Oral Presentation The Annual Scientific Meeting of the Endocrine Society of Australia and the Society for Reproductive Biology 2014

Modern approaches to the management of Cushing’s disease  (#84)

David Torpy 1
  1. Royal Adelaide Hospital, Adelaide, SA, Australia

Cushing’s disease (CD) is the commonest form of endogenous pathological hypercortisolism, first described in relation to its cause, pituitary ACTH excess, in the 1930’s.  Historical turning points in CD diagnosis have included cortisol assays (1930’s), ACTH immunoassay (1960’s), dexamethasone suppression testing (1960’s), corticotropin-releasing hormone stimulation testing (1980’s) as well as pituitary CT/MRI (1980’s-1990’s).  Petrosal sinus sampling (1980s-1990s) remains the most reliable, yet not infallible, differential diagnostic test for ACTH-dependent CD.  The major therapeutic advances have been transphenoidal surgery, pioneered in the 1930’s by H Cushing, reintroduced in the 1960’s with the operating microscope and now refined with endoscopic methods.  In the past 20 years diagnostic advances have included the use of salivary cortisol testing to allow non-invasive (unstressed) testing of the cortisol circadian nadir which is blunted in CD.  In addition there has been better differential diagnostic testing for, as well as more widespread clinical awareness of the pseudocushing’s syndrome.  Novel approaches include the development of new medical therapies incorporating the first moderately effective pituitary-directed agent, the broad spectrum somatostatin receptor agonist Pasireotide, and the glucocorticoid receptor blocker Mifepristone, the first agent formally approved for Cushing’s despite long experience with the steroidogenesis inhibitors ketoconazole and metyrapone.  Early evidence suggests cabergoline may benefit some CD patients.  Novel therapies in development include newer adrenal steroidogenesis inhibitors, particularly directed at the 11-hydroxylase enzyme, and antisense glucocorticoid receptor inhibitors.  These agents are also likely to be used to ameliorate some or all of the features of the metabolic syndrome, especially diabetes mellitus.  Despite these advances, substantial challenges remain in the management of CD, including delayed diagnosis, where various screening strategies, aimed at patients with partial features of Cushing’s syndrome, have not been fruitful and have highlighted the persisting difficulty in biochemically diagnosing mild hypercortisolism.  Although newer medical therapies may play a role there are questions about the universality of the monoclonal tumour model of ACTH secretory autonomy in CD.  Further challenges include the extent to which treatment of CD leads to abatement of the metabolic, cardiovascular, bone and neurocognitive sequelae of CD and the optimal practical management of the near 50% of patients who don't achieve lasting cure of CD with pituitary surgery.