We present the case of a 7-month-old baby with Cushing’s disease due to an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma combined with cells producing thyreotropin-secreting hormone (TSH). In MRI scans, a contrast-enhancing lesion was seen inside the pituitary fossa, and it extended into the suprasellar region. On the assumption of a pituitary adenoma, surgery was performed. Corresponding with biochemical findings, histopathological evaluation revealed an ACTH- and TSH-producing tumor. Genetic analysis did not demonstrate an alteration at codon 201 (Arg) and 227 (Glu). To our knowledge, this is the first case described in a child of this age. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

La majorité des hyperplasies macronodulaires bilatérales des surrénales avec syndrome de Cushing ACTH-indépendant (AIMAH) est due à l’expression aberrante de divers récepteurs hormonaux au niveau du cortex surrénalien. Les gènes responsables des AIMAH familiales avec récepteurs aberrants n’ont pas été identifiés. Le but de ce projet est de les identifier. Une étude de liaison, visant à identifier la ou les régions du génome comprenant le ou les gènes pouvant être en cause dans les AIMAH familiales, a été réalisée en utilisant l’ADN des membres d’une famille (10 malades et 7 sains) originaire du Québec, atteinte d’AIMAH et syndrome de Cushing et caractérisée par l’expression des récepteurs β-adrénergique et V1-vasopressine. Diverses régions chromosomiques entre les personnes atteintes et non-atteintes de la famille ont été soulignées. Un total de 707453 SNPs a été obtenu, et après analyse statistique, 159 SNPs significatifs, pouvant être associés au phénotype, ont été mis en évidence entre les deux groupes. Il a été constaté que la majorité de ces SNPs se situaient sur les régions chromosomiques 1q32.1 et 16q12.2. Une étude du transcriptome a aussi été réalisée en utilisant l’ADN des tumeurs de deux patients de la famille, ainsi que l’ADN d'autres tumeurs surrénaliennes. Les analyses statistiques ont permis d’identifier 15 gènes susceptibles d’être reliés à la maladie (11 surexprimés et 4 sous-exprimés). En utilisant les données de ces deux études, nous avons ciblé six gènes du chromosome 1 (ATP2B4, PPP1R12B, SOX13, CACNA1S, ADORA1et PHLDA3), un du chromosome 16 (CHD9) et un du chromosome 13 (SPRY2), afin de rechercher la présence de mutations. Le séquençage n’a révélé aucun changement de nucléotide dans les gènes PPP1R12B et SOX13. Dans les gènes ATP2B4, CACNA1S, ADORA1et PHLDA3, le séquençage a révélé des changements de nucléotides n’entrainant soit pas de changement d’acide aminé soit un changement d’acide aminé jugé « non pertinent », du fait qu’il ne permettait pas de différencier les sujets sains des sujets atteints. Pour ce qui est de CHD9 et SPRY2, le séquençage a permis d’identifier des changements de nucléotides entrainant des changements d’acides aminés de façon plus fréquente chez les sujets atteints par rapport aux sujets sains. En conclusion, nos travaux nous ont donc permis d’identifier, par étude de liaison et par analyse du transcriptome, des gènes candidats qui pourraient être responsables de cette pathologie. Le séquençage de ces gènes candidats a révélé des mutations de CHD9 et SPRY2. Ces résultats s’avèrent prometteurs puisque ces deux gènes produisent des protéines impliquées dans le remodelage de la chromatine et dans la régulation de la signalisation des protéines kinases. Le phénotypage et le génotypage des patients atteints doivent être poursuivis pour vérification. / The majority of ACTH-independent macronodular adrenal hyperplasia with Cushing's syndrome (AIMAH) is due to the aberrant expression of various receptors in the adrenal cortex. The genes responsible for familial AIMAH with aberrant receptors have not been identified. The aim of this project is to characterize them. A linkage study to identify the region or regions of the genome comprising the gene or genes that may be involved in familial AIMAH was performed using DNA of family members (10 affected and 7 non affected) born in Quebec and harboring AIMAH and Cushing's syndrome, under the aberrant regulation of B-adrenergic and V1-vasopressin receptors. Various chromosomal regions between patients and non-affected family were highlighted. A total of 707,453 SNPs were obtained, and after statistical analysis, 159 significant SNPs, possibly associated with phenotype, were found between the two groups. It was found that the majority of these SNPs were located on chromosomal regions 1q32.1 and 16q12.2. A transcriptome analysis was conducted using DNA from tumours of two patients of the family, as well as DNA from other adrenal tumours; Statistical analysis identified 15 genes that may be linked to disease (11 up-regulated and 4 under-expressed). Using data from these two studies, we identified six genes on chromosome 1 (ATP2B4, PPP1R12B, SOX13, ADORA1, CACNA1S and PHLDA3), one on chromosome 16 (CHD9) and one on chromosome 13 (SPRY2), to investigate the presence of mutations. The sequencing revealed no nucleotide changes in gene PPP1R12B and SOX13. In ATP2B4, CACNA1S, ADORA1 and PHLDA3, the sequencing not revealed nucleotides changes leading to either amino acid changes or an amino acid changes considered “not-relevant”, because they do not differentiate healthy individuals from affected. The sequencing of CHD9 and SPRY2 identified nucleotide changes causing amino acid changes more frequently in patients compared to healthy subjects. In conclusion, our work has therefore identified by linkage analysis and DNA microarray candidate genes that can be responsible to this disease, and mutations in two of these genes, CHD9 and SPRY2. These results are promising because these genes produce proteins involved in chromatin remodeling and regulation of signaling protein kinases. Phenotyping and genotyping of patients should be pursued further.

