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Paraneoplastic Hypercortisolism as a Risk Factor for Severe Infections in Patients with Malignant Diseases

University of Texas, M.D. Anderson Cancer Center Houston, Texas 77030-4095

To the editor:

The work by Sarlis et al. (1) confirms that paraneoplastic hypercortisolism constitutes a risk factor for severe bacterial and opportunistic infections even when patients with small cell lung cancer (SCLC) are excluded. They suggest that inclusion of SCLC cases, as in our earlier paper (2), cloud the question because "these patients have tumor-related features that could confound the association." Indeed, patients with carcinoid or other neuroendocrine tumors are clinically different from patients with SCLC, and both groups are at increased risk.

I would like to emphasize two clinical points about these patients:

1. the superimposition of additional immune compromise, such as follows the application of myelosuppressive cytotoxic chemotherapy creates a highly lethal combination (even in non-SCLC patients). This can be avoided, since
   
2. correction of hypercortisolism can be achieved promptly and safely with the administration of metyrapone (typically 2–4 g in divided doses will normalize serum cortisol within 48 h, if not sooner).
   

At our institution, patients with paraneoplastic hypercortisolism begin metyrapone promptly, whether the treatment plan includes cytotoxic chemotherapy, surgery, or conservative surveillance; this provides the patients with gratifying clinical improvement and decreases complications. When cytotoxic chemotherapy seems to be an urgent priority (as in most patients with SCLC), our colleagues in medical oncology try to avoid myelosuppressive regimens until cortisol has been normalized for a few weeks.

Received January 21, 2000.

References

1. Sarlis NJ, Chanock SJ, Nieman LK. 2000 Cortisolemic indices predict severe infections in Cushing’s syndrome due to ectopic production of adrenocorticotropin. J Clin Endocrinol Metab. 85:42–47.[Abstract/Free Full Text]
2. Dimopoulos MA, Fernandez JF, Samaan NA, Holoye PY, Vassilopoulou-Sellin Rena. 1992 Paraneoplastic Cushing’s syndrome as an adverse prognostic factor in patients who die early with small cell lung cancer. Cancer. 69:66–71.[CrossRef][Medline]

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