Research meetingResearch meeting

Cushing´s disease long term F/U aftCushing´s disease long term F/U after TSAer TSA

Endogenous Cushing´s syndrome anEndogenous Cushing´s syndrome and adipokined adipokine

Hook effect in MacroprolactinomaHook effect in Macroprolactinoma Tertiary hyperparathyroidism of oncoTertiary hyperparathyroidism of onco

genic osteomalaciagenic osteomalacia

Cushing´ s disease Cushing´ s disease Long-term F/U after Long-term F/U after

TSATSA

Cushing´s diseaseCushing´s disease Incidence: 0.7 ~ 2.4 cases/million/yrIncidence: 0.7 ~ 2.4 cases/million/yr If untreated, increased mortality & morbiditIf untreated, increased mortality & morbidit

y(from vascular disease)y(from vascular disease) Tx of choice: TSA(70-90%)Tx of choice: TSA(70-90%) but, not all patients are but, not all patients are cured by this procedure.cured by this procedure. Criteria of remission: variableCriteria of remission: variable

What is a marker for successfWhat is a marker for successful TSA in cushing´s disease?ul TSA in cushing´s disease?

Predictors of outcomePredictors of outcome

Preoperative variables( not significantly inflPreoperative variables( not significantly influence long-term remission rates) uence long-term remission rates) adenoma sizeadenoma size preoperative cortisol concentration preoperative cortisol concentration pretreatment with cortisol lowering agents pretreatment with cortisol lowering agents

The success of the surgery depends on the The success of the surgery depends on the skill & experience of the surgeonskill & experience of the surgeon

Long-term predictive value of postsurgical cortisoLong-term predictive value of postsurgical cortisol concentrations for cure & risk of recurrence in Cl concentrations for cure & risk of recurrence in Cushing´s diseaseushing´s disease

-J Clin Endocrinol Metab.2003-J Clin Endocrinol Metab.2003→→Cortisol predicting remission:5Cortisol predicting remission:5 ㎍㎍ /dL at 3 mo after surge/dL at 3 mo after surge

ryry Postoperative plasma cortisol levels predict long-Postoperative plasma cortisol levels predict long-

term outcome in patients with Cushing´s disease term outcome in patients with Cushing´s disease & determine which pateints should be treated wit& determine which pateints should be treated with pituitary irradiation after surgeryh pituitary irradiation after surgery

-Endocr J.2001-Endocr J.2001→→if, postop (3~8wks) plasma cortisol>2 if, postop (3~8wks) plasma cortisol>2 ㎍㎍ /dL/dL pituitary irradiation is effective in preventing relapse..pituitary irradiation is effective in preventing relapse..

The use of postoperative ACTH levels as a markeThe use of postoperative ACTH levels as a marker for successful transsphenoidal microsurgery in r for successful transsphenoidal microsurgery in Cushing´s diseaseCushing´s disease

-Zentralbl Neurochir. 2003-Zentralbl Neurochir. 2003→→Postop ACTH(<10~20ng/dL) within the first 7 days after sPostop ACTH(<10~20ng/dL) within the first 7 days after s

urgery: early marker for complete removal of an ACTH adeurgery: early marker for complete removal of an ACTH adenoma & indicators for long-term outcomenoma & indicators for long-term outcome

Treatment of recurred CushingTreatment of recurred Cushing´s disease?´s disease?

Persistent & recurrent hypercortisolism after tranPersistent & recurrent hypercortisolism after transsphenoidal surgery for Cushing´s diseasessphenoidal surgery for Cushing´s disease

-Acta Neurochir Suppl.1996-Acta Neurochir Suppl.1996Reoperation in recurrent Cushing´s dz:remission 70.8%Reoperation in recurrent Cushing´s dz:remission 70.8%Early reoperation:56.3%Early reoperation:56.3%→→In recurrent hypercortisolism, reoperation recommended eIn recurrent hypercortisolism, reoperation recommended e

ven when no tumor visible in MRI..ven when no tumor visible in MRI..→→if reoperation fails, RTx indicated..if reoperation fails, RTx indicated..→→if all Tx failed, bilateral adrenalectomy proposed..if all Tx failed, bilateral adrenalectomy proposed..

