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Noriyoshi Yamakita, Celso E Gomez-Sanchez, Tomoatsu Mune, Hiroyuki Morita, Hisashi Yoshida, Seiji Miyazaki, and Keigo Yasuda

Yamakita N, Gomez-Sanchez CE, Mune T, Morita H, Yoshida H, Miyazaki S, Yasuda K. Simultaneous measurement of plasma 18-oxocortisol and 18-hydroxycortisol levels in normal man. Eur J Endocrinol 1994;131:74–9. ISSN 0804–4643

Plasma 18-oxocortisol (18-oxoF) and 18-hydroxycortisol (18-OH-F) were measured in 47 healthy subjects. Plasma 18-oxoF and 18-OH-F in the early morning were 0.827 ± 0.04 nmol/l and 3.29 ± 0.175 nmol/l, respectively. The plasma levels of both steroids correlated with each other and with cortisol, but not with aldosterone. Postural stimulation with or without furosemide administration increased 18-oxoF, 18-OH-F, aldosterone and plasma renin activity (PRA). Two hours after 2 mg of oral dexamethasone administration or after an overnight 2 mg of dexamethasone suppression cortisol, 18-oxoF and 18-OH-F decreased. Cortisol, aldosterone, 18-oxo-F and 18-OH-F increased after the intravenous administration of 250 μg of 1–24 ACTH. Changes in plasma 18-oxo-F and 18-OH-F levels correlated with PRA change during the posture studies and correlated with the change of ACTH during the dexamethasone studies. The ratios of post-/pre-test values of the postural stimulation and dexamethasone suppression in 18-oxoF and 18-OH-F were lower than that of aldosterone. Plasma 18-oxoF and 18-OH-F are more dependent on ACTH than on the reninangiotensin system. The ratio of 18-OH-F/18-oxoF, which is between 4 and 5, remains constant during the various stimulation or suppression maneuvers.

Noriyoshi Yamakita, Department of Internal Medicine, Matsunami General Hospital, Kasamatsu, GifuPrefecture, 501-61 Japan

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Eduardo N Cozza, Mark F Foecking, Maria del Carmen Vila, and Celso E Gomez-Sanchez

Atrial and brain natriuretic peptides specifically bind to primary cultures of calf adrenal glomerulosa cells. Binding of both natriuretic peptides to the same receptor has been proved by: a Dixon plot showing competitive effects for the binding of 125I-labeled brain natriuretic peptide in the presence of increasing concentrations of unlabeled atrial natriuretic peptide; a Scatchard plot showing a lower dissociation constant (Kd) for atrial natriuretic peptide than for brain natriuretic peptide binding, but the maximum binding (Bmax) values were the same; autoradiography of sodium dodecyl sulfate polyacrylamide gels after cross-linking of 125I-labeled atrial natriuretic peptide and 125I-labeled brain natriuretic peptide, showing the same molecular weights for both peptide receptors—a single 66-kD band in whole cells and a main band at 125 kD in membranes. C-Type atrial natriuretic peptide only slightly displaced atrial natriuretic peptide binding. Angiotensin II- and potassium-mediated stimulation of aldosterone production were inhibited strongly and to the same degree by atrial and brain natriuretic peptide but only slightly by C-type atrial natriuretic peptide. Stimulation of aldosterone production mediated by adrenocorticotropin was only partially inhibited by atrial and brain natriuretic peptide, while baseline aldosterone was not affected. These results suggest that atrial and brain natriuretic peptide bind to the same receptors and provoke the same effects on aldosterone production. The weak effects found with C-type atrial natriuretic peptide suggest that the primary culture of calf adrenal glomerulosa cells contain the guanylate cyclase A receptor.

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Jacques W M Lenders, Tracy Ann Williams, Martin Reincke, and Celso E Gomez-Sanchez

Since the early 1980s 18-hydroxycortisol and 18-oxocortisol have attracted attention when it was shown that the urinary excretion of these hybrid steroids was increased in primary aldosteronism. The development and more widespread use of specific assays has improved the understanding of their role in the (patho)physiology of adrenal disorders. The adrenal site of synthesis is not fully understood although it is clear that for the synthesis of 18-hydroxycortisol and 18-oxocortisol the action of both aldosterone synthase (zona glomerulosa) and 17α-hydroxylase (zona fasciculata) is required with cortisol as main substrate. The major physiological regulator is ACTH and the biological activity of both steroids is very low and therefore only very high concentrations might be effective in vivo. In healthy subjects, the secretion of both steroids is low with 18-hydroxycortisol being substantially higher than that of 18-oxocortisol. The highest secretion of both steroids has been found in familial hyperaldosteronism type 1 (glucocorticoid-remediable aldosteronism) and in familial hyperaldosteronism type 3. Lower but yet substantially increased secretion is found in patients with aldosterone-producing adenomas in contrast to bilateral hyperplasia in whom the levels are similar to patients with hypertension. Several studies have attempted to show that these steroids, in particular, peripheral venous plasma 18-oxocortisol, might be a useful discriminatory biomarker for subtyping PA patients. The current available limited evidence precludes the use of these steroids for subtyping. We review the biosynthesis, regulation and function of 18-hydroxycortisol and 18-oxocortisol and their potential utility for the diagnosis and differential diagnosis of patients with primary aldosteronism.