Introdução: Hiperplasia Macronodular Adrenal Primária (PMAH) é uma causa rara de Síndrome de Cushing (SC), caracterizada por macronódulos funcionantes geralmente acometendo ambas as glândulas adrenais. Recentemente, o exame 18F-FDG PET/CT detectou três pacientes com PMAH apresentando captação aumentada de 18F-FDG. No entanto, ainda não foi elucidado o mecanismo pelo qual a PMAH apresentaria uma alta captação de 18F-FDG. Objetivos: Os objetivos deste estudo foram investigar se a expressão de GLUT1, HK1, HK2 e/ou HK3 estão relacionados à alta captação de 18F-FDG na PMAH e comparar estas expressões com tecidos adrenais provenientes de pacientes com AAC e CAA. Métodos: 12 pacientes com PMAH que realizaram 18F-FDG-PET/CT, previamente à adrenalectomia. A captação de 18F-FDG foi quantificada como maximum standardized uptake value (SUVmax). Expressão do RNAm foi investigada através de RT-PCR e a expressão proteica através de técnicas de imunoistoquímica. Expressão gênica e proteica dos pacientes com PMAH foi comparada com 15 pacientes com AAC e 10 pacientes com CAA. As correlações foram realizadas através do teste de coeficiente de correlação de Pearson e as comparações, através do teste Kruskal-Wallis, seguido do ajuste de Dunn. Significância estatística foi considerada quando p < 0.05. Resultados: Todos os pacientes com PMAH apresentaram alta captação de 18F-FDG, cujo SUVmáx variou de 3.3 a 8.9 e o tamanho do maior nódulo variou de 3.5 a 15cm. Foi observada forte correlação positiva entre o tamanho do maior nódulo e o SUVmáx nos pacientes com PMAH. No entanto, não foi estabelecida correlação entre a expressão de GLUT1, HK1, HK2 e HK3 e o SUVmáx nos pacientes com PMAH. A expressão do SLC2A1 e HK2 foi significativamente maior nos pacientes com CAA do que nos pacientes com AAC e PMAH. Conclusões: A captação aumentada de 18F-FDG na PMAH não está relacionada ao aumento da expressão de GLUT1, HK1, HK2 e HK3. Estudos futuros serão necessários para elucidar a via glicolítica que é responsável pelo metabolismo da glicose na PMAH / Introduction: Primary macronodular adrenal hyperplasia (PMAH) is a rare cause of Cushing\'s syndrome, characterized by functioning adrenal macronodules and increased cortisol production. Recently, integrated 18F-FDG-PET/CT examination revealed an increased 18F-FDG uptake in patients with PMAH. However, it is still unclear the mechanism by which PMAH would present with a high 18F-FDG uptake in PET/CT. Objectives: The aim of this study was to investigate whether GLUT1, HK1, HK2 and/or HK3 expression would account for the high18F-FDG uptake in PMAH and compare these expressions with ACA and ACC adrenal tisuue. Methods: 12 patients undergoing adrenalectomy for PMAH with previous 18F-FDG-PET/CT. 18F-FDG uptake was quantified as the maximum standardized uptake value (maxSUV). mRNA expression was investigated through quantitative RT-PCR and protein expression was investigated using immunohistochemical studies. PMAH gene and protein expression were compared to 15 patients with ACA and 10 with ACC. Correlations were performed through Pearson\'s correlation coefficient test and comparisons through Kruskal-Wallis test, followed by Dunn adjust. Statistical significance was considered when p < 0.05. Results: All patients with PMAH presented with high 18F-FDG uptake, the range of SUVmax in these patients varied from 3.3 to 8.9 and the nodule sizes varied from 3.5 to 15 cm. There was a strong positive correlation between the nodule size and 18F-FDG uptake. However, no correlation could be established between gene and protein expression of GLUT1, HK1, HK2 and HK3 and 18F-FDG uptake. SLC2A1 and HK2 expression was significantly higher in patients with CCA than in patients with AAC and PMAH. Conclusions: Increased 18F-FDG uptake in PMAH does not arise from the overexpression of GLUT1, HK1, HK2 or HK3. Further investigation is required to elucidate the glycolytic pathway involved in glucose metabolism in PMAH

