cushing's Syndrome.
1. The Serum Cortisol Level following the Standard 2-day Low-dose
Dexamethasone Test has very high Sensitivity and Specificity.

2. Although the CRH Test alone is less useful,

In combination with the Low-dose Dexamethasone Test,
There is Nearly Complete Discrimination between these two conditions.

3. Finally, a Midnight Cortisol Level obtained in awake patients

May have similar predictive value as the low-dose dexamethasone test
If a cut-off of 210 nmol/L (7.5mic g/dL) is used.
Patients with Acute Illness often have abnormal results on laboratory
tests
And fail to exhibit Pituitary-adrenal Suppression in response to
Dexamethasone,
Since Major Stress (Such as Pain or Fever) interrupts the
Normal Regulation of ACTH Secretion.

Iatrogenic Cushing's Syndrome, induced by the

Administration of Glucocorticoids or other Steroids such as Megestrol
That bind to the Glucocorticoid Receptor,
Is indistinguishable by physical findings from
Endogenous Adrenocortical Hyperfunction.
 The distinction can be made, however,
By Measuring Blood or Urine Cortisol Levels in a Basal State;

In the Iatrogenic Syndrome

These levels are Low
Secondary to Suppression of the Pituitary-adrenal Axis.

The Severity of Iatrogenic Cushing's Syndrome is related to

1. The Total Steroid Dose,
2. The Biologic Half-life of the Steroid, and
3. The Duration of Therapy.
Also, individuals taking Afternoon and Evening Doses of
Glucocorticoids

Develop Cushing's Syndrome

More Readily and With a Smaller Total Daily Dose

Than do Patients Taking Morning Doses Only.
.

Radiologic Evaluation for Cushing's

Syndrome
The preferred radiologic study for visualizing the adrenals is a
CT Scan of the abdomen (Fig. 336-8).

CT is of value both for Localizing Adrenal Tumors and for

Diagnosing Bilateral Hyperplasia.

All patients believed to have Hypersecretion of Pituitary ACTH

Should have a Pituitary MRI scan with Gadolinium Contrast.

Even with this technique, Small Microadenomas may be undetectable;

Alternatively, False-positive Masses

Due to Cysts or
Nonsecretory Lesions of the normal pituitary may be imaged.

In patients with Ectopic ACTH Production,

High-resolution Chest CT is a useful first step.

CT and MRI of the Adrenal Glands.
A. Normal adrenal on CT.
B. Normal adrenal on T1-weighted MRI.
C. CT of benign adrenal adenoma. Right adrenal mass with 1.5 cm homogeneous attenuation (–5
Hounsfield units).
D. Right adrenal mass (2 cm) showing homogeneous intermediate signal intensity on MRI in-phase
gradient echo sequence.
E. There is homogeneous loss of signal on the corresponding out-of-phase sequence, consistent with
a diagnosis of adrenal adenoma.
The evaluation of patients with confirmed Cushing's should be carried
out by an endocrinologist and begins with the differential diagnosis of
ACTH-dependent and ACTH-independent cortisol excess (Fig. 342-9).

Generally, plasma ACTH levels are suppressed in cases of autonomous

adrenal cortisol excess, as a consequence of enhanced negative feedback
to the hypothalamus and pituitary.
By contrast, patients with ACTH-dependent Cushing's have normal or
increased plasma ACTH, with very high levels being found in some
patients with ectopic ACTH syndrome.

Importantly, imaging should only be used after it is established whether

the cortisol excess is ACTH-dependent or ACTH-independent, as
nodules in the pituitary or the adrenal are a common finding in the
general population.
In patients with confirmed ACTH-independent excess, adrenal imaging
is indicated (Fig. 342-10), preferably using an unenhanced CT scan.

This allows assessment of adrenal morphology and determination of

tumor density in Hounsfield Units (HU),

Which helps to distinguish between benign and malignant adrenal

lesions.
For ACTH-dependent cortisol excess (Chap. 339), an MRI of the
pituitary is the investigation of choice, but it may not show an
abnormality in up to 40% of cases because small tumors are below the
sensitivity of detection.

