Cardiometabolic profile of non-functioning and autonomous cortisol-secreting adrenal incidentalomas. Is the cardiometabolic risk similar or are there differences?

Fracture risk by cortisol excess status in patients with adrenal incidentalomas: a population-based cohort study

Adrenal incidentalomas (AIs) may secrete excess cortisol, representing an elevated endogenous exposure to glucocorticoids, which could decrease bone mineral density and increase fracture risk. However, measurement of cortisol excess is not routinely done in patients with AI; thus, those with hormonally active AI at increased risk for fracture are under-identified. We sought to examine the association between excess cortisol levels and the incidence of fragility fracture in people with AI. This retrospective cohort study, conducted within two Kaiser Permanente regions (Southern California and Georgia), comprised women and men aged ≥50 yr with identified AI in the study period January 1, 2015-August 31, 2022. Patients' cortisol excess status was categorized by the type of test conducted (if any) and the test result. Fractures and relevant covariates were ascertained via International Classification of Diseases (ICD)-9/10 codes. Hazard ratios (HR) were estimated using Cox proportional hazard models with mortality as a competing risk. Among the cohort of 14 886 patients with AI, 273 (1.8%) had autonomous cortisol secretion (ACS) confirmed by dexamethasone suppression test (DST) results >1.8 μg/dL (>50 nmol/L), and another 201 (1.4%), tested with urine free or random cortisol tests, had results suggestive of excess cortisol production. Most of the cohort (n = 9353, 62.8%) were untested around AI diagnosis or during follow-up. Compared to patients with normal DST results (and adjusted for age, sex, race/ethnicity, and several other clinical characteristics), the estimated HR of fracture risk for patients with ACS (HR 1.42, CI 0.86-2.32), evidence of cortisol excess (1.41, 0.85-2.32), and untested patients (1.28, 0.88-1.87) were suggestive of elevated risk. However, none of the elevated hazard rates were statistically significant at the 95% significance level. The apparent elevated risk in the untested patients suggests that many untested patients may have hormonally active AI that puts them at risk for fracture from secondary osteoporosis.

Metabolic, hormonal profiles and comorbidities in pituitary Cushing's syndrome, adrenal Cushing's syndrome and mild autonomous cortisol secretion: a comparative study

PURPOSE

Our study aimed to discern disparities in metabolic, hormonal profiles, and comorbidities among patients with pituitary Cushing (PC), adrenal Cushing (AC), and Mild autonomous cortisol secretion (MACS).

METHODS

We conducted a retrospective analysis involving 76 patients diagnosed with PC (n = 26), AC (n = 21), and MACS (n = 29) at our clinic. We compared the groups' demographic data, clinical characteristics, biochemical profiles, hormonal analyses, and surgical interventions.

RESULTS

No significant differences were noted in age, height, body mass index, or gender distribution among the groups, although a higher proportion of females was observed across all three groups. However, PC patients exhibited markedly elevated 24-hour urinary cortisol levels compared to AC and MACS patients. Furthermore, alanine aminotransferase, triglycerides, very low-density lipoprotein, insulin, and basal cortisol levels were significantly elevated in PC and AC cases compared to MACS cases. Interestingly, no significant differences were observed in terms of comorbidities among the groups.

CONCLUSION

Our findings suggest that urinary cortisol levels were significantly higher in the PC group than in the AC and MACS groups, potentially indicating that high-amplitude adrenocorticotropic hormone stimulation may lead to increased cortisol secretion in PC patients. The increased utilization of imaging methods has facilitated the earlier detection of adrenal incidentalomas, enabling the diagnosis of adrenal Cushing's cases with milder cortisol elevations. Additionally, the severity of disease symptoms worsens with increasing cortisol levels.Notably, moderate increases in cortisol are associated with heightened comorbidities, underscoring the importance of vigilant management in Cushing's syndrome patients. Despite a lower degree of hypercortisolism in MACS, there were no differences in comorbidities, suggesting that even mild cortisol secretion abnormalities are sufficient to establish the presence of comorbidities. Even moderate increases in cortisol levels can impact bone metabolism.

Relationship of obesity, body fat, benign adrenal tumors and the mediating mechanism: a two-step mendelian randomization study

BACKGROUND

Benign adrenal tumors comprise the majority of asymptomatic adrenal masses and are often associated with cortisol secretion, which increases the risk of obesity and metabolic syndrome. Hormone secretion by these tumors may confound prevailing epidemiologic findings, and the causal relationships among obesity, body fat, and benign adrenal tumors remain uncertain. Mendelian randomization (MR) uses genetic variation as an instrumental variable to simulate randomized controlled trials, thereby reducing confounding and supporting causal relationships. Therefore, we aim to use MR methods to investigate causal relationships between obesity, body fat, and benign adrenal tumors. And use two-step MR to evaluate potential mediating mechanisms and their mediation proportions.

METHOD

Single nucleotide polymorphisms significantly associated with obesity, body fat and possible mediators were selected as instrumental variables from published genome-wide association studies (GWAS). GWAS data for benign adrenal tumor cases (n = 1,790) and controls (n = 390,633) were obtained from the Finngen database. Univariable MR analysis was performed to evaluate the causal associations of obesity and body fat with benign adrenal tumors, with obesity and body fat quantified using ten anthropometric indicators. In addition, two-step MR was used to examine four categories of possible mediators (metabolic indicators, hormone indicators, inflammation and oxidation indicators, and diseases) to explore potential mechanisms between obesity, body fat, and benign adrenal tumors and to calculate mediation proportions.

