1. Clinical case 2003… A 30 year-old woman…...admitted to our hospital due to obesity and diabetes mellitus...

2. UFC: 120-140-135 µg/24h (1900-2100 cc) (20-90 µg/24 h) Morning cortisol: 25.6-30.6 µg/dl (5.0-20 µg/dl) Morning ACTH: 57-61 pg/ml (8-53 pg/ml) Midnight plasma cortisol: 28.8-30.2 µg/dl 1 mg DEX test: cortisol 11.4 µg/dl Liddle I test: cortisol 7.5 µg/dl Diagnosis of Cushing’s disease 8 mg DEX test: cortisol 4.6 µg/dl hCRH test: cortisol peak vs baseline: 36.5 vs 25.8 µg/dl (41% increase) ACTH peak vs baseline: 91.5 vs 58.7 pg/ml (55.8% increase) Clinical feature: - Moon shaped face, cervical fat pad, supraclavicular fat accumulation, central fat distribution, thinned skin with easy bruising - Metabolic syndrome (visceral obesity BMI 35 kg/m2, DM without complications, hypertension without complications, dislipidemia)

3. Other Exams… HbA1c: 6.8% (Metformin 1500 mg/die) Tot col: 214 mg/dl, HDL: 54 mg/dl, TG 200 mg/dl, LDL: 120 mg/dl Creatinine: 0.6 mg/dl, urea: 22 mg/dl, creatinine clearance: 81 ml/min, albuminuria: negative Na: 139 mmol/l, K: 3.8 mmol/l AST: 16 U/l, ALT: 20 U/l, GGT: 47 U/l Echocardiography: normal range Carotid doppler ultrasound: intimal thickenings along the common carotid artery, without flow alterations; carotid intima- media thickness <0.9 mm ‏ Retina evaluation: no diabetic or hypertensive alterations DEXA: normal (lumbar T score + 0.4)

4. Pituitary Imaging Therapy Resection of the pituitary adenoma by transsphenoidal surgery ( April 2003) Immunoistochemistry: pituitary adenoma, positive for ACTH Ki-67 <1%, P53 negative

5. UFC: 21 µg/24h (1900-2100 cc) (20-90 µg/24 h) Morning cortisol: 7.5 µg/dl (5.0-20 µg/dl) Morning ACTH: 19.4 pg/ml (vn 8-53 pg/ml) Midnight plasma cortisol: 7.1 mcg/dl 1 mg DEX test: cortisol 3.6 µg/dl Patient re-tested 2 weeks later (washout cortisone 25 mg po 3 days before) No symtoms of acute hypoadrenalism Remission not complete… TSH: 0.9 mU/l, fT4: 9.4 pg/ml, fT3: 3.1 pg/ml

6. UFC: 32 µg/24h (1900-2100 cc) (20-90 µg/24 h) Morning cortisol: 15.3 µg/dl (5.0-20 µg/dl) Morning ACTH: 32.8 pg/ml (vn 8-53 pg/ml) Midnight plasma cortisol: 8.1 mcg/dl …re-tested 3 months later… No symtoms of hypoadrenalism, occurrence of menses FSH: 3.2 mU/l, LH: 5.6 mU/l, E2: 80 pg/ml PRL: 15 ng/ml TSH: 1.6 mU/l, fT4: 10.8 pg/ml, fT3: 3.3 pg/ml IGF-I: 215 µg/l DM improved: HbA1c 5.8% (same therapy) Lipid profile improved: LDL 100 mg/dl Blood pressure improved (same therapy) BMI unchanged: 35 kg/m2 1 mg DEX test: cortisol 5.8 µg/dl

7. Pituitary Imaging What can be done?

8. …she showed a good biochemical and clinical profile for 2 years… …the patient underwent a periodic follow up… …January 2006… Weight increase (BMI 37 kg/m2) DM worsening (HbA1c 8.5%) Lipid profile worsening (LDL 130 mg/dl) Blood pressure worsening (>130/80 mm Hg) UFC: 105-103 µg/24h (1900-2100 cc) (20-90 µg/24 h) Morning cortisol: 22.0 µg/dl (5.0-20 µg/dl) Morning ACTH: 28.4 pg/ml (vn 8-53 pg/ml) Midnight plasma cortisol: 16.4 µg/dl Pituitary Imaging: unchanged.

9. What can be done?

10. Second-line therapeutic options in persistent disease after transsphenoidal surgery Repeat pituitary surgery low rate of success (50-70%) in comparison with the first operation risk of pituitary insufficiency Radiotherapy remission rate 53-100% need of other treatments in the “interim” period risk of pituitary insufficiency risk of CNS complications Medical therapy not definitive therapy variable rate of success (different drugs, site of action, doses) Bilateral adrenalectomy definitive treatment need of lifelong hormonal replacement therapy risk of Nelson’s syndrome From: Biller et al, JCEM 2008

20. Clinical variables influencing the choice in persistent disease after transsphenoidal surgery Age Entity of hypercortisolism Comorbidities Presence/absence of pituitary deficiencies Pituitary imaging Risk of Nelson’s syndrome Patient’s compliance

21. Second-line therapeutic options in persistent disease after transsphenoidal surgery Repeat pituitary surgery low rate of success (50-70%) in comparison with the first operation risk of pituitary insufficiency Radiotherapy remission rate 53-100% need of other treatments in the “interim” period risk of pituitary insufficiency risk of CNS complications Medical therapy not definitive therapy variable rate of success (different drugs, site of action, doses) Bilateral adrenalectomy definitive treatment need of lifelong hormonal replacement therapy risk of Nelson’s syndrome From: Biller et al, JCEM 2008

22. UFC 43-58-95-81-110 µg/24h (1900-2100 cc) (20-90 µg/24 h) …medical therapy with ketoconazole (400 mg/die) was started… Metabolic profile firstly improved but later worsened… …at 12 months: Weight (BMI 36 kg/m2) HbA1c 8.1% (LDL 121 mg/dl) Blood pressure not well controlled …during the following 12 months… What can be done?

23. UFC 115-102-90-85-95-99 µg/24h (1900-2100 cc) (20-90 µg/24 h) …cabergoline (up to 3.5 mg/week) was added… Metabolic profile was not significantly modified… Therapy with metformin was increased (up to 2500 mg/die) and atorvastatin (10 mg/die) was added… …during the following 6 months… What can be done?

24. … the patient showed no compliance to increased medical therapy and asked for a more definitive treatment … … she underwent a bilateral adrenalectomy … (January 2008) …at the last follow up (2011): BMI improved: 31 kg/m2 DM improved: HbA1c 6.7 during Metformin 1000 mg/die Lipid profile improved: Tot col 162 mg/dl, HDL 55 mg/dl, TG 158 mg/dl, LDL 75 mg/dl during atorvastatin 10 mg/die Blood pressure normalized medical therapy was stopped Pituitary Imaging

25. …mild hypercortisolism needs to be counteracted in patients with persistent disease after transsphenoidal surgery… …the best balance between the negative influence of hypercortisolism and the risk of the different treatments must be found, expecially in young patients without hypopituitarism… …the choice of medical therapy should take into account not only efficacy and safety, but also over-treatment risk and patient’s compliance…