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Management of Occult Adrenocorticotropin-Secreting Bronchial Carcinoids: Limits of Endocrine Testing and Imaging Techniques

Endocrine Unit (P.L., F.V., E.G., P.D.) and Departments of Nuclear Medicine (M.P.), Thoracic Surgery (M.R.), Radiology (A.V., C.B.), Pathology (C.G.), Clinical Biochemistry (D.V.), and Surgery (O.R.), Niguarda Hospital, 20162 Milan, Italy; and Divisions of Surgery (F.Z.) and Nuclear Medicine (G.L.), 21052 Busto Arsizio Hospital, Busto Arsizio, Italy

Address all correspondence and requests for reprints to: Dr. Paola Loli, U.O. Endocrinologia, Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy. E-mail: ploli{at}iol.it.

The differential diagnosis and the identification of the source of ACTH in occult ectopic Cushing’s syndrome due to a bronchial carcinoid still represents a challenge for the endocrinologist. We report our experience in six patients with occult bronchial carcinoid in whom extensive hormonal, imaging, and scintigraphic evaluation was performed. All patients presented with hypercortisolism associated with high plasma ACTH values. The CRH test and high dose dexamethasone suppression test suggested an ectopic source of ACTH in three of six patients. During bilateral inferior petrosal sinus sampling, none of the patients showed a central to peripheral ACTH gradient. At the time of diagnosis, none of the patients had radiological evidence of the ectopic source of ACTH, whereas pentetreotide scintigraphy identified the lesion in two of four patients. Finally, a chest computed tomography scan revealed the presence of a bronchial lesion in all patients, and pentetreotide scintigraphy identified four of six lesions. In all patients a bronchial carcinoid was found and removed. In one patient with scintigraphic evidence of residual disease after two operations, radioguided surgery, using a hand-held probe after iv administration of radiolabeled pentetreotide, was performed; this allowed detection and removal of residual multiple mediastinal lymph node metastases. In conclusion, our data show that there is not a single endocrine test or imaging procedure accurate enough to diagnose and localize occult ectopic ACTH-secreting bronchial carcinoids. Radioguided surgery appears to be promising in the presence of multiple tumor foci and previous incomplete removal of the tumor.

Abbreviations: BIPSS, Bilateral inferior petrosal sinus sampling; C/P, central to peripheral; CT, computed tomography; MRI, magnetic resonance imaging; PS, pentetreotide scintigraphy.

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