Doctors Use Microwave Therapy on Cushing’s Patient Too Weak to Have Surgery

Microwave therapy improved the Cushing’s syndrome of a woman whose lungs had almost failed, allowing her to have the adrenal surgery needed to control her disease, a case study showed.

Lung infections had led to her near-respiratory failure.

Cushing’s syndrome stems from the pituitary gland producing excessive amounts of adrenocorticotropic hormone. Too much of the hormone leads to the adrenal glands generating excessive amounts of another hormone, cortisol — and that overproduction results in Cushing’s. The disease’s symptoms include increasing obesity, skin problems, muscle weakness, bone loss, fatigue, cognitive difficulties, and an inability to control emotions.

Doctors often remove patients’ adrenal glands to prevent cortisol production. But in this case, the patient was not in good enough condition to have the surgery. So doctors used microwave technology to reduce her cortisol levels to the point where surgeons could operate.

The case study, published in BMJ Case Reports, was titled “Ectopic ACTH syndrome complicated by multiple opportunistic infections treated with percutaneous ablation of the adrenal glands.

Excessive pituitary gland production of adrenocorticotropic hormone is the cause of 80 percent of Cushing’s cases.

In 5 to 10 percent of cases, a tumor in another part of the body also produces the hormone, leading to excessive amounts of it in the body. When a tumor is generating the hormone, the condition is called ectopic ACTH syndrome. The patient in the case study had ACTH syndrome.

The 63-year-old woman had complained to her family doctor about weight gain, headache, weakness, and flushing. When laboratory tests led to her being diagnosed with ectopic ACTH-dependent Cushing’s syndrome, she was admitted to a hospital’s internal medicine department.

Doctors planned surgery to remove her adrenal glands, but two days before the operation was scheduled, respiratory failure sent her to the hospital’s Intensive Care Unit. There, physicians treated her for two infections in her lungs, plus infections in her blood and urinary tract. She experienced serious medical complications while in the Intensive Care Unit.

After a month, she was in good enough condition to leave intensive chair but too frail for surgery. Instead, doctors used microwaves to destroy as much of her adrenal glands as they could.

Within two weeks, her condition was better. She had been unable to leave her hospital bed while in intensive care. After the microwave treatment, she engaged in physiotherapy that led to her being able to use a two-wheeled walker to go short distances. She could also make short excursions outside the hospital with her family.

Six months later she returned to the hospital for surgical removal of her adrenal glands.

There were no complications from the operation, and doctors discharged her two days later. Her cortisol levels have been at acceptable levels since then.

“Our experience demonstrates that percutaneous ablation is a viable alternative in patients with ectopic ACTH syndrome in whom medical therapy has failed and surgical adrenalectomy is not feasible,” the researchers wrote. “Further research comparing the efficacy and complication rates between percutaneous ablation [microwave therapy] and surgical adrenalectomy is needed.” In addition, “research is needed to determine the optimal method of percutaneous intervention,” the team wrote.

From https://cushingsdiseasenews.com/2017/12/01/case-study-shows-microwave-therapy-helped-cushings-patient-who-was-too-frail-for-surgery/

Exophthalmos and Cushing’s Syndrome

A woman experienced red, irritated and bulging eyes. She saw an ophthalmologist who strongly suspected Graves’ ophthalmopathy. However, the patient did not have and never had hyperthyroidism.

Indeed, she had primary hypothyroidism optimally treated with levothyroxine. Her thyroid stimulating hormone level was 1.197 uIU/mL.

An MRI of the orbits showed normal extraocular muscles without thickening, but there was mild proptosis and somewhat increased intraorbital fat content. Both thyroid-stimulating immunoglobulins as well as thyrotropin receptor antibodies were negative.

The patient presented to her primary care physician a few months later. She had experienced a 40-lb weight gain over only a few months and also had difficult-to-control blood pressure.

After failing to respond to several antihypertensive medications, her primary care physician astutely decided to evaluate for secondary causes of hypertension. A renal ultrasound was ordered to evaluate for renal artery stenosis, and the imaging identified an incidental right-sided adrenal mass. A CT confirmed a 3.4-cm right-sided adrenal mass. Her morning cortisol was slightly high at 24.7 ug/dL (4.3 – 22.4) and her adrenocorticotropic hormone was slightly low at 5 pg/mL (10-60).

At this point I saw the patient in consultation. She definitely had many of the expected clinical exam findings of Cushing’s syndrome, including increased fat deposition to her abdomen, neck, and supraclavicular areas, as well as striae. Her 24-hour urine cortisol was markedly elevated at 358 mcg/24hrs (< 45) confirming our suspicions.

She asked me, “Do you think that my eye problem could be related to this?”

“I’ve not heard of it before,” I replied, “but that doesn’t mean there can’t be a connection. Wouldn’t it be wonderful if your eyes got better after surgery?”