The Long-Term Outcome of Pituitary Irradiation after UnsucThe Long-Term Outcome of Pituitary Irradiation after Unsuccessful Transsphenoidal Surgery in Cushing´s disease cessful Transsphenoidal Surgery in Cushing´s disease

-NEJM. J Estrada.1997-NEJM. J Estrada.1997

F/U: 42 monthsRemission: 25/30(83%)6~60 months after radiation

→Pituitary irradiation is effective & well-tolerated Tx after unsuccessful TSA..

Long-term effects of ketoconazole in the treatmeLong-term effects of ketoconazole in the treatment of residual or recurrent Cushing´s disease nt of residual or recurrent Cushing´s disease

-Endocr J. Chou SC. 2000-Endocr J. Chou SC. 2000-ketoconazole 200~1200mg/day-ketoconazole 200~1200mg/day-65, 83, 86 month F/U-65, 83, 86 month F/U-24hr urine FC : 114~143-24hr urine FC : 114~143 ㎍㎍ /24h/24h-F/U MRI: no significant changes-F/U MRI: no significant changes

→→Ketoconazole is valuable in the long-term Tx of residual or Ketoconazole is valuable in the long-term Tx of residual or recurrent Cushing´s Dz (unsuccessful surgery)recurrent Cushing´s Dz (unsuccessful surgery)

ObjectiveObjective

Analyse the outcome following surAnalyse the outcome following surgery in our centre.gery in our centre.

Patients & methodsPatients & methods 1990~20041990~2004 38 pts with cushing´dz undergone TSA.38 pts with cushing´dz undergone TSA.

M=11(29%)M=11(29%) F=27(71%)F=27(71%) Mean age=32.8yr(19~51yr)Mean age=32.8yr(19~51yr)

BMI, BP, medication.BMI, BP, medication. Tumor size, Name of operation, BiopsyTumor size, Name of operation, Biopsy Basal cortisol/ACTH/24hr urine FCBasal cortisol/ACTH/24hr urine FC Post OP #7, cortisol/ACTH/FCPost OP #7, cortisol/ACTH/FC Post OP # 1 month, cortisol/ACTH/FCPost OP # 1 month, cortisol/ACTH/FC Remission: 24hr urine FCRemission: 24hr urine FC Duration of remissionDuration of remission

Remission was defined asRemission was defined as Regression of symptoms & signs of Cushing´ s Regression of symptoms & signs of Cushing´ s

syndromesyndrome Normal urinary cortisol excretionNormal urinary cortisol excretion

ComparisonComparison Recurred Cushing´dz groupRecurred Cushing´dz group Remission groupRemission group

ResultsResults

Cushing´s dz undergone TSA(n=38)Cushing´s dz undergone TSA(n=38) Remission(n=18)Remission(n=18)

M=4M=4 F=14F=14 F/U:mean 4.7yrs (8 month~11 yrs)F/U:mean 4.7yrs (8 month~11 yrs)

Recurrence(n=20)(52%)Recurrence(n=20)(52%) M=7M=7 F=13F=13 Interval:28.5 month (2 month~7.4 yr)Interval:28.5 month (2 month~7.4 yr)

Remission RecurrenceRemission RecurrenceSexSex(M/F) 4/14(77%) 7/13(65%)(M/F) 4/14(77%) 7/13(65%)AgeAge(yr) 33.5(±8.5) 35.5(±12.5)(yr) 33.5(±8.5) 35.5(±12.5)BMI BMI 27.27(±3.7) 27.62(±3.5) 27.27(±3.7) 27.62(±3.5)BPBP(sys) 153.3(±13.7) 147.3(±12.4)(sys) 153.3(±13.7) 147.3(±12.4)DM DM 0/17 5/21 0/17 5/21TumorTumor(( ㎜㎜ ) 7.6(±4.7) 6.8(±3.8)) 7.6(±4.7) 6.8(±3.8)(Macroadenoma) 2 cases 1 case(Macroadenoma) 2 cases 1 caseS-cortisol(S-cortisol( ㎍㎍ /dL)/dL) (basal) 26.95 (±15.1) 31.09(±11.3)(basal) 26.95 (±15.1) 31.09(±11.3)(postop#7) (postop#7) 5.7(±6.7) 18.34(±20.4)5.7(±6.7) 18.34(±20.4)S-ACTHS-ACTH(basal) 131.8(±186) 88.19(±65.18)(basal) 131.8(±186) 88.19(±65.18)(postop#7) 22.9(±20) 33.40(±22.19)(postop#7) 22.9(±20) 33.40(±22.19)OP OP hemihypophysectomy 4 hemihypo 2hemihypophysectomy 4 hemihypo 2 GTR 4 NTR 1,STR 1,GTR 16GTR 4 NTR 1,STR 1,GTR 16

