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ACTH increment post total bilateral adrenalectomy for Cushing’s disease: a consistent biosignature for predicting Nelson’s syndrome

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Abstract

Purpose

Nelson’s syndrome (NS) is regarded as an aggressive complication of total bilateral adrenalectomy (TBA) for Cushing’s disease (CD). This challenge may be addressed by using clinical criteria to guide frequency of neuroimaging to enable timely management of NS and also avoid unnecessary frequent imaging.

Methods

All patients (n = 43) with CD subjected to TBA over 35 years at a tertiary care centre were included. NS was defined as a newly appearing or expanding (> 2 mm) pituitary adenoma with or without ACTH levels exceeding 500 pg/ml. Pre-and post-TBA parameters like clinical symptomatology, cortisol, ACTH and radiology were analysed for the prediction of NS.

Results

NS developed in 39.5% (n = 17) patients with a median follow-up of 7 years. Half of them had new appearance, while rest had an expansion of pre-existing pituitary tumour. Majority (90%) had ACTH above 500 pg/ml. On Cox proportional hazards analysis, frequent discriminatory features of protein catabolism (≥ 4) (HR 1.15, CI 0.18, 7.06), proximal myopathy (HR 8.82, CI 1.12, 69.58) and annual ACTH increment of 113 pg/ml (HR 12.56, CI 1.88, 88.76) predicted NS. First post-operative year ACTH indices predicting NS included ACTH rise of 116 pg/ml and absolute ACTH of 142 pg/ml (sensitivity, specificity exceeding 90%). Annual ACTH increment exceeding 113 pg/ml, ≥ 4 discriminatory features and uncontrolled hypertension had the best overall prediction.

Conclusion

Patients who developed NS had higher rebound rise of ACTH following TBA and a more severe disease phenotype at baseline. Consistent ACTH increment can be used as a marker for predicting the development of NS.

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Abbreviations

NS:

Nelson’s syndrome

CD:

Cushing’s disease

CS:

Cushing’s syndrome

TSS:

Trans-sphenoidal surgery

TBA:

Total bilateral adrenalectomy

ACTH:

Adrenocorticotropic hormone

ONDST:

Overnight dexamethasone suppression test

LDDST:

Low dose dexamethasone suppression test

HDDST:

High dose dexamethasone suppression test

IRMA:

Immunoradiometric assay

ECLIA:

Electrochemiluminescence assay

CV:

Coefficient of variation

IQR:

Interquartile range

SD:

Standard deviation

UFC:

Urinary free cortisol

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Acknowledgements

We are highly indebted to late Prof Kanchan Kumar Mukherjee, who was instrumental in providing neurosurgical expertise as part of the treating team catering to these patients of Cushing’s disease at our centre. Unfortunately, he is no more with us but his legacy continues to live on.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Author information

Authors and Affiliations

  1. Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

    Liza Das, Anil Bhansali, Pinaki Dutta, Sanjay Kumar Bhadada & Rama Walia

  2. Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131, Naples, Italy

    Rosario Pivonello

  3. Department of Radiology, PGIMER, Chandigarh, India

    Chirag Kamal Ahuja

  4. Department of Urology, PGIMER, Chandigarh, India

    Ravimohan Mavuduru & Santosh Kumar

  5. Department of General Surgery, PGIMER, Chandigarh, India

    Arunanshu Behera

  6. Department of Histopathology, PGIMER, Chandigarh, India

    Uma Nahar Saikia

  7. Department of Neurosurgery, PGIMER, Chandigarh, India

    Sivashanmugam Dhandapani

Authors
  1. Liza Das
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Contributions

LD did data compilation and analysis, drafted the manuscript, edited it and reviewed the literature. AB edited the manuscript and supervised patient management. RP was involved in interpretation of data and editing the manuscript. PD edited the manuscript and supervised patient management. SKB supervised patient management. CA provided neuro-radiological expertise in terms of imaging interpretation and/or inferior petrosal sinus sampling. SK, RM and ARB did adrenal surgery. UNS performed histopathological analysis. SSD did pituitary surgery. RW conceived the study, managed the patients, collected the data, performed interpretation of data and statistical analysis and edited the manuscript.

Corresponding author

Correspondence to Rama Walia.

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Das, L., Bhansali, A., Pivonello, R. et al. ACTH increment post total bilateral adrenalectomy for Cushing’s disease: a consistent biosignature for predicting Nelson’s syndrome. Pituitary 23, 488–497 (2020). https://doi.org/10.1007/s11102-020-01047-x

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