bluuebunny/crossref_metadata_2025 huggingface dataset:
Leptin Mediates Obesity-Induced DNA Damage in BRCA1 Breast Epithelial Cells
Authors: Bhardwaj Priya , Bareja Rohan , Oshchepkova Sofya , Iyengar Neil , Elemento Olivier , Morrow Monica , Spector Jason , Brown Kristy A
Published: May 2021

Background: Obesity is a risk factor for breast cancer development in women who carry a mutation in the DNA repair enzymes BRCA1 or BRCA2. Previously, we found that obesity was positively associated with DNA damage in breast epithelium from BRCA mutation carriers. Furthermore, factors secreted by obese breast adipose tissue stimulated DNA damage in BRCA mutant breast epithelial cells, suggesting a cross-talk between breast epithelial cells and the adipose tissue that surrounds them. We hypothesized that leptin, a hormone secreted in abundance by obese adipose tissue, may be a driver of DNA damage and/or decrease capacity for DNA repair in breast epithelial cells. If true, this would provide a molecular target for intervention to reduce the risk of tumor formation in this high-risk population of women. Methods: RNA-seq followed by Ingenuity Pathway Analysis (IPA) was conducted on primary breast epithelial organoids isolated from lean and obese BRCA mutation carriers. Breast adipose tissue obtained from lean and obese women were cultured as explants for 24 hours to produce lean and obese conditioned media (CM). The effect of leptin on DNA damage was assessed in a non-cancerous breast epithelial cell line (MCF10A) carrying a heterozygous BRCA1 mutation. Immunofluorescence staining of the DNA damage marker ƴH2AX was carried out after treatment with leptin (100ng-800ng), CM, or CM+leptin antibody, used to neutralize leptin. To test whether leptin affects DNA repair capacity, BRCA1+/- MCF10A cells were treated with leptin or vehicle and then irradiated (1Gy) to induce DNA damage. Resolution of damage was quantified at 0, 0.5, 4, 12, and 24 hrs post-irradiation. Results: IPA analysis identified leptin signaling as significantly upregulated in breast epithelial organoids from obese women compared with lean women. Both obese CM and leptin treatment induced DNA damage in BRCA1+/- MCF10A cells while lean CM did not have this effect. Neutralizing leptin in obese CM was sufficient to inhibit obese CM-mediated induction of DNA damage. No significant difference was observed between leptin or vehicle treatments on DNA repair capacity after irradiation of BRCA+/- MCF10A cells. Conclusions: These data identify leptin, an adipose-derived hormone, as a novel driver of DNA damage in breast epithelial cells. To date, no studies have elucidated the molecular mechanisms that explain the increased penetrance of breast cancer in obese BRCA mutation carriers compared to lean BRCA mutation carriers. This work suggests that leptin may be a mediator of the link between obesity and breast cancer development in this population. Further studies are warranted to determine if targeting the leptin signaling axis will be an effective risk reduction strategy in BRCA mutation carriers who have excess adiposity.
Long Intergenic Non Coding RNA and MicroRNA Profiles of Pheochromocytoma and Paraganglioma as Prognostic Biomarkers
Authors: Ghosal Suman
Published: May 2021

microRNAs (miRNAs) and long intergenic noncoding RNAs (lincRNAs) have been reported as important markers for many cancers. In search of new markers for the metastatic or aggressive phenotypes in the neuroendocrine tumor pheochromocytomas and paragangliomas (PCPG), we analyzed the non-coding transcriptome from patient gene expression data in The Cancer Genome Atlas. We used differential expression analysis and an elastic-net machine-learning model to identify miRNA and lincRNA transcriptomic signature specific to PCPG molecular subtypes. Similarly, miRNAs and lincRNAs specific to aggressive PCPGs were identified, and univariate and multivariate analysis were performed for identifying factors associated with metastasis-free survival. Upregulation of 13 lincRNAs and 4 miRNAs was found to be associated with aggressive/metastatic PCPGs. RT-PCR validation in tumor samples from PCPG patients confirmed the overexpression of 4 miRNAs and 4 lincRNAs in metastatic compared to non-metastatic PCPGs. Kaplan-Meier analysis identified 3 miRNAs and 5 lincRNAs as prognostic markers for metastasis-free survival of patients in PCPGs. In a multivariate Cox regression analysis combining these miRNA and lincRNA expression signatures with the previously identified clinically relevant parameters like SDHB germline mutation, ATRX somatic mutation, tumor location and hormone secretion phenotypes, we identified the miRNA miR-182 and lincRNA HIF1A-AS2 as independent predictors of poor metastasis-free survival. We formulated a risk-score model using multivariate analysis of lincRNA and miRNA expression profiles, presence of SDHB and ATRX mutations, tumor location, and hormone secretion phenotypes. Stratification of PCPG patients with this risk-score showed significant differences in metastasis-free survival.
Molecular Genetics in a Cohort of Patients With Concurrent PTC and Melanoma
Authors: Joshi Tripti , Gupta Ruta , Olaya A Luisa Fernanda , Yu Bing , McLennan Susan , Chua Elizabeth Lian
Published: May 2021

PTC and melanoma are known to harbour common mutations, but this has not been extensively investigated. Targeted therapies for BRAF and PD-L1 have been used for melanoma and there are ongoing clinical trials for use of PD-L1 inhibitors in PTC but its utility is uncertain. Additionally, many of these patients have multiple cancers, so, whether they have a tumour predisposition syndrome is also unclear. Both germline and somatic mutations in BRCA1-associated protein 1 (BAP1) are associated with a wide spectrum of tumours. We hypothesized that a common genetic link may be present in our cohort of patients who have both PTC and melanoma.

The aim of this study was to elucidate molecular genetics, specifically BRAF, NRAS, KRAS, KIT using OncoFocus Mass Array System as well as expression of PD-L1 and BAP1, using a standard antibody (SP263) and C-4 respectively, in an Australian cohort with concurrent PTC and melanoma.