Characteristically, pituitary corticotrope adenomas fail to enhance

following gadolinium administration on T1-weighted MRI images.

In all cases of confirmed ACTH-dependent Cushing's,

Further tests are required for the differential diagnosis of
pituitary Cushing's disease and ectopic ACTH syndrome.
These tests exploit the fact that most pituitary corticotrope adenomas
still display regulatory features, including residual ACTH suppression by
high-dose glucocorticoids and CRH responsiveness.

In contrast, ectopic sources of ACTH are typically resistant to

dexamethasone suppression and unresponsive to CRH (Fig. 342-9).

However, it should be noted that a small minority of ectopic ACTH-

producing tumors exhibit dynamic responses similar to pituitary
corticotrope tumors.
If the two tests show discordant results, or if there is any other
reason for doubt,

The differential diagnosis can be further clarified by performing

Bilateral Inferior Petrosal Sinus Sampling (IPSS)
With concurrent blood sampling for ACTH
In the right and left inferior petrosal sinus and a peripheral vein.
An increased central/peripheral plasma ACTH ratio >2 at baseline and
>3 after CRH injection is indicative of Cushing's Disease (Fig. 342-9),
with very high sensitivity and specificity.

Of note, the results of the IPSS Cannot Be Reliably Used For

Lateralization (i.e. prediction of the location of the tumor within the
pituitary),
Because there is broad interindividual variability in the venous drainage
of the pituitary region.

Importantly, No cortisol-lowering agents should be used prior to IPSS.

If the differential diagnostic testing indicates Ectopic ACTH Syndrome,

Then further imaging should include

High-Resolution, Fine-Cut CT Scanning of the Chest and Abdomen
For scrutiny of the Lung, Thymus, and Pancreas.

If no lesions are identified,

An MRI of the Chest can be considered
As Carcinoid Tumors usually show high signal intensity on T2-weighted
images.
 Furthermore, Octreotide Scintigraphy can be helpful in some cases

As Ectopic ACTH-producing Tumors often express Somatostatin

Receptors.

Depending on the suspected cause,

Patients with ectopic ACTH syndrome should also undergo blood

sampling for
1. Fasting Gut Hormones,
2. Chromogranin A,
3. Calcitonin, and
4. Biochemical Exclusion of Pheochromocytoma.
A. Adrenal CT showing normal bilateral adrenal morphology (arrows).
B. MRI showing bilateral adrenal hyperplasia due to excess ACTH stimulation in Cushing's
disease.
Adrenal Imaging in Cushing's Syndrome.

C. CT scan depicting a right adrenocortical adenoma (arrow) causing Cushing's syndrome.

D. MRI showing bilateral macronodular hyperplasia causing Cushing's syndrome.
.

Evaluation of Asymptomatic Adrenal

Masses
Many Incidental Masses (so-called Incidentalomas) are discovered
during radiographic testing for another condition, rather than testing
performed because of a suspected adrenal disorder.

This is not surprising since ~6% of adult/elderly subjects at autopsy

have Adrenocortical Adenomas.

However, the prevalence of incidental adenomas is Age-dependent,

i.e., Cortical Adenomas are very uncommon
In individuals <30 years of age.
An important early step in the evaluation of adrenal incidentalomas is to
determine whether the patient has a History of Prior Malignancy.

In this circumstance, the adrenal mass will be a Metastasis in about One-half

of the patients.

If the primary tumor is being treated and there are no other metastases,
it may be prudent to obtain a biopsy of the mass.

A CT-guided Fine-Needle Aspiration (FNA) can usually identify

Nonadrenal or Metastatic Tissue.

However, Pheochromocytoma should always be excluded before a FNA is

performed.
The next step is to determine whether the tumor is Functioning,
although the great majority (70–80%) are Nonsecretory.

