Day Twelve, Cushing’s Awareness Challenge 2015

Today’s Cushing’s Awareness Challenge post is about kidney cancer (renal cell carcinoma). You might wonder how in the world this is related to Cushing’s. I think it is, either directly or indirectly.

I alluded to this yesterday when I said:

I finally started the Growth Hormone December 7, 2004.
Was the hassle and 3 year wait worth it?
Stay tuned for tomorrow, April 12, 2015 when all will be revealed.

So, as I said, I started Growth Hormone for my panhypopituitarism on December 7, 2004.  I took it for a while but never really felt any better, no more energy, no weight loss.  Sigh.

April 14 2006 I went back to the endo and found out that the argenine test that was done in 2004 was done incorrectly. The directions were written unclearly and the test run incorrectly, not just for me but for everyone who had this test done there for a couple years. My endo discovered this when he was writing up a research paper and went to the lab to check on something.

So, I went off GH again for 2 weeks, then was retested. The “good news” was that the argenine test is only 90 minutes now instead of 3 hours.

Wow, what a nightmare my argenine retest started! I went back for that Thursday, April 27, 2006. Although the test was shorter, I got back to my hotel and just slept and slept. I was so glad that I hadn’t decided to go home after the test.

Friday I felt fine and drove back home, no problem. I picked up my husband for a biopsy and took him to an outpatient surgical center. While I was there waiting for the biopsy to be completed, I started noticing blood in my urine and major abdominal cramps.

There were signs all over that no cellphones were allowed so I sat in the restroom (I had to be in there a lot, anyway!) and I left messages for several of my doctors on what I should do. It was Friday afternoon and most of them were gone 😦  I finally decided to see my PCP after I got my husband home.

When Tom was done with his testing, his doctor took one look at me and asked if I wanted an ambulance. I said no, that I thought I could make it to the emergency room ok – Tom couldn’t drive because of the anaesthetic they had given him. I barely made it to the ER and left the car with Tom to park. Tom’s doctor followed us to the ER and instantly became my new doctor.

They took me in pretty fast since I was in so much pain, and had the blood in my urine. At first, they thought it was a kidney stone. After a CT scan, my new doctor said that, yes, I had a kidney stone but it wasn’t the worst of my problems, that I had kidney cancer. Wow, what a surprise that was! I was admitted to that hospital, had more CT scans, MRIs, bone scans, they looked everywhere.

My new “instant doctor” felt that he wasn’t up to the challenge of my surgery, so he called in someone else.  My next new “instant doctor” came to see me in the ER in the middle of the night.  He patted my hand, like a loving grandfather might and said “At least you won’t have to do chemotherapy”.  And I felt so reassured.

It wasn’t until later, much after my surgery, that I found out that there was no chemo yet that worked for my cancer.  I was so thankful for the way he told me.  I would have really freaked out if he’d said that nothing they had was strong enough!

My open radical nephrectomy was May 9, 2006 in another hospital from the one where the initial diagnosis was made. My surgeon felt that he needed a specialist from that hospital because he believed preop that my tumor had invaded into the vena cava because of its appearance on the various scans. Luckily, that was not the case.

My entire left kidney and the encapsulated cancer (10 pounds worth!) were removed, along with my left adrenal gland and some lymph nodes. Although the cancer (renal cell carcinoma AKA RCC) was very close to hemorrhaging, the surgeon believed he got it all.

He said I was so lucky. If the surgery had been delayed any longer, the outcome would have been much different. I will be repeating the CT scans every 3 months, just to be sure that there is no cancer hiding anywhere. As it turns out, I can never say I’m cured, just NED (no evidence of disease). This thing can recur at any time, anywhere in my body.

I credit the argenine re-test with somehow aggravating my kidneys and revealing this cancer. Before the test, I had no clue that there was any problem. The argenine test showed that my IGF is still low but due to the kidney cancer I couldn’t take my growth hormone for another 5 years – so the test was useless anyway, except to hasten this newest diagnosis.

So… either Growth Hormone helped my cancer grow or testing for it revealed a cancer I might not have learned about until later.

My five years are up now.  My kidney surgeon *thinks* it would be ok to try the growth hormone again.  I’m still a little leery about this, especially where I didn’t notice that much improvement.

 

What to do?

 

Time to Recovery of Adrenal Function After Curative Surgery for Cushing’s Syndrome Depends on Etiology

Address all correspondence and requests for reprints to: Martin Reincke, MD, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1, D-80336 Munich, Germany. E-mail: .

Successful tumor resection in endogenous Cushing’s syndrome (CS) results in tertiary adrenal insufficiency requiring hydrocortisone replacement therapy.

The aim was to analyze the postsurgical duration of adrenal insufficiency of patients with Cushing’s disease (CD), adrenal CS, and ectopic CS.

We performed a retrospective analysis based on the case records of 230 patients with CS in our tertiary referral center treated from 1983–2014. The mean follow-up time was 8 years.