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Minna Soinio, Anna-Kaarina Luukkonen, Marko Seppänen, Jukka Kemppainen, Janne Seppänen, Juha-Pekka Pienimäki, Helena Leijon, Tiina Vesterinen, Johanna Arola, Eila Lantto, Semi Helin, Ilkka Tikkanen, Saara Metso, Tuomas Mirtti, Ilkka Heiskanen, Leena Norvio, Mirja Tiikkainen, Tuula Tikkanen, Timo Sane, Matti Valimaki, Celso E Gomez-Sanchez, Ilkka Pörsti, Pirjo Nuutila, Pasi I Nevalainen, and Niina Matikainen


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Minna Soinio, Anna-Kaarina Luukkonen, Marko Seppänen, Jukka Kemppainen, Janne Seppänen, Juha-Pekka Pienimäki, Helena Leijon, Tiina Vesterinen, Johanna Arola, Eila Lantto, Semi Helin, Ilkka Tikkanen, Saara Metso, Tuomas Mirtti, Ilkka Heiskanen, Leena Norvio, Mirja Tiikkainen, Tuula Tikkanen, Timo Sane, Matti Välimäki, Celso E Gomez-Sanchez, Ilkka Pörsti, Pirjo Nuutila, Pasi I Nevalainen, and Niina Matikainen


Endocrine Society guidelines recommend adrenal venous sampling (AVS) in primary aldosteronism (PA) if adrenalectomy is considered. We tested whether functional imaging of adrenal cortex with 11C-metomidate (11C-MTO) could offer a noninvasive alternative to AVS in the subtype classification of PA.


We prospectively recruited 58 patients with confirmed PA who were eligible for adrenal surgery.


Subjects underwent AVS and 11C-MTO-PET without dexamethasone pretreatment in random order. The lateralization of 11C-MTO-PET and adrenal CT were compared with AVS in all subjects and in a prespecified adrenalectomy subgroup in which the diagnosis was confirmed with immunohistochemical staining for CYP11B2.


In the whole study population, the concordance of AVS and 11C-MTO-PET was 51% and did not differ from that of AVS and adrenal CT (53%). The concordance of AVS and 11C-MTO-PET was 55% in unilateral and 44% in bilateral PA. In receiver operating characteristics analysis, the maximum standardized uptake value ratio of 1.16 in 11C-MTO-PET had an AUC of 0.507 (P = n.s.) to predict allocation to adrenalectomy or medical therapy with sensitivity of 55% and specificity of 44%. In the prespecified adrenalectomy subgroup, AVS and 11C-MTO-PET were concordant in 10 of 19 subjects with CYP11B2-positive adenoma and in 6 of 10 with CYP11B2-positivity without an adenoma.


The concordance of 11C-MTO-PET with AVS was clinically suboptimal, and did not outperform adrenal CT. In a subgroup with CYP11B2-positive adenoma, 11C-MTO-PET identified 53% of cases. 11C-MTO-PET appeared to be inferior to AVS for subtype classification of PA.

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Martin Reincke, Adriana Albani, Guillaume Assie, Irina Bancos, Thierry Brue, Michael Buchfelder, Olivier Chabre, Filippo Ceccato, Andrea Daniele, Mario Detomas, Guido Di Dalmazi, Atanaska Elenkova, James Findling, Ashley B Grossman, Celso E Gomez-Sanchez, Anthony P Heaney, Juergen Honegger, Niki Karavitaki, Andre Lacroix, Edward R Laws, Marco Losa, Masanori Murakami, John Newell-Price, Francesca Pecori Giraldi, Luis G Pérez‐Rivas, Rosario Pivonello, William E Rainey, Silviu Sbiera, Jochen Schopohl, Constantine A Stratakis, Marily Theodoropoulou, Elisabeth F C van Rossum, Elena Valassi, Sabina Zacharieva, German Rubinstein, and Katrin Ritzel


Corticotroph tumor progression (CTP) leading to Nelson’s syndrome (NS) is a severe and difficult-to-treat complication subsequent to bilateral adrenalectomy (BADX) for Cushing’s disease. Its characteristics are not well described, and consensus recommendations for diagnosis and treatment are missing.


A systematic literature search was performed focusing on clinical studies and case series (≥5 patients). Definition, cumulative incidence, treatment and long-term outcomes of CTP/NS after BADX were analyzed using descriptive statistics. The results were presented and discussed at an interdisciplinary consensus workshop attended by international pituitary experts in Munich on October 28, 2018.


Data covered definition and cumulative incidence (34 studies, 1275 patients), surgical outcome (12 studies, 187 patients), outcome of radiation therapy (21 studies, 273 patients), and medical therapy (15 studies, 72 patients).


We endorse the definition of CTP-BADX/NS as radiological progression or new detection of a pituitary tumor on thin-section MRI. We recommend surveillance by MRI after 3 months and every 12 months for the first 3 years after BADX. Subsequently, we suggest clinical evaluation every 12 months and MRI at increasing intervals every 2–4 years (depending on ACTH and clinical parameters). We recommend pituitary surgery as first-line therapy in patients with CTP-BADX/NS. Surgery should be performed before extrasellar expansion of the tumor to obtain complete and long-term remission. Conventional radiotherapy or stereotactic radiosurgery should be utilized as second-line treatment for remnant tumor tissue showing extrasellar extension