In our cohort of 21 patients (43% females, all Caucasian), melanoma was diagnosed about 8 years prior to PTC (50.3 ± 18.3 vs. 58.6 ± 12.8 years). The most common mutation was BRAFV600E seen in 88% of PTC, followed by NRAS mutation in 12% of PTC. Majority of the PTC (68%) stained negative for PD-L1. There was no significant association between PD-L1 tumour status and clinicopathologic outcomes. Interestingly, majority of multifocal, bilateral and both bilateral and multifocal PTC were PD-L1 negative (85%,69% and 69% respectively, P<0.05); only extrathyroidal extension was found to be associated with positive (≥1%) PD-L1 staining (83.3 vs.30.8; p=0.057). Regarding melanoma, clinicopathologic and mutation data were obtained for 15/21 patients and 8/15 patients respectively. Superficial spreading type of melanoma was present in 50% patients. The BRAFV600E and NRAS mutation were present in 3/8 patients each, and 2/8 patients had no mutations. PD-L1 staining was negative in 7/12 (58%) of melanoma tissues. Of the 5 cases that stained positive for PD-L1, 4 were at >25%, a much higher degree of staining compared to PTC group. Among 7 patients where data were available for both tissues, concordant mutations were found in only 2 patients (both BRAFV600E). In addition, 11 of the 21 patients had at least one other cancer apart from PTC and melanoma. Nine of the 11 patients who had more than one cancer were BRAF positive. BAP1 staining was retained in the majority of PTCs and melanoma tissues, indicating no loss of BAP1 protein.

PTC and melanoma both share molecular markers including BRAF, NRAS, PD-L1 as shown in our cohort. This is the largest study describing the mutation status of both PTC and melanoma. It is also the only study describing the PD-L1 and BAP1 expression in PTC and melanoma. BRAFV600E was the most common mutation. Majority of the PTC and melanoma stained negative for PD-L1. BAP1 expression was retained in both either PTC and melanoma tissues thus making presence of BAP1 tumour predisposition syndrome unlikely.
Taking Advantage of the TGFB1 Biology in Differentiated Thyroid Cancer to Stimulate Sodium Iodide Symporter (NIS)-Mediated Iodide Uptake in Engineered Mesenchymal Stem Cells
Authors: Han Yang , Koehler Viktoria F , Schwenk Nathalie , Schmohl Kathrin A , Spellerberg Rebekka , Kitzberger Carolin , Nelson Peter J , Spitzweg Christine
Published: May 2021

The sodium iodide symporter (NIS) mediates the active transport of iodide into thyroid follicular cells, providing the basis for the use of radioiodide for diagnostic imaging and therapy of differentiated thyroid cancer and also non-thyroidal tumors after tumor-selective NIS gene transfer. Based on their excellent tumor-homing capacity, mesenchymal stem cells (MSCs) can be employed as tumor-selective NIS gene delivery vehicles. Transgenic expression of NIS in genetically engineered MSCs allows noninvasive imaging of functional NIS expression as well as therapeutic application of 131I. The use of promoters activated by tumor micromilieu-derived signals to drive NIS expression enhances selectivity and effectiveness, while limiting potential off-target effects. In this study we aimed to exploit the central role of transforming growth factor B1 (TGFB1) in tumor milieu-associated signaling using a TGFB1-inducible synthetic SMAD-responsive promoter to selectively drive NIS-transgene expression in engineered MSCs (SMAD-NIS-MSC) in the context of differentiated thyroid cancer based on the critical role of TGFB1 in the pathogenesis of radioiodine refractory differentiated thyroid cancer. To evaluate the TGFB1 expression in thyroid cancer cell lines, the TGFB1 concentration in conditioned medium (CM) from an array of established human papillary thyroid cancer (PTC) cell lines (BCPAP and K1) was measured by ELISA. BCPAP-CM showed a higher concentration of TGFB1, while a lower concentration was measured in K1-CM. Stimulation of SMAD-NIS-MSCs with PTC-CM showed a significant increase of NIS-mediated radioiodide-125 uptake in these MSCs in vitro. In addition, iodide uptake in SMAD-NIS-MSCs was significantly stimulated by co-culture with thyroid cancer cells. Cell migration assay was performed to validate the effect of PTC-CM in MSC recruitment. MSCs subjected to a gradient between tumor CM and serum free medium showed a directed chemotaxis towards CM with increased forward migration index (FMI) and center of mass (CoM). In a next step, based on the in vitro studies, SMAD-NIS-MSCs will be systemically applied via the tail vein to mice harboring subcutaneous PTC tumors and tumoral iodide uptake will be monitored by 123I-scintigraphy. Taken together, these data indicate the feasibility of commandeering TGF-β/SMAD signaling in the TGFB1-rich tumor environments of radioiodine refractory differentiated thyroid carcinomas to re-establish functional NIS expression using engineered mesenchymal stem cells as therapy vehicles.
VERU-111: An Oral Tubulin Inhibitor That Suppresses Taxane-Sensitive and Taxane-Resistant Breast Cancer
Authors: Deng Shanshan , Krutilina Raisa I , Parke Deanna , Chen Hao , Miller Duane D , Li Wei , Seagroves Tiffany Nicole
Published: May 2021