Overt clinical symptoms are usually absent in incidentally discovered

adrenal masses,

But the clinician should search for subtle signs and symptoms of
Hormonal Overproduction,
Such as Cushingoid Features and Paroxysmal Symptomatology.
 All patients with Incidentally Discovered Masses should be screened for
Pheochromocytoma,

Regardless of radiographic features that are considered

Typical for Cortical Adenomas (see below).

Measurement of Plasma Free Metanephrines is the recommended test

1. Due its High Sensitivity, and
2. A negative test essentially rules out this disorder.
All patients should also be screened with an
Overnight Dexamethasone-Suppression Test

Since Autonomous Cortisol Production in patients without typical

features of hypercortisolism (so-called Preclinical or Subclinical
Cushing's Syndrome)
Is the most common Hypersecretory Syndrome in incidentally discovered
adrenal masses (Fig. 336-9).
Such patients may experience side effects of Mild Overproduction of
Cortisol
(Such as Hypertension, Glucose Intolerance, and Osteoporosis)
And may benefit from excision of the mass.

Patients with hypertension should also be screened for Primary

Aldosteronism
By measurement of Plasma Aldosterone and Plasma Renin Activity.

Finally, Females with signs of Androgen Excess or Males with

Feminization
Should be tested for the overproduction of the appropriate sex steroids.
 Incidentaloma.

*Adrenocortical hormonal evaluation:

Dexamethasone suppression test in all patients;

Plasma renin activity/aldosterone ratio for hypertensives;

Sex steroid (DHEA sulfate, estradiol) for clinical signs in females and males, respectively.

Hounsfield units (HU): a measurement of x-ray attenuation or lipid content of neoplasms.

A lipid-rich mass (< 10 HU) is diagnostic of a benign cortical adenoma.

‡
Benign characteristics: homogeneous mass, smooth borders, HU <10.

¶
Benign adrenal adenomas are also characterized by earlier washout of contrast enhancement than
other neoplasms.
A major consideration is whether the incidentally discovered mass is an
Adrenocortical Carcinoma (ACC).

Although the probability of ACC is very low ( <0.01% ),

And the vast majority of adrenal masses are benign adenomas,
ACC is associated with a poor prognosis, especially if discovered at a
late stage.

Radiographic Characterization of the adrenal mass has been crucial in

this decision-making process;

Size and Imaging Phenotype are the best predictors of possible

malignancy.
Imaging in adrenocortical carcinoma. MRI scan with
A. frontal and
B. lateral views of a left adrenocortical carcinoma that was detected incidentally.
CT scan with
C. coronal and
D. transverse views depicting a right-sided adrenocortical carcinoma. Note the irregular border
and inhomogeneous structure. CT scan
E. and PET-CT F. visualizing a peritoneal metastasis of an
adrenocortical carcinoma in close proximity to the left kidney
(arrow).
 Features suggestive of Malignancy include:

1. Large Size ( >4–6 cm ),

2. Irregular Margins and Tumor Inhomogeneity,
3. Soft Tissue Calcifications Visible On CT, and
4. High Unenhanced CT Attenuation Values ( >10 HU ).

Similar findings characteristic of malignancy are seen on

Chemical-Shift MRI.
In contrast, the common Benign Adrenocortical Adenoma is
characterized by

Diameter < 4 cm and Tumor Homogeneity

With Sharp Margins and Low Unenhanced CT Values ( <10 HU ).

FNA is not useful to distinguish between

Benign and Malignant Primary Adrenal Tumors.
If the radiographic criteria favor a Benign Adrenocortical Neoplasm,

Reassurance is gained if the mass remains unchanged in size

At follow-up Scanning in 3–6 months.

On the other hand, Benign Cortical Adenomas may increase in size

(Up to 1–2 cm) over several years of follow-up.

.

Treatment:
Cushing's Syndrome
.

Adrenal Neoplasm
Adrenal Adenomas may be resected using Laparoscopic Techniques.

Because of the possibility of Atrophy of the Contralateral Adrenal,

The patient should be treated with Glucocorticoids and

Mineralocorticoids
Pre- and postoperatively As if for Total Adrenalectomy,
Even when a unilateral lesion is suspected,
The routine being similar to that for an Addisonian Patient
Undergoing elective surgery.
Despite operative intervention, most patients with Adrenal Carcinoma
die within 3 years of diagnosis.