La majorité des hyperplasies macronodulaires bilatérales des surrénales avec syndrome de Cushing ACTH-indépendant (AIMAH) est due à l’expression aberrante de divers récepteurs hormonaux au niveau du cortex surrénalien. Les gènes responsables des AIMAH familiales avec récepteurs aberrants n’ont pas été identifiés. Le but de ce projet est de les identifier. Une étude de liaison, visant à identifier la ou les régions du génome comprenant le ou les gènes pouvant être en cause dans les AIMAH familiales, a été réalisée en utilisant l’ADN des membres d’une famille (10 malades et 7 sains) originaire du Québec, atteinte d’AIMAH et syndrome de Cushing et caractérisée par l’expression des récepteurs β-adrénergique et V1-vasopressine. Diverses régions chromosomiques entre les personnes atteintes et non-atteintes de la famille ont été soulignées. Un total de 707453 SNPs a été obtenu, et après analyse statistique, 159 SNPs significatifs, pouvant être associés au phénotype, ont été mis en évidence entre les deux groupes. Il a été constaté que la majorité de ces SNPs se situaient sur les régions chromosomiques 1q32.1 et 16q12.2. Une étude du transcriptome a aussi été réalisée en utilisant l’ADN des tumeurs de deux patients de la famille, ainsi que l’ADN d'autres tumeurs surrénaliennes. Les analyses statistiques ont permis d’identifier 15 gènes susceptibles d’être reliés à la maladie (11 surexprimés et 4 sous-exprimés). En utilisant les données de ces deux études, nous avons ciblé six gènes du chromosome 1 (ATP2B4, PPP1R12B, SOX13, CACNA1S, ADORA1et PHLDA3), un du chromosome 16 (CHD9) et un du chromosome 13 (SPRY2), afin de rechercher la présence de mutations. Le séquençage n’a révélé aucun changement de nucléotide dans les gènes PPP1R12B et SOX13. Dans les gènes ATP2B4, CACNA1S, ADORA1et PHLDA3, le séquençage a révélé des changements de nucléotides n’entrainant soit pas de changement d’acide aminé soit un changement d’acide aminé jugé « non pertinent », du fait qu’il ne permettait pas de différencier les sujets sains des sujets atteints. Pour ce qui est de CHD9 et SPRY2, le séquençage a permis d’identifier des changements de nucléotides entrainant des changements d’acides aminés de façon plus fréquente chez les sujets atteints par rapport aux sujets sains. En conclusion, nos travaux nous ont donc permis d’identifier, par étude de liaison et par analyse du transcriptome, des gènes candidats qui pourraient être responsables de cette pathologie. Le séquençage de ces gènes candidats a révélé des mutations de CHD9 et SPRY2. Ces résultats s’avèrent prometteurs puisque ces deux gènes produisent des protéines impliquées dans le remodelage de la chromatine et dans la régulation de la signalisation des protéines kinases. Le phénotypage et le génotypage des patients atteints doivent être poursuivis pour vérification. / The majority of ACTH-independent macronodular adrenal hyperplasia with Cushing's syndrome (AIMAH) is due to the aberrant expression of various receptors in the adrenal cortex. The genes responsible for familial AIMAH with aberrant receptors have not been identified. The aim of this project is to characterize them. A linkage study to identify the region or regions of the genome comprising the gene or genes that may be involved in familial AIMAH was performed using DNA of family members (10 affected and 7 non affected) born in Quebec and harboring AIMAH and Cushing's syndrome, under the aberrant regulation of B-adrenergic and V1-vasopressin receptors. Various chromosomal regions between patients and non-affected family were highlighted. A total of 707,453 SNPs were obtained, and after statistical analysis, 159 significant SNPs, possibly associated with phenotype, were found between the two groups. It was found that the majority of these SNPs were located on chromosomal regions 1q32.1 and 16q12.2. A transcriptome analysis was conducted using DNA from tumours of two patients of the family, as well as DNA from other adrenal tumours; Statistical analysis identified 15 genes that may be linked to disease (11 up-regulated and 4 under-expressed). Using data from these two studies, we identified six genes on chromosome 1 (ATP2B4, PPP1R12B, SOX13, ADORA1, CACNA1S and PHLDA3), one on chromosome 16 (CHD9) and one on chromosome 13 (SPRY2), to investigate the presence of mutations. The sequencing revealed no nucleotide changes in gene PPP1R12B and SOX13. In ATP2B4, CACNA1S, ADORA1 and PHLDA3, the sequencing not revealed nucleotides changes leading to either amino acid changes or an amino acid changes considered “not-relevant”, because they do not differentiate healthy individuals from affected. The sequencing of CHD9 and SPRY2 identified nucleotide changes causing amino acid changes more frequently in patients compared to healthy subjects. In conclusion, our work has therefore identified by linkage analysis and DNA microarray candidate genes that can be responsible to this disease, and mutations in two of these genes, CHD9 and SPRY2. These results are promising because these genes produce proteins involved in chromatin remodeling and regulation of signaling protein kinases. Phenotyping and genotyping of patients should be pursued further.