Triple negative breast cancer (TNBC) patients have poorer overall prognosis relative to patients diagnosed with other molecular subtypes due to rapid onset of drug resistance to conventional chemotherapies and increased risk of visceral metastases. The microtubule inhibitor paclitaxel (Taxol, a taxane) is a frontline therapy for advanced breast cancer. We evaluated in TNBC models the preclinical safety and efficacy of a novel, potent, and orally bioavailable tubulin inhibitor, VERU-111, a tubulin inhibitor targeting the colchicine binding site. VERU-111 showed potent anti-proliferative and anti-migratory activity against several taxane-sensitive and taxane-resistant TNBC breast cancer cell lines. Based on these observations, taxane-resistant HER2+ cell lines were generated, and were also found to be responsive to VERU-111 treatment. In vivo, orally administered VERU-111 inhibited MDA-MB-231 tumor growth in a dose-dependent manner with antitumor potency similar to paclitaxel, and repressed metastases originating from the mammary fat pad or following tail vein injection. In contrast, in a MDA-MB-231 paclitaxel-resistant (TxR) subline, tumor growth was refractory to paclitaxel whereas VERU-111 significantly inhibited primary tumor growth and reduced lung and liver metastases. VERU-111 was then tested in a luciferase-labeled, multidrug resistant patient-derived xenograft (PDX) TNBC model. VERU-111 significantly inhibited HCI-10 PDX tumor growth and suppressed the expansion of axillary lymph node metastases present prior to initiation of therapy while suppressing lung, liver, bone and kidney metastases at study endpoint. Moreover, in contrast to paclitaxel, VERU-111 therapy did not cause a significant decrease in mouse body weight during treatment. Evaluation of efficacy of VERU-111 in taxane-sensitive and -resistant HER2+ xenograft models is in progress. Overall, we conclude that VERU-111 is a new generation orally bioavailable tubulin inhibitor that potently inhibits the growth of taxane-sensitive and taxane-resistant breast cancers with reduced adverse side effects relative to paclitaxel. Importantly, VERU-111 is well-tolerated in patients as evaluated in phase I/II clinical trials for advanced prostate cancer patients (NCT03752099). We propose that VERU-111 will be an effective second line therapy for patients with advanced breast cancer who progress on taxane-based therapeutic regimens.
Double the Battle: Two Cases of Irreversible Endocrinopathies in Patients Already Fighting Metastatic Cancer
Authors: Petrenko Olesya , Stucky Nicholas
Published: May 2021

Immune Checkpoint Inhibitors (ICI) have been approved since 2011 to treat patients with advanced solid and hematological malignancies and have had remarkable results. However, case reports of endocrine adverse events are becoming increasingly reported and can be fatal if not recognized early. Here we present two unique cases of rare endocrinopathies after the use of ICIs. A 47 year old male with metastatic melanoma presented with nausea, vomiting, polyuria, polydipsia of 5 days. Three weeks prior, he was started on nivolumab and ipilimumab. On presentation, he was tachycardic and tachypneic. Lab work was remarkable for a glucose of 676, Na 129, K 6.2, CO2 6, Cr 2.43 (baseline of 1.1) and beta-hydroxybutyrate of 11.7 with elevated HgA1c of 7.1%. DKA was diagnosed and fluids and insulin drip were started. Further work up revealed a normal cortisol level, TFTs and C-peptide <1 consistent with new-onset type I diabetes mellitus in the setting of two ICI agents. Patient was started on insulin regimen. An 81 year old female with metastatic bladder cancer on Pembrolizumab was admitted with 2 weeks of fatigue, positional dizziness and dyspnea. She recently presented with hyperkalemia attributed to dehydration. On admission, she was hypotensive with a blood pressure of 81/59 with normal heart rate and no fever. She had dry mucous membranes on exam but no abnormal skin. Further work up revealed an AM cortisol of <1, ACTH of 458 and positive Cosyntropin stim test, consistent with primary adrenal insufficiency. CT-Abdomen Pelvis did not reveal any acute adrenal masses. She was started on hydrocortisone at discharge with fludrocortisone due to hypotension. ICIs are categorized as target programmed death-1 receptor inhibitors (PD-1) nivolumab, pembrolizumab, cemiplimab, programmed death-ligand 1 inhibitors (PDL1) atezolizumab, avelumab, durvalumab and cytotoxic T-lymphocyte associated protein-4 (CTLA-4) iplimumab. Immune checkpoint proteins are T-cell surface receptors that cause inhibition when they bind to their ligands to limit the immune response. Tumors manipulate these inhibitory pathways to evade rejection. ICIs no longer halt the immune response and result in effective cancer treatment. However, a robust immune response can go on to attack healthy tissue resulting in endocrinopathies such as hypophysitis, hypo-or hyperthyroidism, diabetes mellitus or adrenal insufficiency. Acute hypocortisolemia or thyroid storm can be fatal if not identified acutely. Current guidelines recommend baseline screening with TFTs, morning cortisol and ACTH and screening monthly thereafter in patients on ICIs. In this report, we present two unique cases of irreversible endocrinopathies in patients treated with ICI who developed type I diabetes and primary adrenal insufficiency. These cases warn physicians to be vigilant with patients on ICI and consider the possibility of life-threatening endocrinopathies.
Adrenal Crisis in Long Term Use of Exogenous Steroid With Inappropriate Tapering off Process
Authors: Oktavia Nani , Pratiwi Chici , Nasaruddin Jerry , Mokoagow Muhammad Ikhsan , Epriliawati Marina , Kshanti Ida Ayu
Published: May 2021

Background: Adrenal crisis is an emergency condition in endocrinology that commonly found in primary adrenal insufficiency but also occur in chronic adrenal insufficiency triggered by various conditions such as sepsis, infection, trauma, burns, surgery, and myocardial infarction. In chronic adrenal insufficiency, adrenal crisis can be induced by excessive reductions or inadequate discontinuation of steroid treatment.

Case Illustration: A 40-year old-man admitted with chief complaint abdominal pain since seven days before admission. He felt pain in the umbilical area and slowly radiated to all the part of abdomen. Other than that, he also felt nausea, had vomitus, fever, and constipation for five days. He was immobilized for four months, with muscles weakness and atrophy. He was diagnosed with Focal Segmented Glomerulosclerosis and had a high dose of methylprednisolone (48 mg) for 6 months, 40 mg for the next 2 months and methylprednisolone 12 mg for the last 2 months. The last two month, he began to have severe general weakness and hypotension. On physical examination we found hypotension, fever (38.1o C), pale conjunctiva, moon face, buffalo hump, slightly distended and tenderness of abdomen, normal bowel sound, and purple striae all over the abdomen and extremities. On laboratory examination, Hb was 8.2 (n 11.7 – 15.5 g/dl), leukocytes 10,400 (5.00 – 10.00 x 103/μL), Na 123 (n 135 – 147 mmol/L), random blood glucose 74 (n 70 – 140 mg/dL). On abdominal X ray, there was prominent faecal material and no signs of ileus. No sign of infection found in urinalysis. He had sodium correction, packed red cell transfusion, symptomatic therapy including laxative, methylprednisolone 12 mg, but no improvement of signs and symptoms beside be able to defecate. The abdominal ultrasound gave a normal result. The morning cortisol level was then examined, with the result 14.4 (n 3.7–19.4). The patient was then diagnosed with adrenal crisis based on the clinical manifestations and had hydrocortisone therapy 100 mg a day for 2 consecutive days. After hydrocortisone administration, the symptoms improved, no fever and abdominal pain, he had normotension, increased sodium level 132 (n 135 – 147 mmol/L) and blood glucose level 118 (n 70 – 140 mg/dL). On the third day the patient discharged with oral hydrocortisone 15 mg in the morning and 10 mg in the afternoon.