ResultsResults

Recurred cushing 20 명

Surgery 7 명 RTx 8 명 Ketoconazol 2 명GKS 3 명

Remission 5 명(6mo~10yr)

RTx 2 명 (4yr7mo,5yr)

Remission 2 명(~3yr)

Recur 1 명 ( 약물 )4yr,7yr 유지

Remission7 명(~13yr)F/U loss 1 명

ConclusionConclusion

The rate of recurrence in cushing´s dz after The rate of recurrence in cushing´s dz after TSA : 52%TSA : 52%

Postoperative hypocortisolemia is good indPostoperative hypocortisolemia is good indicator of cure..icator of cure..

Pituitary irradiation is effective after unsucPituitary irradiation is effective after unsucessful TSA or in recurred disease.essful TSA or in recurred disease.

Cushing´s syndrome and adipoCushing´s syndrome and adipokinekine

IntroductionIntroduction

The wt gain & visceral obesity ass with CushThe wt gain & visceral obesity ass with Cushing´s syn has been linked to elevated plasming´s syn has been linked to elevated plasma leptin levels, although the mechanism is ua leptin levels, although the mechanism is unknown..nknown..

- J Endocrinol Invest.2000- J Endocrinol Invest.2000 - Horm Metab Res. 1996- Horm Metab Res. 1996 -J Clin Endocrinol Metab 1998-J Clin Endocrinol Metab 1998

Interleukin-1 Rec Antagonist is associated wiInterleukin-1 Rec Antagonist is associated with fat distribution in endogenous Cushing´s sth fat distribution in endogenous Cushing´s s

yndromeyndrome-J Clin Endocrinol & metab.2003-J Clin Endocrinol & metab.2003

--Hypothalamic effects of leptin on fHypothalamic effects of leptin on food intake are mediated ood intake are mediated

by IL-1by IL-1-Interactions among the hypothala-Interactions among the hypothala

mic-pituitary-adrenal axis, leptimic-pituitary-adrenal axis, leptin, IL-1 systemn, IL-1 system

LeptinLeptin Leptin production is regulated by a variety Leptin production is regulated by a variety

of hormones & chemicals both of hormones & chemicals both inin vivovivo & & in in vitrovitro Up-regulated:by insulin, glucocorticoids, neuroUp-regulated:by insulin, glucocorticoids, neuro

peptide Ypeptide Y Down-regulated:by cAMP or thiazolidinedione dDown-regulated:by cAMP or thiazolidinedione d

erivativeserivatives

Interactions between insulin & glucInteractions between insulin & glucocorticoid in leptin regulationocorticoid in leptin regulation

Synergism between insulin & cortisol in promotinSynergism between insulin & cortisol in promoting leptin expression has been noted in vitro.g leptin expression has been noted in vitro.

-Wabitsch et al.1996-Wabitsch et al.1996 Similarly, in vivo, insulin also promotes a dexameSimilarly, in vivo, insulin also promotes a dexame

thasone induced rise in serum leptin.thasone induced rise in serum leptin. -Laferrere et al.1998-Laferrere et al.1998

AdiponectinAdiponectin

apM1 gene productapM1 gene product Plasma adiponectin level ↓Plasma adiponectin level ↓

ObesityObesity Type 2 DMType 2 DM HypertensionHypertension LypodistrophiesLypodistrophies

Possible regulation of adiponectin by glucoPossible regulation of adiponectin by glucocorticoidscorticoids

Plasma adiponectin response to hydrocortisoPlasma adiponectin response to hydrocortisone 25mgne 25mg-Eur-Eur J Endocrinol.2004J Endocrinol.2004

11 obese Cushing´ pts11 obese Cushing´ pts 10 non-obese Cushing´ pts10 non-obese Cushing´ pts Sex, age, BMI, Waist circ. glucose, Sex, age, BMI, Waist circ. glucose,

insulin, lipidinsulin, lipid 가 가 matchingmatching 되는 되는 controlcontrol군과 비교함군과 비교함 ..

