Twenty-one months after the patient’s second pituitary tumor resection, significant elevations of serum ACTH and 24-hour urine cortisol to 142 pg/mL (normal range 10–60 pg/mL) and 541 μg/day (normal range 3.5–45 μg/day), respectively, were detected (Fig. 3) despite stability of her pituitary MRI (Fig. 1e). This evidence concerns the gene POMC and pituitary tumor.