Conclusion: Adrenal crisis was generally found in primary adrenal insufficiency but could also occur in secondary adrenal insufficiency due to inappropriate tapering off process of long term glucocorticoid use.
Adrenal Insufficiency Presenting as Hypoglycemia & Hyponatremia in a Patient With Liver Cirrhosis; Hepatoadrenal Syndrome
Authors: Farrukh Hina , Mehrab Amina , Khan Abeera
Published: May 2021

Hepatoadrenal syndrome is described as a progressive impairment in the adrenocortical reserve in advanced liver disease resulting in relative adrenal insufficiency (AI). This can present as critical hypoglycemia and hyponatremia as in the case described.

54 year old male with past medical history of hypothyroidism, pericardial effusion, liver cirrhosis and prior alcohol use disorder presented to the hospital with altered mental status. He felt lethargic and complained of recurrent diarrhea for a month. His blood sugar was 30 mg/dl (n=70–140 mg/dl) for which he received dextrose and his mentation improved. He was hypothermic with stable vitals otherwise. There was no skin hyperpigmentation. Labs demonstrated sodium of 123 mmol/L (n=136–145 mmol/L) and pancytopenia. TSH, ammonia, renal and hepatic functions were within normal limits except mildly elevated AST and total bilirubin. Total protein, albumin, HDL, Insulin and cortisol levels were low. Hepatitis panel was negative. CT Chest, abdomen and pelvis revealed massive abdominopelvic ascites, hepatic cirrhosis and splenomegaly. Adrenal glands appeared normal. Urine studies were consistent with salt-wasting nephropathy. Patient was started on intravenous fluids as well as dexamethasone. Diagnostic and therapeutic paracentesis was performed. Cosyntropin stimulation test revealed a baseline AM cortisol of 2.0 ug/dl (n=4.3–22.4 ug/dl), 30 min value of 4.0 ug/dl and 60 min value of 5.8 ug/dl (n=18-22ug/dl). Delta cortisol level was also low. Treatment with hydrocortisone was initiated until ACTH levels became available. To rule out sarcoidosis, ACE levels were obtained, which were normal. Dihydroxy 1,25 Vitamin D levels were low. ACTH returned as 21.7 pg/ml (n=7.2–63.3 pg/ml). 21 hydroxylase antibody was negative. MRI brain with IV contrast demonstrated no pituitary mass or abnormality. Blood cultures, body fluid cultures, AMA and ASMA were negative. Anti- tTG and Anti Gliadin antibodies were positive confirming celiac disease. Patient was started on gluten free diet which resolved his diarrhea. He responded well to steroids however, he remained intermittently confused which was thought to be related to hypoglycemic brain injury. Patient was converted to hydrocortisone PO 20 mg in AM and 10 mg in PM and advised to follow up outpatient with endocrinologist and gastroenterologist.

Hepatoadrenal syndrome is an important differential to consider in patients with liver disease presenting with hypoglycemia and hyponatremia. It is a potentially life-threatening condition requiring immediate treatment and appropriate work up. The condition improves with corticosteroid replacement therapy.

Reference: Anastasiadis SN, Giouleme OI, Germanidis GS, Vasiliadis TG. Relative adrenal insufficiency in cirrhotic patients. Clin Med Insights Gastroenterol. 2015;8:13–17. Published 2015 Mar 2. doi:10.4137/CGast.S18127
Adrenal Mass Hemorrhage Clinically Mimicking a Pheochromocytoma
Authors: Panjawatanan Panadeekarn , Daniyal Muhammad , Delgado Hurtado Juan Jose
Published: May 2021

Background: A pheochromocytoma is diagnosed clinically using correlation of clinical, imaging, and laboratory studies. We report the case of an adrenal mass hemorrhage that presented with significantly elevated urine metanephrines mimicking a pheochromocytoma.

Clinical Case: A 59-year-old healthy woman presented to the ED with chest pain, left flank and upper quadrant pain associated with diaphoresis and palpitations. Vital signs were significant for a pulse of 92 bpm, and a BP of 213/88 mm Hg. Physical exam revealed tenderness to palpation on the left upper quadrant and left costovertebral angle. Laboratory tests were significant for an elevated D-dimer (2,449 ng/mL, reference range 215–499 ng/mL). CT abdomen with IV contrast showed a 3.5 x 2.9 cm round mass abutting the lateral limb of the left adrenal gland with surrounding fat stranding with suspicion of inflammation or hemorrhage. 24-hour urine metanephrines showed elevated metanephrine (7,227 mcg/24hr; reference range <400 mcg/24 hr) and normetanephrine (1,209 mcg/24hr; reference range 900 mcg/24 hr). In the setting of up trending cardiac enzymes and inferior-lateral ST segment depression, a cardiac catheterization was performed which was unrevealing. She was discharged from the hospital and referred to endocrinology. On that visit, ~ 1 month after the patient was admitted to the hospital, plasma metanephrines were ordered which showed mildly elevated plasma metanephrine (0.83 nmol/L; reference range <0.5 nmol/L) and normetanephrine (1.2 nmol/L; reference ranges <0.9 nmol/L). An MRI abdomen with and without contrast revealed a 2.7 x 2.2 x 1.8 cm nodule arising from the lateral limb, with loss of signal on in-phase images suggestive of blood products. Plasma metanephrines and MRI findings ruled out the diagnosis of a pheochromocytoma.