The patient underwent surgery to remove what fortunately turned out to be a benign adrenal adenoma.

When we saw her in follow-up 2 weeks later, her blood pressures were normal off medication and her eye symptoms had improved. I had a medical student rotating with me, so I suggested that we do a PubMed literature search.

The first article to come up was a case report titled “Exophthalmos: A Forgotten Clinical Sign of Cushing’s Syndrome.” Indeed, not only did Harvey Cushing describe this clinical finding in his original case series in 1932, but others have reported that up to 45% of patients with active Cushing’s syndrome have exophthalmos.

The cause is uncertain but is theorized to be due to increased intraorbital fat deposition. Unlike exophthalmos due to thyroid disease, the orbital muscles are relatively normal — just as they were with our patient.

Some of you may have seen exophthalmos in your Cushing’s patients; however, this was the first time I had seen it. Just because one has not heard of something, does not mean it could never happen; no one knows everything. “When in doubt, look it up” is a good habit for both attending physicians and their students.

For more information:

Giugni AS, et al. Case Rep Endocrinol. 2013; 2013: 205208.

From http://www.healio.com/endocrinology/adrenal/news/blogs/%7B779bf3e5-e1da-459e-af27-955c9b4274a5%7D/thomas-b-repas-do-facp-face-cde/exophthalmos-and-cushings-syndrome

Cushing’s Syndrome is Hazardous to Your Health

morbidity

People with Cushing’s syndrome, even when treated, have higher morbidity and mortality rates that comparable controls. That is the conclusion of a new study published in the June issue of the Journal of Clinical Endocrinology Metabolism. The study by Olaf Dekkers et al, examined data records from the Danish National Registry of Patients and the Danish Civil Registration System of 343 patients with benign Cushing’s syndrome of adrenal or pituitary origin (i.e., Cushing’s disease) and a matched population comparison cohort (n=34,300).  Due to the lengthy delay of many patients being diagnosed with Cushing’s syndrome, morbidity was investigated in the 3 years before diagnosis while  morbidity and mortality were assessed during complete follow-up after diagnosis and treatment.

The study found that mortality was twice as high in Cushing’s syndrome patients (HR 2.3, 95% CI 1.8-2.9) compared with controls over a mean follow-up period of 12.1 years. Furthermore, patients with Cushing’s syndrome were at increased risk for:

  • venous thromboembolism (HR 2.6, 95% CI 1.5-4.7)
  • myocardial infarction (HR 3.7, 95% CI 2.4-5.5)
  • stroke (HR 2.0, 95% CI 1.3-3.2)
  • peptic ulcers (HR 2.0, 95% CI 1.1-3.6)
  • fractures (HR 1.4, 95% CI 1.0-1.9)
  • infections (HR 4.9, 95% CI 3.7-6.4).

The study also found that this increased multimorbidity risk was present before diagnosis indicating that it was due to cortisol overproduction rather than treatment.

Many of the Cushing’s syndrome patients underwent surgery to remove the benign tumor. For this group, the investigators performed a sensitivity analysis of the  long-term mortality and cardiovascular risk in this  subgroup (n=186)  considered to be cured after operation (adrenal surgery and patients with pituitary surgery in combination with a diagnosis of hypopituitarism in the first 6 months after operation).  The risk estimates for mortality (HR 2.31, 95% CI 1.62-3.28), venous thromboembolism (HR 2.03, 95% CI 0.75-5.48), stroke (HR 1.91, 95% CI 0.90-4.05), and acute myocardial infarction (HR 4.38, 95% CI 2.31-8.28) were also increased in this subgroup one year after the operation.

The standard treatment for endogenous Cushing’s syndrome is surgery. This past year, Signifor (pasireotide) was approved for treatment of adults patients with Cushing’s disease for whom pituitary surgery is not an option or has not been curative.  Cushing’s disease, which accounts for the majority of Cushing’s syndrome patients, is defined as the presence of an ACTH producing tumor on the pituitary grand. In the study by Dekker’s et al, the percentage of patients with Cushing’s disease is not known. We look forward to reexamination of this dataset in a few years following the introduction of more treatment options for Cushing’s disease as well as an analysis that explores the differences in mortality/morbidity rates in the different subsets of patients that make of Cushing’s syndrome (Cushing’s disease, ectopic Cushing’s syndrome, Exogenous Cyshing’s syndrome).

References

Dekkers OM, Horvath-Pujo, Jorgensen JOL, et al, Multisystem morbidity and mortality in Cushing’s syndrome: a cohort study. J Clin Endocrinol Metab 2013 98(6): 2277–2284. doi: 10.1210/jc.2012-3582

– See more at: http://www.raredr.com/medicine/articles/cushing%E2%80%99s-syndrome-hazardous-your-health-0

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