Similar levels of adiponectin in obese Cushing´pts Similar levels of adiponectin in obese Cushing´pts & obese controls:Obesity may act as a predominan& obese controls:Obesity may act as a predominan

t factor in masking t factor in masking

Relationship bwt urinary cortisol & plasma aRelationship bwt urinary cortisol & plasma adiponectin in non-obese Cushing´s patientsdiponectin in non-obese Cushing´s patients

Hormonal regulation of adiponectin gene expressHormonal regulation of adiponectin gene expression in 3T3-L1 adipocytes ion in 3T3-L1 adipocytes

--Biochemical & Biophysical Research Communicaions.2002Biochemical & Biophysical Research Communicaions.2002

->Dexamethasone has been shown to reduce ->Dexamethasone has been shown to reduce adiponectin gene expression in murine 3T3-L1 adiponectin gene expression in murine 3T3-L1 adipocytesadipocytes

Secretion of adiponectin & regulation of apM1 geSecretion of adiponectin & regulation of apM1 gene expression in human adipose visceral tissuene expression in human adipose visceral tissue

--Biochemical & Biophysical Research Communicaions.2001Biochemical & Biophysical Research Communicaions.2001

->Glucocorticoids negatively regulate adiponectin ->Glucocorticoids negatively regulate adiponectin mRNA in human visceral adipose tissuemRNA in human visceral adipose tissue

Adiponectin is stimulated by adrenalectomy in obAdiponectin is stimulated by adrenalectomy in ob/ob mice and is highly correlated with resistin m/ob mice and is highly correlated with resistin mRNARNA

-Am J Physiol Endocrinol metab. 2002-Am J Physiol Endocrinol metab. 2002

->Adiponectin expression in white adipose tissue is stim->Adiponectin expression in white adipose tissue is stimulated by adrenalectomy in ulated by adrenalectomy in ob/obob/ob mice mice

목적목적

쿠싱증후군 환자에서 치료전후의 쿠싱증후군 환자에서 치료전후의 cortisol, cortisol, BMI, fat distributionBMI, fat distribution 의 변화와 관련된 의 변화와 관련된 AdipAdipokine(adiponectin, Leptin)okine(adiponectin, Leptin) 의 변화 의 변화 상관관계를 알아보고자 함상관관계를 알아보고자 함 ..

대상 및 방법대상 및 방법 내인성 쿠싱환자와 이들과 내인성 쿠싱환자와 이들과 BMI matched BMI matched

정상대조군정상대조군 측정항목측정항목 :: 나이나이 , , 성별성별 , , 혈압혈압 , , 당뇨유무당뇨유무 , , 내인성 쿠싱의 원인내인성 쿠싱의 원인 신체계측신체계측 :: 치료전후의 치료전후의 BMI, Fat CT(visceral to suBMI, Fat CT(visceral to su

bcutaneous fat ratio)bcutaneous fat ratio) 혈액검사혈액검사

치료전후의 치료전후의 plasma leptin, adiponectin, cortisol, fastiplasma leptin, adiponectin, cortisol, fasting insulin, fasting glucose, urinary cortisol.ng insulin, fasting glucose, urinary cortisol.

정상 대조군에서의 정상 대조군에서의 plasma leptin, adiponectin, fastinplasma leptin, adiponectin, fasting glucose, fasting insulin.g glucose, fasting insulin.

High Dose Hook EffectHigh Dose Hook Effectin macroprolactinomain macroprolactinoma

““High dose hook effectHigh dose hook effect”” Large quantities of antigenLarge quantities of antigen in an immunoassay syste in an immunoassay syste

m m impair antigen-antibody bindingimpair antigen-antibody binding, resulting in , resulting in falsely lfalsely l

ow antigen determination (low hormone levels)ow antigen determination (low hormone levels)

Can be detected in macroprolactinomaCan be detected in macroprolactinoma

Non-functioning adenoma Non-functioning adenoma vs.vs. Prolactinoma Prolactinoma Nonfunctioning tumor : operation + RTNonfunctioning tumor : operation + RT

Prolactinoma : initial medical therapy Prolactinoma : initial medical therapy

(or operation + medical therapy)(or operation + medical therapy)