Metastases occur most often to Liver and Lung.

The principal drug for the treatment of Adrenocortical Carcinoma is

Mitotane (o,p'-DDD), an isomer of the Insecticide DDT.

Mitotane Suppresses Cortisol Production

And decreases plasma and urine steroid levels.
Although its cytotoxic action is relatively selective for the
Glucocorticoid-secreting Zone of the Adrenal Cortex,
The Zona Glomerulosa may also be inhibited.

Because Mitotane also alters the Extraadrenal Metabolism of Cortisol,

Plasma and urinary cortisol levels must be assessed to titrate the effect.
 The drug is usually given in divided doses three to four times a day, with
the dose increased gradually to tolerability (usually <6 g daily).

At higher doses, almost all patients experience side effects, which may
be
1. Gastrointestinal (anorexia, diarrhea, vomiting) or
2. Neuromuscular (lethargy, somnolence, dizziness).

All patients treated with mitotane should receive

Long-term glucocorticoid maintenance therapy, and,
In some, mineralocorticoid replacement is appropriate.
In approximately One-third of patients,
Both tumor and metastases regress,
But long-term survival is not altered.

In many patients, mitotane only inhibits steroidogenesis

And does not cause regression of tumor metastases.

Osseous Metastases are usually refractory to the drug

And should be treated with radiation therapy.
Mitotane can also be given as adjunctive therapy after surgical resection
of an Adrenal Carcinoma,
Although there is no evidence that this improves survival.

Because of the Absence of a long-term benefit with Mitotane,

Alternative chemotherapeutic approaches
Based on Platinum Therapy have been used.

However, there are no data presently available

Indicating a prolongation of life.
.

Bilateral Hyperplasia
Patients with hyperplasia usually have a Relative or Absolute increase
in ACTH Levels.

Since therapy would logically be directed at reducing ACTH levels,

The ideal primary treatment for ACTH- or CRH-producing tumors,
Whether pituitary or ectopic, is Surgical Removal.

Occasionally (Particularly with Ectopic ACTH Production)

Surgical excision is not possible because the disease is far advanced.

In this situation, "Medical" or Surgical Adrenalectomy may correct the

hypercortisolism.
Controversy exists as to the proper treatment for Bilateral Adrenal
Hyperplasia when the source of the ACTH overproduction is not
apparent.

In some centers, these patients (especially those who suppress after the
administration of a high-dose dexamethasone test)
Undergo surgical exploration of the pituitary via a transsphenoidal
approach
In the expectation that a microadenoma will be found.
However, in most circumstances selective Petrosal Sinus Venous
Sampling is recommended,
And the patient is referred to an appropriate center
If the procedure is not available locally.

If a Microadenoma is not found at the time of exploration,

Total hypophysectomy may be needed.
 Complications of Transsphenoidal Surgery include

1. Cerebrospinal fluid rhinorrhea,

2. Diabetes insipidus,
3. Panhypopituitarism, and
4. Optic or cranial nerve injuries.
 In other centers, Total Adrenalectomy is the treatment of choice.

The Cure Rate with this procedure is close to 100%.

The adverse effects include

1. The certain need for Lifelong Mineralocorticoid and
Glucocorticoid Replacement
2. And a 10–20% probability of a Pituitary Tumor developing
Over the next 10 years (Nelson's Syndrome).
It is uncertain whether these tumors arise de novo or if they were present
prior to adrenalectomy but were too small to be detected.

Periodic radiologic evaluation of the pituitary gland by MRI as well as

serial ACTH measurements should be performed in all individuals after
bilateral adrenalectomy for Cushing's disease.

Such pituitary tumors may become locally invasive and impinge on the
optic chiasm or extend into the cavernous or sphenoid sinuses.
Except in children, pituitary irradiation is rarely used as primary
treatment, being reserved rather for postoperative tumor recurrences.