Conclusion: To our knowledge, few cases of an adrenal mass hemorrhage clinically mimicking a pheochromocytoma have been reported. Although the inpatient clinical presentation of our patient was consistent with this, the outpatient plasma metanephrines and MRI were not. An adrenal adenoma hemorrhage should be considered as a potential differential diagnosis for elevated metanephrines, which can clinically mimick a pheochromocytoma.

References: (1)Sekos K, Short T, Ing SW. Adrenal hemorrhage due to hypercoagulable state mimicking pheochromocytoma. Journal of Clinical and Translational Endocrinology: Case Report. 8. 9–12. 2018.(2)Wordsworth S, Thomas B, Agarwal N, Hoddell K, Davies S. Elevated urinary cathecholamines and adrenal haemorrhage mimicking phaechromocytoma. BMJ Case Reports. 2010.
Aldosterone/Direct Renin Concentration Ratio Versus Aldosterone/Plasma Renin Activity for Diagnosis of Primary Hyperaldosteronism: Case Presentation
Authors: Shanik Michael Howard , Romao Isabela J , Velayati Sara
Published: May 2021

Aldosterone/Direct Renin concentration ratio versus Aldosterone/Plasma renin activity for diagnosis of Primary Hyperaldosteronism: Case presentation.

Introduction: Primary hyperaldosteronism (PA) is the most common cause of secondary hypertension. Endocrine Society guidelines recommend using aldosterone-to-renin ratio (ARR) for screening of PA1. This ratio can be obtained using two different methods. The first is plasma aldosterone concentration (PAC) divided by plasma renin activity. ARR greater than 20 is suggestive of PA. Further testing is required for confirmation. Due to limitations and challenges in obtaining PRA, another method of measurement was developed in which the direct renin concentration (DRC) is measured. There have been inconsistent recommendations regarding what ratio is appropriate using this assay to diagnose hyperaldosteronism. The aim of this case presentation is to review a patient with PA in whom both measurement methods were used and compared for screening.

Case Presentation: A 45-year woman with past medical history of Graves’ disease and hypertension presented with hypokalemia. Blood pressure was well-controlled on amlodopine for 3 years. PAC and DRC were measured. PAC was 21.2 ng/dL and DRC 2.8 pg/ml with ARR 7.6. This was repeated and confirmed (PAC 19.6 ng/dL and DRC 3.9 pg/ml with ARR 5). Plasma Renin Activity (PRA) was measured. PAC was 36.3 ng/dL and PRA was 0.19 ng/ml/hr (ARR 191), suggestive of hyperaldosteronism. Further workup including a CT scan of the abdomen with IV and oral contrast demonstrated an enhancing 1.8 cm nodule in the left adrenal gland. Adrenal vein sampling was performed. Left adrenal vein aldosterone level was 1400 ng/dl and on the right, 33.1 ng/dl. The patient was treated with left laparoscopic adrenalectomy. The pathological evaluation of the specimen demonstrated a 2.5 cm adenoma of benign etiology. Later follow-up showed the patient was normokalemic with PAC of 3.1.

Conclusion: Patients with PA despite controlled hypertension, experience higher rates of cardiovascular events, hence early and accurate diagnosis is essential. PRA measurement has multiple limitations including inter-laboratory variations, higher cost, availability in only advanced laboratories and values influenced by blood pressure medications. Therefore, some institutions have replaced it with direct renin concentration (DRC) which is cheaper and more widely available. DRC has limitations with fewer positive ARR results. When the clinical suspicion is high, PRA is the more precise study to calculate ARR. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. John W. Funder, Robert M. Carey, Franco Mantero, et al. The Journal of Clinical Endocrinology & Metabolism, Volume 101, Issue 5, 1 May 2016, Pages 1889–1916, https://doi.org/10.1210/jc.2015–4061.
Bilateral Pheochromocytoma Due to Von Hippel Lindau With Adrenal-Sparing Adrenalectomy in a Child
Authors: Hilk Kelly , Agrawal Anurag K , Cadenas Nicola , Roman Sanziana , Srivastava Priya S , Yen Kevin , Lodish Maya Beth
Published: May 2021

Background: More than 40% of pediatric pheochromocytoma or paragangliomas have associated underlying genetic germline mutation. (1) Clinical Case: We present an 8-year-old male who arrived the emergency department with hypertension to 170/115. MRI of the abdomen revealed bilateral well demarcated adrenal masses with central necrosis. Urine metanephrines showed elevated normetanephrine of 15244 µg/24 hr (reference range, 58 - 670 µg/24 hr) and normal urine metanephrines. Urinary vanillylmandelic acid was mildly elevated 35 mg/gCr and homovanillic acid was normal. MIBG scan revealed increased radiotracer activity correlating to the bilateral adrenal masses without evidence of metastasis. Diagnosis of bilateral pheochromocytomas was made. Genetic testing revealed a novel, heterozygous, pathogenic variant of VHL tumor suppressor gene, consistent with Von Hippel-Lindau syndrome. Perioperative blockade was achieved with prazosin, amlodipine, and metoprolol. Due to low likelihood of metastasis in pheochromocytomas due to VHL, adrenal sparing bilateral adrenalectomy was attempted and resulted in 15% sparing of left adrenal gland vs radial bilateral adrenalectomy. (2) Clinical Lessons: 1. Endocrine etiologies of hypertension, although rare, are important causes of hypertension in the pediatric population. 2. Genetic testing prior to surgical intervention could determine surgical course and preservation of adrenals. 3. A multidisciplinary approach to care and referral to a center with experienced surgery, oncology, nephrology, endocrinology, anesthesiology, critical care and genetics is crucial to maximizing outcomes with pheochromocytoma. Reference: 1. NGS in PPGL (NGSnPPGL) Study Group, Toledo RA, Burnichon N, Cascon A, Benn DE, Bayley JP, Welander J, Tops CM, Firth H, Dwight T, Ercolino T, Mannelli M, Opocher G, Clifton-Bligh R, Gimm O, Maher ER, Robledo M, Gimenez-Roqueplo AP, Dahia PL. Consensus Statement on next-generation-sequencing-based diagnostic testing of hereditary phaeochromocytomas and paragangliomas. Nat Rev Endocrinol. 2017 Apr;13(4):233–247. 2. King KS, Prodanov T, Kantorovich V, Fojo T, Hewitt JK, Zacharin M, Wesley R, Lodish M, Raygada M, Gimenez-Roqueplo AP, McCormack S, Eisenhofer G, Milosevic D, Kebebew E, Stratakis CA, Pacak K. Metastatic pheochromocytoma/paraganglioma related to primary tumor development in childhood or adolescence: significant link to SDHB mutations. J Clin Oncol. 2011 Nov 1;29(31):4137–42.
Efficacy of Treatment With PARP Inhibitor and Immunotherapy for Aggressive Adrenocortical Carcinomawith Cushing’s Syndrome Refractory to Treatment With EDP Chemotherapy and Mitotane
Authors: Greb Alexandra C , Reikes Andrew R
Published: May 2021

