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881 - The Challenges of Rehabilitating Patients with Ectopic Cushing Syndrome

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

DT

Daniel Q. Trinh, MD

Fellow Physician
Atrium Health-Carolinas Rehabilitation
Charlotte, North Carolina, United States

Co-Author(s)

CM

Charles Mitchell, DO

Assistant Professor
Carolinas Rehabilitation
Charlotte, North Carolina, United States
BP

Bhavesh D. Patel, DO

Oncologic Rehabilitation Attending, Associate Program Director Oncologic Rehabilitation Fellowship
Atrium Health Carolinas Rehabilitation
Charlotte, North Carolina, United States

Case Diagnosis: Small-Cell Lung Cancer; Ectopic Cushing Syndrome; Paraneoplastic Syndrome

Case Description: A 66-year-old female with significant history of type 2 diabetes and newly diagnosed small-cell lung cancer (SCLC) was transferred from a SNF to an acute care hospital due to clinical and functional decline. Oncology team started chemotherapy and transferred her to an IRF between planned cycles of chemotherapy. Her profound weakness with limited functional recovery was not consistent with generalized weakness or deconditioning, therefore the inpatient Cancer Rehabilitation team broadened the differential diagnosis. Ectopic Cushing Syndrome (ECS) was considered due to proximal weakness, hypertension, hypernatremia, and hypokalemia refractory to intervention. Additional labs revealed elevated ACTH, cortisol, and urine potassium which was best explained by ECS due to SCLC. Nephrology and Endocrinology consultants initiated ketoconazole, acetazolamide, and spironolactone with some benefit. However, she clinically declined requiring acute care transfer where she ultimately transitioned to comfort care before end of life.

Discussions: ECS is a rare paraneoplastic syndrome associated with SCLC in up to 7% of cases. ECS occurs when non-pituitary cells produce ACTH, resulting in excessive cortisol production. Clinical presentation, driven by hypercortisolism, includes proximal weakness, hypertension, hypernatremia, hypokalemia, and hyperglycemia. Treatment includes management of the primary malignancy, hypercortisolism and associated functional decline, hypercortisolism managed with medications which inhibit cortisol production and ACTH release. Patients with ECS tend to have worse outcomes and are less likely to complete their chemotherapy, perhaps due to challenges managing significant weakness and metabolic derangements. Literature recommends considering adrenalectomy prior to starting chemotherapy

Conclusions: Practice guidelines encourage supportive oncology involvement earlier in the timeline of cancer management. As this case highlighted, an accurate diagnosis for neurological impairment could impact patient care before initiation of chemotherapy. Consulting a Cancer Rehabilitation specialist to participate in the work-up and management of new cancer diagnoses might offer valuable insights for the Oncology treatment team