PMC8299119_01
Radiological images and histological panel of the lung nodules. Chest CT scan: (A) nodule in the right superior lobe (arrow), axial projection; (B) nodule in the right middle lobe (arrow), axial projection. [18F]-FDG-PET/CT: (C) uptake of the right superior nodule (arrow), axial projection. Histological panel: the nodule from the superior right lobe (D Hematoxylin-Eosin, 100x) consists of a metastatic carcinoma, with its colo-rectal primitivity confirmed upon CDX2 positivity at immunohistochemistry (inset). Detail from the middle lobe nodule lobe (E Hematoxylin-Eosin, 100x) depicts an epithelial neoplasm growing in an organoid fashion, composed of bland-looking cells with low mitotic rate and proliferative index (F Ki67/Mib1, 100x), estimated within a 1-2% range, and featuring intense positivity for ACTH at immunohistochemistry (G 100x).
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This dose allowed a rapid and important reduction of basal cortisol levels and a normalization of free urinary cortisol ( Figure 1 ).
Serum cortisol, ACTH, glycemia, potassium and urinary free cortisol levels at presentation, during medical therapy and after thoracic surgery.
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The CT scan revealed a significant increase of the lung nodule located in the right superior lobe (from 5 to 12 mm), while the nodule in the right middle lobe was unchanged ( Figure 2 ). On a [18F]-FDG-PET/CT (capillary glycemia <150 mg/dl before examination), the right superior nodule took-up the radiopharmaceutical with a maximum standardized uptake value (SUV) of 2.4, while the other pulmonary nodule did not accumulate [18F]-FDG ( Figure 2 ). ACTH immunostaining, in the middle lobe ( Figure 2 ). After surgery, low levels of morning plasmatic ACTH and cortisol (ACTH <5 pg/ml, cortisol 1.52 microg/dl) confirmed EAS remission.