A 39-year-old female with a past medical history of Ehlers-Danlos syndrome, Celiac disease, Hashimoto’s hypothyroidism and germline BRCA mutation presented with abdominal pain and distension. CT imaging demonstrated innumerable bilateral pulmonary nodules concerning for metastases, paraoesophageal adenopathy, multiple right adrenal masses, left adnexal cyst, and a small sclerotic lesion within the right iliac bone. CT guided biopsy of a 6 cm right adrenal mass revealed high grade carcinoma with areas of necrosis, and tumor markers were positive for synaptophysin, Melan-A and inhibin but negative for TTF1 and CK7, HMB45 and S100. A diagnosis of stage IV adrenocortical carcinoma was made and, at the time of diagnosis, a 24-hour urinary cortisol was elevated at 791.4 mcg (nl<45.0 mcg). Surgery was deferred given widespread metastatic disease. She initially completed 4 cycles of chemotherapy with EDP-Mitotane along with Metyrapone to normalize her urine cortisol. Subsequent restaging CT imaging revealed a mixed response to chemotherapy with new focal sclerotic areas in the left fifth rib concerning for new metastases.

Due to suboptimal initial therapeutic response, less traditional treatment options were explored. PARP inhibitor and immunotherapy were considered, and she received Rucaparib followed by two cycles of Ipilimumab and Nivolumab, resulting in a limited response and complicated by reversible myocarditis likely due to immunotherapy. Further restaging CT imaging demonstrated disease progression, and patient then completed one month of Cisplatin and Etoposide and palliative radiation to the right adrenal tumor all while continuing Mitotane and Metyrapone. Her most recent restaging CT images indicated further disease progression. She was then transitioned to Sorafenib, Mebendazole, and Sulindac daily for CTNNB1 mutation with plans to rechallenge with a different PARP inhibitor (Olaparib) for BRCA1 mutation. Most recently, patient has self-discontinued Mitotane due to intolerable side effects. In conclusion, a highly aggressive adrenocortical carcinoma associated with Cushing’s syndrome was treated with PARP inhibitor and immunotherapy, after initial failure with a traditional EDP+Mitotane regimen, with limited benefit.

References:

1. Berruti A, Terzolo M, Sperone P, et al. Etoposide, doxorubicin and cisplatin plus mitotane in the treatment of advanced adrenocortical carcinoma: a large prospective phase II trial. Endocr Relat Cancer. 2005;12(3):657–666. doi:10.1677/erc.1.010252.

2. Mohan DR, Lerario AM, Hammer GD. Therapeutic Targets for Adrenocortical Carcinoma in the Genomics Era. J Endocr Soc. 2018;2(11):1259–1274. Published 2018 Sep 26. doi:10.1210/js.2018-00197
Hypercalcemia in an Infant With Pseudohypoaldosteronism Type 1
Authors: Jeng Henry , Broussard Julia Rodica
Published: May 2021

Background: Pseudohypoaldosteronism type 1 (PHA1) is an aldosterone resistance syndrome due to insensitivity of target tissues to aldosterone action, with supraphysiologic aldosterone and renin levels. PHA1 presents usually in infancy and is divided into autosomal dominant (AD) and autosomal recessive (AR) form. A secondary form of PHA1 associated with UTI and/or renal malformations was described. In AD PHA1, salt loss is due to renal mineralocorticoid resistance while hyponatremia in AR PHA1 is caused by multi-organ salt loss. PHA1 has variable signs/symptoms associated with hyponatremia and hyperkalemia; thus, this clinical picture can be attributed to more common conditions such as dehydration, poor feeding, congenital adrenal hyperplasia. Clinical Case: A 5-month old male was admitted for airway evaluation. He was a 23-week gestation preemie, with chronic lung disease, failure to thrive. Patient was found to have hyponatremia, hyperkalemia, high FeNa of 1.3% (intrinsic renal disease) and elevated BUN/Cr (92/1.15). Renal US found echogenic kidneys with poor cortical medullary differentiation suggesting renal disease. Further evaluation noted high aldosterone (1700 ng/dL) and renin (400 ng/mL/hr) levels. He was placed on low protein formula to help optimize BUN level. Baby was diagnosed with secondary PHA1 due to renal disease and started on NaCl supplementation. This led to normalization of BUN, creatinine and improvement in electrolytes. Patient also had high serum calcium ranging from 11.1 to 12.0 mg/dL. Hyponatremia, hyperkalemia, hypercalcemia could be attributed to possible CAH, however state screen and ACTH stimulation test were normal. Further workup showed high 25-OH-vitamin D > 99 ng/mL, PTH 46.9 pg/mL, phosphorous 5.4 mg/dL and 1,25-OH-vitamin D 63.1 pg/mL. Urine Ca/cr ratio was 0.522. Vitamin D supplementation was stopped and daily total fluids increased. Subsequently, there was improvement in serum Ca at 10.9 mg/dL and 25-OH Vitamin D of 74 pg/mL. Next Generation Sequencing (NGS) was carried out, with a focus on the etiology of persisting hypercalcemia, including familial forms of hypercalcemia and Williams Syndrome. NGS revealed a likely pathogenic variant, c.2365 + 2T>C (p.?), in NR3C2, consistent with a diagnosis of AD PHA 1. Conclusion: This is a case of AD PHA1, marked by renal mineralocorticoid receptor resistance associated with persisting hypercalcemia. Initial hypercalcemia could be explained by hypervitaminosis D. It is important to note that electrolyte abnormalities, including persistent hypercalcemia, could be also secondary to the kidney disease found on renal US. There are only few reports of hypercalcemia in patients with PHA1 in the literature. In children with electrolyte abnormalities and failure to thrive, monitoring of serum and urine electrolytes would facilitate early accurate diagnosis and timely treatment.
Limited Efficacy of Mifepristone Due to Poor Tolerance: A Clinical Challenge in Managing Cortisol Excess
Authors: Mora Osoria Gabriel Jose , Marin Luis Norberto Madera , Cruz Alegyari Figueroa , Torres Yineli Ortiz , Garcia-Mateo Jose M
Published: May 2021

