Delineating endogenous Cushing's syndrome by GC-MS urinary steroid metabotyping

Leah T Braun; Andrea Osswald; Stephanie Zopp; German Rubinstein; Frederick Vogel; Anna Riester; Jürgen Honegger; Graeme Eisenhofer; Georgiana Constantinescu; Timo Deutschbein; Marcus Quinkler; Ulf Elbelt; Heike Künzel; Hanna F Nowotny; Nicole Reisch; Michaela F Hartmann; Felix Beuschlein; Jörn Pons-Kühnemann; Martin Reincke; Stefan A Wudy

doi:10.1016/j.ebiom.2023.104907

Delineating endogenous Cushing's syndrome by GC-MS urinary steroid metabotyping

EBioMedicine. 2024 Jan:99:104907. doi: 10.1016/j.ebiom.2023.104907. Epub 2023 Dec 20.

Authors

Leah T Braun¹, Andrea Osswald¹, Stephanie Zopp¹, German Rubinstein¹, Frederick Vogel¹, Anna Riester¹, Jürgen Honegger², Graeme Eisenhofer³, Georgiana Constantinescu⁴, Timo Deutschbein⁵, Marcus Quinkler⁶, Ulf Elbelt⁷, Heike Künzel¹, Hanna F Nowotny¹, Nicole Reisch¹, Michaela F Hartmann⁸, Felix Beuschlein⁹, Jörn Pons-Kühnemann¹⁰, Martin Reincke¹, Stefan A Wudy¹¹

Affiliations

¹ Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany.
² Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Straße 3, Tübingen 72076, Germany.
³ Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, Dresden 01307, Germany; Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, Dresden 01307, Germany.
⁴ Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, Dresden 01307, Germany.
⁵ Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany; Medicover Oldenburg MVZ, Elisenstr. 12, Oldenburg 26122, Germany.
⁶ Endocrinology in Charlottenburg, Stuttgarter Platz 1, Berlin 10627, Germany.
⁷ Division of Medicine B, University Hospital Ruppin-Brandenburg, Brandenburg Medical School, Fehrbelliner Str. 38, Neuruppin 16816, Germany; Endokrinologikum Berlin MVZ, Friedrichstraße 76, Berlin 10117, Germany; Medical Department, Division of Psychosomatic Medicine, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin 12203, Germany.
⁸ Division of Pediatric Endocrinology & Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Feulgenstr. 10-12, Giessen 35392, Germany.
⁹ Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstraße 5, München 80336, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitäts-Spital Zürich (USZ) und Universität Zürich (UZH), Raemistrasse 100, Zürich CH-8091, Switzerland.
¹⁰ Medical Statistics, Institute of Medical Informatics, Justus Liebig University Giessen, Rudolf-Buchheim-Str. 6, Giessen D-35392, Germany.
¹¹ Division of Pediatric Endocrinology & Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Feulgenstr. 10-12, Giessen 35392, Germany. Electronic address: [email protected].

Abstract

Background: Diagnosing Cushing's syndrome (CS) is highly complex. As the diagnostic potential of urinary steroid metabolome analysis by gas chromatography-mass spectrometry (GC-MS) in combination with systems biology has not yet been fully exploited, we studied a large cohort of patients with CS.

Methods: We quantified daily urinary excretion rates of 36 steroid hormone metabolites. Applying cluster analysis, we investigated a control group and 168 patients: 44 with Cushing's disease (CD) (70% female), 18 with unilateral cortisol-producing adrenal adenoma (83% female), 13 with primary bilateral macronodular adrenal hyperplasia (PBMAH) (77% female), and 93 ruled-out CS (73% female).

Findings: Cluster-Analysis delineated five urinary steroid metabotypes in CS. Metabotypes 1, 2 and 3 revealing average levels of cortisol and adrenal androgen metabolites included patients with exclusion of CS or and healthy controls. Metabotype 4 reflecting moderately elevated cortisol metabolites but decreased DHEA metabolites characterized the patients with unilateral adrenal CS and PBMAH. Metabotype 5 showing strong increases both in cortisol and DHEA metabolites, as well as overloaded enzymes of cortisol inactivation, was characteristic of CD patients. 11-oxygenated androgens were elevated in all patients with CS. The biomarkers THS, F, THF/THE, and (An + Et)/(11β-OH-An + 11β-OH-Et) correctly classified 97% of patients with CS and 95% of those without CS. An inverse relationship between 11-deoxygenated and 11-oxygenated androgens was typical for the ACTH independent (adrenal) forms of CS with an accuracy of 95%.

Interpretation: GC-MS based urinary steroid metabotyping allows excellent identification of patients with endogenous CS and differentiation of its subtypes.

Funding: The study was funded by the Else Kröner-Fresenius-Stiftung and the Eva-Luise-und-Horst-Köhler-Stiftung.

Keywords: Cushing’s disease; GC-MS analysis; Hypercortisolism; Steroid profiling.

MeSH terms

Androgens
Cushing Syndrome* / diagnosis
Cushing Syndrome* / urine
Dehydroepiandrosterone
Female
Gas Chromatography-Mass Spectrometry
Humans
Hydrocortisone
Male
Steroids

Substances

Hydrocortisone
Steroids
Androgens
Dehydroepiandrosterone