Introdução: Hiperplasia Macronodular Adrenal Primária (PMAH) é uma causa rara de Síndrome de Cushing (SC), caracterizada por macronódulos funcionantes geralmente acometendo ambas as glândulas adrenais. Recentemente, o exame 18F-FDG PET/CT detectou três pacientes com PMAH apresentando captação aumentada de 18F-FDG. No entanto, ainda não foi elucidado o mecanismo pelo qual a PMAH apresentaria uma alta captação de 18F-FDG. Objetivos: Os objetivos deste estudo foram investigar se a expressão de GLUT1, HK1, HK2 e/ou HK3 estão relacionados à alta captação de 18F-FDG na PMAH e comparar estas expressões com tecidos adrenais provenientes de pacientes com AAC e CAA. Métodos: 12 pacientes com PMAH que realizaram 18F-FDG-PET/CT, previamente à adrenalectomia. A captação de 18F-FDG foi quantificada como maximum standardized uptake value (SUVmax). Expressão do RNAm foi investigada através de RT-PCR e a expressão proteica através de técnicas de imunoistoquímica. Expressão gênica e proteica dos pacientes com PMAH foi comparada com 15 pacientes com AAC e 10 pacientes com CAA. As correlações foram realizadas através do teste de coeficiente de correlação de Pearson e as comparações, através do teste Kruskal-Wallis, seguido do ajuste de Dunn. Significância estatística foi considerada quando p < 0.05. Resultados: Todos os pacientes com PMAH apresentaram alta captação de 18F-FDG, cujo SUVmáx variou de 3.3 a 8.9 e o tamanho do maior nódulo variou de 3.5 a 15cm. Foi observada forte correlação positiva entre o tamanho do maior nódulo e o SUVmáx nos pacientes com PMAH. No entanto, não foi estabelecida correlação entre a expressão de GLUT1, HK1, HK2 e HK3 e o SUVmáx nos pacientes com PMAH. A expressão do SLC2A1 e HK2 foi significativamente maior nos pacientes com CAA do que nos pacientes com AAC e PMAH. Conclusões: A captação aumentada de 18F-FDG na PMAH não está relacionada ao aumento da expressão de GLUT1, HK1, HK2 e HK3. Estudos futuros serão necessários para elucidar a via glicolítica que é responsável pelo metabolismo da glicose na PMAH / Introduction: Primary macronodular adrenal hyperplasia (PMAH) is a rare cause of Cushing\'s syndrome, characterized by functioning adrenal macronodules and increased cortisol production. Recently, integrated 18F-FDG-PET/CT examination revealed an increased 18F-FDG uptake in patients with PMAH. However, it is still unclear the mechanism by which PMAH would present with a high 18F-FDG uptake in PET/CT. Objectives: The aim of this study was to investigate whether GLUT1, HK1, HK2 and/or HK3 expression would account for the high18F-FDG uptake in PMAH and compare these expressions with ACA and ACC adrenal tisuue. Methods: 12 patients undergoing adrenalectomy for PMAH with previous 18F-FDG-PET/CT. 18F-FDG uptake was quantified as the maximum standardized uptake value (maxSUV). mRNA expression was investigated through quantitative RT-PCR and protein expression was investigated using immunohistochemical studies. PMAH gene and protein expression were compared to 15 patients with ACA and 10 with ACC. Correlations were performed through Pearson\'s correlation coefficient test and comparisons through Kruskal-Wallis test, followed by Dunn adjust. Statistical significance was considered when p < 0.05. Results: All patients with PMAH presented with high 18F-FDG uptake, the range of SUVmax in these patients varied from 3.3 to 8.9 and the nodule sizes varied from 3.5 to 15 cm. There was a strong positive correlation between the nodule size and 18F-FDG uptake. However, no correlation could be established between gene and protein expression of GLUT1, HK1, HK2 and HK3 and 18F-FDG uptake. SLC2A1 and HK2 expression was significantly higher in patients with CCA than in patients with AAC and PMAH. Conclusions: Increased 18F-FDG uptake in PMAH does not arise from the overexpression of GLUT1, HK1, HK2 or HK3. Further investigation is required to elucidate the glycolytic pathway involved in glucose metabolism in PMAH