A 53-year male with incidental bilateral adrenal masses along with symptoms of proximal muscle weakness, anxiety, and depression. Past medical history of uric acid nephrolithiasis, hypertension, hyperlipidemia, type 2 diabetes mellitus, anxiety, and depression. A right adrenal mass of 2.8cm and a left adrenal mass of 1.5cm both of <10 HU on non-enhancing CT. Hormonal activity workup was ordered which showed cortisol levels of 4.7mcg/dL on 1mg ONDST suggestive of autonomous cortisol excess and workup for primary hyperaldosteronism was negative. On follow up CT adrenal masses remained stable, but the patient underwent the annual hormonal workup for incidentaloma with 1mg ONDST and found with cortisol 4.5mcg/dL, eventually repeated with 2-day LDDST which showed no suppression of cortisol with levels at 4.5 mcg/dL confirming the diagnosis of autonomous cortisol excess. ACTH found to be suppressed at 3.1pg/dL (7.2–63.3 pg/dL) which helped confirm the diagnosis of non-ACTH dependent autonomous cortisol excess. Referred to surgery evaluation due to complications associated with cortisol excess as osteoporosis and uncontrolled hyperglycemia however surgical intervention was deferred until the source of cortisol excess could be identified within the bilateral adrenal masses and it was recommended to continue with medical therapy.

As the cortisol excess source cannot be identified by localizing procedures and despite adequate medical therapy and stable adrenal masses on imaging, patient persisted with uncontrolled DM/hypertension and worsening BMD in the spine and hip with surgery not being an option. The patient was started on glucocorticoid receptor antagonist mifepristone in which upon reevaluation weakness and fatigue were noticeable along with hypokalemia of 3.1mmol/L after 2 weeks of therapy that was eventually replaced but 2 weeks later the patient discontinued therapy as he could not tolerate side effects related to adrenal insufficiency associated with mifepristone, such as weakness, fatigue, and dependence of potassium supplementation due to hypokalemia.

This effect is physiologically important, because cortisol binds as avidly as aldosterone to the mineralocorticoid receptor, and the plasma cortisol concentration is approximately 100-fold higher than the plasma aldosterone concentration and it can lead to hypokalemia by the mechanism of apparent mineralocorticoid excess. Also, as mifepristone blocks cortisol action, the levels of ACTH and cortisol increase so high that hormonal measurement cannot be used to judge either therapeutic efficacy or adrenal insufficiency, we must go based on signs and symptoms.
Metastatic Adrenocortical Carcinoma Co-Secreting Multiple Steroid Hormones
Authors: Lee Tien-Hao , Galagan Robert
Published: May 2021

Background: Adrenocortical carcinoma is a rare disease which may be complicated by co-secretion of multiple steroid hormones.

Clinical Case: A 53- year-old female was discovered to have 1 cm left and 1.7 cm right adrenal nodules by Chest CT scan in 2004. She had a follow-up abdominal CT scan in 2011 revealing enlargement of the left adrenal mass to 5.7 cm and a stable 1.8 cm right adrenal nodule. A laparoscopic left adrenalectomy was performed in 2012 and the surgical pathology diagnosis was benign adrenal hyperplasia. In 5/2016 the patient developed left abdominal pain and a CT scan revealed a 1.7 cm mass in the left adrenalectomy surgical bed, a 1.4 cm nodular density adjacent to the left diaphragm and the stable 1.8 cm right adrenal nodule. 6/2016 lab tests: 24 hr urinary cortisol 15 ug/24 hr (<50 μg/24hr), aldosterone 8.7 ng/dL (<31 ng/dL), renin activity 0.7 ng/ml/hr (0.5–4 ng/mL/hr) and DHEA-S 94 ug/dL (32–240 μg/dL). A re-examination of the 2012 surgical pathology resulted in an addendum diagnosis of an adrenal cortical neoplasm of indeterminate malignant potential. In 1/2018 she underwent an exploratory laparotomy with surgical resection of the 1.7 cm mass in left paracolic gutter and biopsy of numerous small retro-peritoneal and multiple liver lesions. Pathology revealed metastatic adrenocortical carcinoma with low grade mitotic activity (3 mitoses per 10 HPF) and intermediate grade Ki-67 (15–25%). 5/2018 lab results: 1. aldosterone 20 ng/dL, 2. renin activity 0.2 ng/mL/hr and 3. testosterone 34 ng/dL (<75 ng/dL). Mitotane was started in 06/2018 but was discontinued in 9/2018 due to side effects. In 3/2020 she was hospitalized for generalized weakness and was discovered to be severely hypokalemic K+ 1.5 mmol/L (3.6–5.2 mmol/L) with an aldosterone of 300 ng/dL and renin activity of 0.1 ng/mL/hr. She was treated with IV KCl to correct her hypokalemia and was discharged on oral KCl 20 meq bid and spironolactone 50 mg bid. She was readmitted to the hospital on 10/12/2020 after a near-syncopal event and lab tests revealed a K+ of 1.4, aldosterone 508 ng/dL, renin activity 0.7 ng/mL/hr, AM cortisol 13.6 μg/dL (5–20 ug/dL), testosterone 161 ng/dL, and DHEA-S 377 ug/dL, indicating co-secretion of multiple steroid hormones. Her hypokalemia was treated with IV KCl and her spironolactone dose was increased to 100 mg bid.

