Cabergoline therapy of paraneoplastic cushing syndrome in children

Abstract

To the Editor: Segers et al. [1] recently reported an interesting review of Cushing syndrome in children diagnosed with a renal tumor. Indeed, paraneoplastic Cushing syndromes due to an ectopic secretion of adrenocorticotropin (EAS) are rare, and have been described in other types of pediatric cancers including neuroblastoma [2,3], pancreatoblastoma [4], ovarian steroid cell tumor [5], Ewing sarcomas [6,7], and adrenal ganglioneuroma [8]. Like many other paraneoplastic syndromes, EAS is often difficult to cure, and its treatment depends on the tumor localization and resectability.The treatment usually relies on the resection of the tumor, with or without neoadjuvant chemotherapy, but also can include somatostatin analogs, ketoconazole, chemoembolization, radiofrequency ablation, and radiation therapy [9]. Some paraneoplastic Cushing syndromes remain difficult to treat, especially when they do not respond to tumor surgery or when they occur in patients with metastases or with occult ectopic adrenocorticotropin (ACTH) syndrome. For these cases, medical therapy to block cortisol production or bilateral adrenalectomy [9] could be warranted.Data published in adults have shown that cabergoline, a D2 dopaminergic receptor agonist, could alone [10,11] or in association with lanreotide [12] or ketoconazole [13], cure ACTH-dependent Cushing syndromes. Here we report a pediatric case of cabergoline therapy for paraneoplastic Cushing syndrome due to EAS.A 15-year-old female was referred to our institution due to a Cushing syndrome with cushingoid face, rapid weight gain, high blood pressure (130/100), stretch marks, and secondary amenorrhea. Blood samples showed hypokaliemia (2.2 mmol/L), high ACTH level (437 pmol/L, normal 1.6-13.9 pmol/L), high serum cortisol (2,244 g/L), and high urinary free cortisol (10,365 nmol/L). CT scan revealed a thoracic tumor of 28 cm × 16 cm × 12.5 cm, and normal suprarenal glands. A biopsy of the tumor showed it to be an Ewing sarcoma. By immunocytochemistry, 80% of the tumor cells were positive for ACTH and ␤-lipotropin, which are both derivatives of the pro-opiomelanocortin peptide, normally secreted by the corticotroph cells of the anterior pituitary. Cabergoline therapy was given at the dose of 0.5 mg/day for 1 month, and induction neoadjuvant chemotherapy started 24 hr later following the Euro-Ewing Protocol Guidelines (www.cancer.gov/clinicaltrials/EURO-EWING-INTERGROUP-EE99). Normalization of blood pressure occurred 3 days after initiation of cabergoline treatment. Within 10 days, the serum cortisol level decreased to 306 g/L. At the end of cabergoline therapy, serum ACTH level was at 6.9 pmol/L and serum cortisol level was at 491 g/L. These hormone levels remained normal 1 month after cabergoline cessation. The primary thoracic tumor could be resected after six courses of vincristine ifosfamide doxorubicin and etoposide. Surgery was followed by local radiotherapy and eight courses of vincristine actinomycin and cyclophosphamide. Thirty months post-therapy, she remains in complete remiss...

Cabergoline in severe ectopic or occult Cushing’s syndrome

“…Cabergoline, a dopamine receptor agonist, has already proven to have some effect in the treatment of CD (3,6,7), with most papers reporting a 20-40% response rate (6). In terms of the effectiveness of cabergoline in EAS or occult CS, its use has been reported only in a few isolated case reports (8,9,10,11,12,13) and in one prospective study limited to three patients and with a short follow-up (14). All of these studies support the potential effectiveness of cabergoline.…”

Cushing disease in pediatrics: an update

“…70) The use of somatostatin analogs such as pasireotide or a dopamine agonist such as cabergolide has been described as a valid option in conjunction with TSS, RT, or in cases where there is a postsurgical remnant. 1,71) Some case reports of adolescents with CD (12-, 15-, and 17-year-old patients) achieved successful outcomes after the use of somatostatin analogs [72][73][74] ; however, there is no strong evidence of the use of these drugs in pediatric patients.…”