Reported in measurement of TSH, LH, Reported in measurement of TSH, LH, ββ-hCG, IgE, PS-hCG, IgE, PS

AA

Patients & Methods 1Patients & Methods 1

RetrospectiveRetrospective 1999 – 2003. 8 1999 – 2003. 8 Nonfunctioning adenoma patientsNonfunctioning adenoma patients Tumor Size : > 3.0 cm Tumor Size : > 3.0 cm Immunoradiometric assay (DPC kit)Immunoradiometric assay (DPC kit) N= 42 (M : 26, F : 16)N= 42 (M : 26, F : 16)

Patients & Methods 2Patients & Methods 2 ProspectiveProspective

2003.9 – 2004.32003.9 – 2004.3Nonfunctioning adenoma patients Nonfunctioning adenoma patients Tumor Size : > 3.0 cm Tumor Size : > 3.0 cm Immunoradiometric assay (DPC kit)Immunoradiometric assay (DPC kit)N=6 (M : 4, F : 2)N=6 (M : 4, F : 2)

ResultsResults

RetrospectiveN=42

ProspectiveN=6

PRL levels increaseafter surgery

N=4

PRL levels increaseafter dilution

N=1

Hook effect in macroadenoma5/48

ResultsResults

Non-functioning Hook effect

adenoma adenoma

N (%) 43/48(89.5%) 5/48(10.4%)

Sex (M/F) 25/18(58.1%)* 5/0(100%)

Age (yr) 48 ±13(14~74) 33±11(18~44)

Prolactin(ng/ml) 18(1~87)** 74(53~95)

Size (mm) 36 ± 10(30~70)* 46 ± 9(35~55)

*p<0.05 vs hook. **p<0.005 vs hook.

Macroprolactinoma

13

8/5(61.5%) *37±13(15~65)

3957(563~20000) **36 ± 9(30~60) *

Repeated test using another kitsRepeated test using another kits Daiichi IRMA, made in JapanDaiichi IRMA, made in Japan Biosource IRMA, made in FranceBiosource IRMA, made in France→→High dose hook effect is not observed..High dose hook effect is not observed..

SummarySummary The frequency of The frequency of ““Hook effectHook effect”” in non-functioning pituitary in non-functioning pituitary

macroadenomas(>3cm) : 10.4%(5/48) macroadenomas(>3cm) : 10.4%(5/48) The characteristics of the patients : male more likely,The characteristics of the patients : male more likely,

very large tumor (3.5 – 5.5cm)very large tumor (3.5 – 5.5cm)

In order to avoid the high dose hook effect, PRL shouIn order to avoid the high dose hook effect, PRL shou

ld be assayed in 1: 100 – 1: 200 or even higher dilutild be assayed in 1: 100 – 1: 200 or even higher diluti

ons of serum in all patients( esp, male) with large pitons of serum in all patients( esp, male) with large pit

uitary tumors..uitary tumors..

Remnant parathyroid infarction of Remnant parathyroid infarction of tertiary hyperparathyroidism inductertiary hyperparathyroidism induceded in oncogenic osteomalaciaeded in oncogenic osteomalacia

Factors implicated in Factors implicated in phosphate homeostasisphosphate homeostasis FGF23FGF23(fibroblast growth factor)↑:(fibroblast growth factor)↑:

Degraded by proteases such as PHEX/phex & furinDegraded by proteases such as PHEX/phex & furin Matrix extracellular phosphoglycoproteinMatrix extracellular phosphoglycoprotein↑↑

inhibits bone formation & mineralization inhibits bone formation & mineralization inadequately processed by PHEX in tumorinadequately processed by PHEX in tumor

FRP-4(Frizzled-related protein-4)↑FRP-4(Frizzled-related protein-4)↑ PHEXPHEX 14-3-314-3-3γγ peptide peptide*PHEX:phosphate-regulating gene with homologies to endopeptidases o*PHEX:phosphate-regulating gene with homologies to endopeptidases o

n the X chromosomen the X chromosome

RT-PCR for FGF23 from tumor tissue

Primers :Sense : 5’-TGGCCAGTGACCCATTAGGG-3’Antisense : 5’-TGAGGAAGGCGGTGAAACCC-3’

302 bp

RT(-

)

RT-P

CR