News - A Report From Endo 2003

For the 8th year, the CSRF exhibited at the annual meeting of The Endocrine Society, Endo 2003. This year's meeting was held June 19-22 in Philadelphia. The booth was staffed by Jane Ancharski, Renee Brooks, Karen Campbell, Dori Middleman, Michelle Molen, and Louise Pace. Mary Walsh also attended the conference. It was wonderful to have so many of us together at one time. The booth was in an excellent location and while booth traffic ebbed and flowed, we were generally very pleased with the number of endocrinologists that stopped by.

This year's conference had many talks and posters on Cushing's and related areas. It is impossible to summarize all of the presentations, but here are some highlights.

At both the Endo 2003 and the Pituitary Congress, Dr. Anthony Heaney of Cedars Sinai presented very, very interesting papers on a potential drug treatment for ACTH secreting tumors. Three patients with failed pituitary surgery for Cushing's and no response to ketoconazole were given a drug usually used to treat type II diabetes, called rosiglitazone. A favorable response was observed in two out of the three patients. Given that previously no drug has shown promise in treating ACTH secreting tumors, these results, while very preliminary are encouraging. Rosigliazone also appears promising for other types of pituitary tumors. A study protocol is under development at Cedars Sinai.

Carol Woodburn, CCRC, and Dr. Mary Lee Vance (Univ. of Virginia) presented the results of a survey of 90 patients with confirmed Cushing's. Most patients saw 2-4 doctors prior to diagnosis and most patients had Cushing's for 3-5 years prior to diagnosis. Dr. Monica Starkman (Univ. of Michigan) presented data relating to changes in brain structure and improvements in depression, anxiety and learning 1 year after successful treatment of Cushing's.

In a very well attended Sunday morning Cushing's symposium chaired by Dr. J. Blake Tyrrell (UCSF), Dr. Findling (St. Luke's, Milwaukee, WI) presented the latest information on using night time salivary cortisol to test for Cushing's. The salivary test was shown to be superior to 24 hour urinary cortisol and the overnight dex suppression test for making the initial diagnosis of Cushing's, particularly in patients in the earlier stages of Cushing's. In several instances, nighttime salivary cortisol was the only test result that was abnormal. There is now an FDA approved salivary cortisol test for the diagnosis of Cushing's that is commercially available. Hopefully, wider usage of this test will lead to earlier diagnosis. This work is included in a recently published review article (Raff H, Findling JW, Annals of Internal Medicine, 2003 June 17; 138(12):980-91). You can also find more information on our web site under About Cushing's - Testing.

In the same session, as well as at the Pituitary Congress, Dr. Lynnette Nieman (NIH) presented the latest information on determining the cause of Cushing's. In patients with Cushing's due to an adrenal tumor, ACTH values are usually below normal and the adrenal tumor visible on an abdominal CT scan. In patients with higher ACTH values, the diagnosis becomes more difficult. Of those with elevated ACTH, approximately 80% have a pituitary tumor (Cushing's disease) and 20% have ectopic tumors. Up to 50% of those with pituitary tumors have a normal pituitary MRI and approximately 10% of the normal population have small pituitary tumors. Differentiation between pituitary and ectopic tumors is further discussed in the Report From the Pituitary Congress also in this newsletter.

Also in this session, Dr. Bruno Allolio, (Medical University Klinik, Wuerzburg, Germany) presented on Adrenocortical Cancer. Adrenal cancer has an incidence of approximately 1-2 per million compared to current estimates for Cushing's of 10-15 per million. A substantial number of patients present with symptoms of hormone excess, such as Cushing's, or virilization. Surgical removal of the tumor is the preferred treatment when possible. Chemotherapy has been used in some cases as has localized radiation, however more studies are necessary to determine if these treatments are beneficial in minimizing recurrences. Current chemotherapy agents appear limited in their ability to produce remission and other chemotherapy agents are clearly needed. Adrenal cancer is the subject of an upcoming consensus meeting in September hosted by Dr. David Schteingart at the University of Michigan.

In a symposium titled Advances in Endocrine Surgery, Dr. Geoffrey Thompson (Mayo Clinic, Rochester, MN) presented a wonderful paper on Laparoscopic Adrenalectomy, complete with a video of the surgery. Compared to traditional open procedures, laparascopic adrenalectomies offer shorter hospital stays, lower surgical complication rates and a faster recovery. From 1992-2002, 290 patients underwent laparoscopic adrenealecties at the Mayo Clinic. Cushing's tumors accounted for 25% and 16% of patients had bilateral adrenalectomies. Cure rates for functional tumors using laparoscopy are identical to the open procedure. Laparoscopic adrenalectomies do have a surgical learning curve and are "safe and efficacious for adrenalectomy when performed by endocrine surgeons with advanced laparoscopic skills."

Several other papers addressed surgical outcomes of pituitary surgery for Cushing's Disease. Dr. Serhat Aytug (Univ. of Virginia) presented data that when a pituitary source of Cushing's is confirmed with petrosal sinus sampling, the rate of successful surgery does not differ between patients who underwent sinus sampling and those who did not. Dr. Sylvie Salenave of France reported on 49 patients with confirmed Cushing's Disease. In the study group, 24 patients had pituitary tumors that were visible on an MRI and 25 patients had "normal" MRI's. The surgical outcome did not differ between the two groups, thus "we recommend pituitary neurosurgical exploration as the first line treatment in Cushing's disease provided that the pituitary origin of ACTH secretion has been previously checked by petrosal sampling in patients with normal MRI's."

The cardiovascular risk (high blood pressure, obesity, diabetes, high cholesterol, etc.) associated with Cushing's was the subject of numerous presentations and posters. The area of Subclinical Cushing's, adrenal incidentalomas and Cushing's in children were also addressed. Dr. Neiman (NIH) and Dr. Grossman (St. Bartholomew's Hospital, London) both presented Meet-the-Professor sessions on Cushing's where endocrinologists had many opportunities to ask questions. You can check the abstracts yourself after signing in at www.endo-society.org.