Conclusion: This case report details the rare occurrence of an adrenocortical carcinoma which was hormonally silent but eventually metastasized and became hormonally active, co-secreting multiple steroid hormones with a predominance of aldosterone. Serial adrenal hormone lab profiles are important for optimal management of patients with this disease.
Mifepristone (Korlym ®) Use Interferes With Accurate Serum Measurement of Sex Steroids
Authors: Uwaifo Gabriel Ikponmosa
Published: May 2021

Introduction: Mifepristone (MFP) aka RU-486/Korlym is a synthetic steroid analog originally developed in 1980 as an abortifacient that is now used in the management of Cushing’s syndrome (CS). It is both a progesterone (PG) and glucocorticoid (GC) receptor blocker. CS is often associated with reproductive functional anomalies including hypogonadism, menstrual irregularities and infertility. Due to its mode of action, measurement of serum PG and/or cortisol in patients on MFP are inaccurate indices of systemic PG and/or GC deficiency or excess. However, the potential impact of MFP use on other serum steroid assays has not been widely studied. We report the case of a 55 yr old man on treatment with MFP for adrenal CS found to have striking artefactual changes in serum androgen and estrogen levels. Case Summary: A 55 yr old African American man was referred with poorly controlled type 2 diabetes, hypertension, hyperlipidemia, obesity and untreated hypogonadism. He had a 3.2cm left adrenal incidentaloma associated with adrenal CS and he chose medical management rather than surgery. Upon starting MFP at 300mg QD serum total estrogen (by radio-immunoassay; RIA) and estradiol (by chemiluminescence immunoassay; CIA) were markedly elevated while serum total, free, bioavailable testosterone and dihydrotestosterone were all markedly reduced. His HBA1c, weight and energy levels improved on MFP despite these findings. The serum steroid levels normalized to pre-treatment levels after stopping MFP for ~ 4weeks but the changes recurred after restarting therapy. After MFP dose escalation to 300mg BID the serum steroid levels normalized after stopping MFP for ~ 6 weeks. The artefactual low testosterone levels also occured with measurement by equilibrium dialysis but “normal accurate” results were obtained when measured by liquid chromatography-Tandem mass spectrometry (LC-TMS). He remains on MFP 300mg BID without need for androgen repletion. Discussion: With increased use of MFP for CS, indices for tracking its clinical and biochemical effects assume great importance. There are few reports of the possible effects of MFP on estrogen and testosterone serum assays despite its touted low cross reactivity with sex steroids. Our case suggests that the significance, extent and prevalence of artefactual changes on serum sex steroid assays may be underestimated and under- appreciated. Conclusions: Our case of wide disparities in serum estrogen and androgen measures in a patient on MFP indicates that caution needs to be exercised in the interpretation of such results in patients on current MFP therapy. Our clinical observations suggest depending on the dose that a wash out period of 4–6 weeks is required to ensure accurate measures. Studies to ascertain the prevalence of this artefactual effect are needed and it appears testosterone measurement by LC-TMS obviates the testosterone assay artefact.
Not Your Typical Low T - Hypogonadism From a Feminizing Adrenal Carcinoma
Authors: Patel Reshma , Angell Trevor E
Published: May 2021

Introduction: Adrenocortical Carcinoma (ACC) is a rare disease, with an incidence of 0.7–2 cases per million people. Approximately 80% of ACC tumors are functional, with the majority of tumors secreting glucocorticoids, however a small proportion concurrently secrete androgens in addition to glucocorticoids. Here, we describe a case of ACC presenting with feminization, without clinical evidence of Cushing’s syndrome.

Case Description: A 35 year old male with no significant history presented with sudden onset non-radiating, 7/10, abdominal pain 4 days prior to admission. On exam, the patient had diffuse tenderness to palpation in the right upper quadrant without other abdominal findings. He also was noted to have palpable breast tissue bilaterally. Upon persistent questioning, he reported an 8-month history of gradual breast development, decreased libido and decreased morning erections. He had no history of hypertension, headaches, diabetes, palpitations, flushing, sweating, weight gain, striae, bruising, or muscle weakness. Diagnostic CT imaging of the abdomen and pelvis showed a 14 cm right adrenal mass without invasion or lymphadenopathy. Laboratory testing showed a total testosterone of 37 ng/dL (reference range:249–846 ng/dL), estradiol of 181 pg/mL (8–43 pg/mL), prolactin of 14.5 ng/ml (4.0–15.2), and FSH and LH were both <0.1 mIU/mL. Serum metanephrines and normetanephrines, renin and aldosterone showed no evidence of excess secretion. Urine free cortisol measurement was 111mcg over 24 hrs (<50 mcg/24hr) and ACTH was <1.0 pg/mL (7.2–63.3 pg/mL). Surgical resection was performed with histopathologic diagnosis of an 18cm ACC confined to the adrenal gland. Post-surgical prophylactic hydrocortisone replacement was given. At outpatient follow-up, testing revealed normalization of his estradiol and testosterone levels. The patient had no clinical evidence of adrenal insufficiency and plans were made to assess endogenous adrenal function.

Conclusion: This case highlights the importance of discussing symptoms of hypogonadism, virilization or feminization with patients in detail when evaluating for ACC. Careful history and physical exam may be key to identifying sex hormone excess and prompting preoperative workup. In this case of a feminizing ACC, pre-surgical assessment allows for estrogen to be as a marker of tumor progression. A sex steroid producing ACC should be evaluated for cortisol secretion as prompt detection can avoid post-operative adrenal insufficiency.