We included 91 patients of the three subtypes of CS undergoing curative intended surgery and documented followup after excluding cases with persistent disease, pituitary radiation, concurrent adrenostatic or somatostatin analog treatment, and malignant adrenal disease.

The probability of recovering adrenal function within a 5 years followup differed significantly between subtypes (P = .001). It was 82% in ectopic CS, 58% in CD and 38% in adrenal CS. In the total cohort with restored adrenal function (n = 52) the median time to recovery differed between subtypes: 0.6 years (interquartile range [IQR], 0.03–1.1 y) in ectopic CS, 1.4 years (IQR, 0.9–3.4 y) in CD, and 2.5 years (IQR, 1.6–5.4 y) in adrenal CS (P = .002). In CD the Cox proportional-hazards model showed that the probability of recovery was associated with younger age (hazard ratio, 0.896; 95% confidence interval, 0.822–0.976; P = .012), independently of sex, body mass index, duration of symptoms, and basal ACTH and cortisol levels. There was no correlation with length and extend of hypercortisolism or postoperative glucocorticoid replacement doses.

Time to recovery of adrenal function is dependent on the underlying etiology of CS.

Day 3 Coverage of ENDO 2015

ENDO_2015

 

OR24-Adrenal Tumors: Clinical Implications of the Recent Molecular and Genetic Findings

Long term follow-up of a pivotal phase 2 study of Ultratrace® Iobenguane I-131 (AZEDRA) in patients with malignant relapsed/refractory pheochromocytoma/paraganglioma
C Jimenez, DA Pryma, DC Sullivan, JK Schwarz, RB Noto, N Stambler, T Armor, JD Jensen, RJ Israel


OR27-Hyperandrogenic Ovarian Dysfunction — Winner: Outstanding Abstract Award

The neurokinin B receptor antagonist AZD4901 decreases LH and testosterone secretion in women with PCOS: A randomized, double-blind, placebo-controlled clinical trial
JT George, R Kakkar, J Marshall, ML Scott, R Finkelman, T Ho, S McIntosh, JD Veldhuis, RA Anderson, L Webber


OR28-Lipids – Liver, Muscle, and Patient Bench to Bedside

Diagnosing familial hypercholesterolemia (FH) in the United States: Results from the CASCADE FH patient registry
Z Ahmad, C Newman, E O’Brien, P Shrader, EM deGoma, CD Ahmed, PM Moriarty, MRF Linton, MD Shapiro, PB Due, CM Ballantyne, WA Neal, D Duffy, L Hudgins, LC Hemphill, JA Underberg, KE Watson, SS Gidding, S Baum, K Wilemon, D Pickhardt, I Kindt, DJ Rader, M Roe, JW Knowles


OR30-Neuroendocrinology

Assessment of primary cancers in growth hormone-treated pediatric patients compared to population databases: An epidemiological analysis of a large, multinational, prospective observational study
CJ Child, AG Zimmermann, N Jia, LL Robison, JH Bramswig, WF Blum


Hypophysitis in the age of cancer immunotherapy: Experience in a large cancer center
MJoelle Pitteloud, R Dadu, ME Cabanillas, K Shah, MI-N Hu, MA Habra, SG Waguespack


OR34-Testosterone Replacement Therapy: Risks and Benefits

The association between testosterone use and major adverse cardiovascular events (MACE): An exploratory retrospective cohort analysis of two large, contemporary, coronary heart disease clinical trials
S Janmohamed, G Cicconetti, CE Koro, RV Clark, E Tarka


Oral Presentations in Reproductive Science–Winner: Oral Abstract Award in Reproductive Science

Effects of androgens and estrogens on cardiometabolic parameters in young adult men
EW Yu, H Lee, S-AM Burnett-Bowie, SC Hirsch, G Abrishamian-Garcia, LF Borges, DW Goldstein, AP Taylor, KE Wulczyn, AF Moore, JS Finkelstein


PP27-Hyperandrogenic Ovarian Dysfunction

Role of insulin resistance and hyperandrogenemia in early vascular dysfunction in adolescents with PCOS
SK Bartz, MC Caldas, R Krishnamurthy, R Krishnamurthy, FF Bacha


SAT 379-412-Cushing’s Syndrome

Does a normal urine free cortisol result rule out Cushing’s syndrome?
ST Sharma, LK Nieman


SAT 418-443-Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus

Clinical and molecular differences between invasive and non-invasive pituitary adenomas
DA Cano, M Mendez-Muros, E Venegas, N Gros, E Dios, N Garcia-Hernandez, A Madrazo-Atutxa, I Martin-Scheffer, E Cardenas, A Kaen, F Roldan, A Soto-Moreno

Hypothalamus-Pituitary- Adrenal Axis

I am a huge fan of Coursera.  This lecture is on the HPA Axis.

You may have to sign up/log in to view this video but Coursera is free – and you might find other courses of interest!

https://www.coursera.org/learn/physiology/lecture/DceZ9/hypothalamus-pituitary-adrenal-axis

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