In some centers, high levels of gamma radiation can be focused on the

desired site with less scattering to surrounding tissues by using
stereotactic techniques.

Side effects of radiation include Ocular Motor Palsy and

Hypopituitarism.

There is a long lag time between treatment and remission,

And the Remission Rate is usually <50%.
Finally, in occasional patients in whom a surgical approach is not
feasible,

"Medical" Adrenalectomy may be indicated (Table 336-5).

Inhibition of Steroidogenesis may also be indicated

In Severely Cushingoid Patients

Prior to surgical intervention.
 Chemical Adrenalectomy may be accomplished by the administration of

The inhibitor of Steroidogenesis ketoconazole (600–1200 mg/d).

In addition, Mitotane (2 or 3 g/d) and/or

The Blockers of Steroid Synthesis

1. Aminoglutethimide (1 g/d) and
2. Metyrapone (2 or 3 g/d)

May be effective either alone or in combination.

Mitotane is slow to take effect (Weeks).

Mifepristone,

A competitive inhibitor of the binding of glucocorticoid to its receptor,

May be a treatment option.

Adrenal Insufficiency is a risk with all these agents,

And Replacement Steroids may be required.

Overt Cushing's is associated with a poor prognosis if left untreated.

In ACTH-independent disease, treatment consists of surgical removal of

the adrenal tumor.

For smaller tumors, a minimally invasive approach can be employed,

Whereas for larger tumors and those suspected of malignancy,

An open approach is preferred.
In Cushing's disease, the treatment of choice is selective removal of the
pituitary corticotrope tumor, usually via a transsphenoidal approach.

This results in an initial cure rate of 70–80% when performed by a

highly experienced surgeon.

However, even after initial remission following surgery,

Long-term follow-up is important

As late relapse occurs in a significant number of patients.
 If pituitary disease recurs, there are several options, including

1. Second surgery,
2. Radiotherapy,
3. Stereotactic radiosurgery, and
4. Bilateral adrenalectomy.

These options need to be applied in a highly individualized fashion.

In some with very severe, overt Cushing's (e.g., difficult to control
hypokalemic hypertension or acute psychosis),

It may be necessary to introduce medical therapy

To rapidly control the cortisol excess during the period leading up to
surgery.

Similarly, patients with metastasized,

Glucocorticoid-producing carcinomas may require
Long-term antiglucocorticoid drug treatment
In case of ectopic ACTH syndrome, in which the tumor cannot be
located,

One must carefully weigh whether drug treatment or bilateral

adrenalectomy is the most appropriate choice,
With the latter facilitating immediate cure but requiring life-long
corticosteroid replacement.

In this instance, it is paramount to ensure regular imaging follow-up

For identification of the ectopic ACTH source.
Oral agents with established efficacy in Cushing's syndrome are
Metyrapone and Ketoconazole.

Metyrapone inhibits cortisol synthesis at the level of 11-hydroxylase,

Whereas the antimycotic drug ketoconazole inhibits the early steps of

steroidogenesis.

Typical starting doses are 500 mg/tid for Metyrapone (maximum dose, 6
g)
And 200 mg/tid for Ketoconazole (maximum dose, 1200 mg).
Mitotane, a derivative of the insecticide o,p'DDD,

Is an adrenolytic agent that is also effective for reducing cortisol.

Because of its side effect profile, it is most commonly used in the context
of adrenocortical carcinoma,
But low-dose treatment (500–1000 mg per day)
Has also been used in benign Cushing's.
In severe cases of cortisol excess,

Etomidate can be used to lower cortisol.

It is administered by continuous IV infusion

In low, nonanesthetic doses.
After the successful removal of an ACTH- or Cortisol-producing Tumor,

The HPA axis will remain suppressed.

Thus, hydrocortisone replacement needs to be initiated

At the time of surgery and slowly tapered following recovery,

To allow physiologic adaptation to normal cortisol levels.
Depending on degree and duration of cortisol excess,

The HPA axis may require many months or even years

To resume normal function.