Hypercortisolism

Question 1

What is the difference between cushing syndrome and disease?

Answer 1

Syndrome is Hypercortislism

Disease is an adrenal tumor

Question 2

What is seen clinically in Cushing Synd?

Answer 2

Purple Striae
Central obesity
Buffalo Hump

Question 3

What is Exogenous vs Endogenous Cushings?

Answer 3

Ex: Oral Prednisone for non endocrine diseases (ACTH independant)

Increased secretion

Question 4

What are the categories of Endogenous Cushings?

Answer 4

Pituitary/Hypothalamus/Ectopic Tumor

• Inc Cortisol
• Inc ACTH
• ACTH DEPENDANT

Adrenal Glands

• inc Cortisol
• inc ACTH
• ACTH INDEPENDANT

Question 5

What is the Cause of ACTH DEPENDANT Cushings?

Answer 5

Pituitary (CUSHING’S DIS) 90%
Ectopic ACTH 5-10%
Ectopic CRH rare

Question 6

What are the findings in Cushings due to Ectopic ACTH?

Answer 6

ELEVATED ACTH (5-10x > Cushings Disease)
Hirsuitism
Hyperpigmentation

Question 7

What are the types of endogenous ACTH-INDEPENDANT Cushings?

Answer 7

Unilateral Adrenal Disease:
-Adenoma
-Carcinoma
Bilateral Adrenal Disease
-Micronoduar hyperplasia
-Macronodular hyperplasia

Question 8

What is the Difference between Adrenal Adenoma and Adrenal CA?

Answer 8

AD: Unilateral, Well circumscribed, normal adrenal cortex histology

CA: Large, irreguar shaped nodules, 5-20cm, areas of hemorrhage/necrosis, nuclear pleomorphism/mititic figures, capsular and vascular invasion

Question 9

What is the Process for diagnosis of Cushing’s Syndrome?

Answer 9

1. Confirm Hypercortisol
2. Determine Subtype
3. Localize source of overprod

Question 10

What tests are done to confirm Hypercortisolemia?

Answer 10

24 hour Urinary Free Cortisol Excretion
11pm salivary or serum cortisol
Low dose dexamethasone supression test

Question 11

What are the Urinary Cortisol levels indicative of Cushings?

Answer 11

150 likely Hypercortisol

Question 12

What is Pseudo-Cushings Syndrome?

Answer 12

High Cortisol from another disease process that stimulates CRH or ACTH Production

Question 13

What are causes of Pseudo-Cushings SYndrome?

Answer 13

Major Depressive Disorder
Chronic Alcoholism
Severe Stress
Major Surgery
Severe infection
Severe Obesity/Polycystic Ovary
Rapid Wt loss/Anorexia Nervosa
Meds: Carbemazapine (dec cort clearance)
DO DEXA Supression test NOT 24hr Urinary Collection

Question 14

What is Midnight Salivary Testing?

Answer 14

Chew on cotton swab for 2 min
put in container
7.5 likely cush

Question 15

What is the low dose DEXA supression test?

Answer 15

1mg Dexa at 11pm
next day measure morning serum cortisol
10 likely Cushings

Question 16

WHat is considered a confirmatory test for Hypercortisolism?

Answer 16

24 hour urine PLUS another test

Question 17

What imaging studies are done for Pit, Adrenal, or ectopic?

Answer 17

Pit: MRI
Adrenal: CT
Ectopic: Chest CT (50% of tumors)

Question 18

What is the Tx of Cushings?

Answer 18

Remove Adrenocortical Adenoma or adrenalectomy
-Other Adrenal Gland may atrophy
Adrenal CA
-Debulking or mitocaine to reduce Cort for QoL improvement

Question 19

What is done to differentiate Pit vs Ectopic Cortisolism?

Answer 19

High Dose DST
if Pit you WILL have ACTH supression
Ectopic Cannot be supressed

Inf Petrosal sinus Sampling
compare drainage of each side of pituitary after giving CRH

Question 20

What is the Tx of Cushing’s Disease?

Answer 20

Pit Surgery
Pit Irradiation
Adrenal Surg
Drug Tharapy

Question 21

What is the cause of death from Cushing’s Syndrome?

Answer 21

Immune Supression

Sepsis

Question 22

WHat are the Drugs that are used for Cushing’s?

Answer 22

Aminoglutethimide: dec all 3 
-Blocks chol => Pregnenalone
Ketoconazole: dec cort, ald, DHEA
-Blocks 11 beta hydroxylase
Mitotane: Dec cort, Ald , DHEA
-Blocks 11 beta hydroxylase
(same as ketoconazole)

Question 23

What is the Tx of Ectopic ACTH Syndrome?

Answer 23

Resection of 1^ tumor
Radiation/chemo
Bilat. Adrenalectomy
Medical Adrenal inhib