RESULT

Our results show that all anthropometric indicators are risk factors for benign adrenal tumors (OR range from 1.59 to 2.49 with FDR < 0.05). In addition, two-step MR analysis shows that both total and bioavailable testosterone levels significantly mediate body fat percentage, trunk fat percentage, and trunk fat mass on benign adrenal tumors in women (mediation proportion: 4.07%-15.58%). In addition, bioavailable testosterone levels mediate whole body fat mass (10.95%) and body mass index (17.04%), while total testosterone levels mediate hip circumference (7.27%) in women.

CONCLUSION

Our study demonstrates that obesity and elevated body fat may serve as risk factors for benign adrenal tumors. Furthermore, we identify the mediating role of total/bioavailable testosterone levels in women, suggesting its potential target for prevention and intervention of benign adrenal tumors in individuals with obesity or high body fat.

The Influence of Remnant Cholesterol on Cardiovascular Risk and Mortality in Patients with Non-Functional Adrenal Incidentalomas and Mild Autonomous Cortisol Secretion: A Retrospective Cohort Study

Background: Increased cardiovascular risk has been described in individuals with adrenal incidentalomas. The aim of the present study is to assess the effect of remnant cholesterol (RC) on the cardiovascular risk and mortality of patients with adrenal incidentalomas. Methods: A retrospective cohort study was conducted with patients with adrenal incidentalomas between 2001 and 2024. One hundred thirty-seven patients (mean age of 61.2 ± 11.5 years; 56.6% women) with non-functioning adrenal incidentalomas and with mild autonomous cortisol secretion (MACS) (cortisol post-dexamethasone suppression test ≥1.8 µg/mL) were included. The patients were divided into two groups using 30 mg/dL as the cut-off for RC. Logistic regression models were used to study the impact of RC on major adverse cardiovascular events and mortality (MACEs). Results: Patients with RC ≥ 30 mg/dL exhibited a higher prevalence of type 2 diabetes mellitus (T2D) (p < 0.001), lower HDL-C (p < 0.001) and LDL-C (p = 0.025) levels, a higher frequency of treatment with statins (p = 0.032), and a higher rate of non-fatal major cardiovascular events (p = 0.038) and MACEs (p = 0.038). Patients with MACS showed no differences in RC or complications during the follow-up. The relative risk of high RC was 2.65 (1.04-6.77) for cardiovascular events and 2.27 (1.05-4.92) for MACEs, with p < 0.05 in both cases. The only variables independently affecting MACEs were age ([odds ratio] OR = 1.13 [p = 0.004]), female sex (OR = 0.20; p = 0.016), LDL-C (OR = 1.02; p = 0.029), and RC (OR = 1.06; p = 0.014). T2D and HDL-C were not independently associated with MACEs. Conclusions: RC ≥30 mg/dL in patients with adrenal incidentalomas was associated with a higher prevalence of T2D, lower HDL-C levels, and a higher risk of MACEs. MACS was not associated with RC or MACEs during the follow-up.

Increased cardiometabolic risk and prevalence of ascending aorta dilation in patients with nonfunctioning adrenal incidentaloma: a retrospective propensity score-matched study

The cardiometabolic implications of Non-Functioning Adrenal Incidentaloma (NFAI) is still matter of debate. This study takes a novel approach to analyze this association, accounting for the influence of various confounding factors. We present the findings of a retrospective, cross-sectional, and case-control study. Data from all NFAI patients in primary prevention, referred to the University of Turin between 2000 and 2023, were collected and compared with subjects without adrenal disease, using propensity score matching analysis. A total of 1997 patients were included (906 patients with NFAI; 1091 controls). Adrenal tumor group was associated with high levels of cardiovascular risk scores in both univariate and multiple linear regression analyses (Progetto CUORE: EC 11.00, 95% CI 2.72-44.46, p = 0.001; SCORE: EC 1.97, 95% CI 1.01-3.81, p = 0.046). Regarding cardiometabolic complications, multivariable logistic regression revealed an independent association between NFAI and ascending aorta dilation (OR 4.64, 95% CI 2.24-9.63, p = 0.000), after adjusting for age, sex, smoking status, metabolic syndrome, number of antihypertensive drugs, estimated glomerular filtration rate (eGFR), and normetanephrine levels. Propensity score matching analysis (1:1 matching ratio), based on the same logistic regression model, confirmed the association of NFAI with aortic dilation (β = 0.083, 95% CI 0.008-0.157, p = 0.030). No significant associations were found with metabolic syndrome, type II diabetes, eGFR <60 mL/min/1.73 m2, microalbuminuria, atrial fibrillation, or hypertensive heart disease. This study suggests that patients with NFAI face increased cardiometabolic risk and high prevalence of ascending aorta dilation. Routine evaluation of NFAI patients should include thorough cardiovascular assessment and consideration of treatments aimed at reducing cardiovascular risk.

Clinical Evaluation of Adrenal Incidentaloma: The Experience of a Referral Center

The number of adrenal incidentaloma (AI) cases has increased in the last few years due to the widespread use of imaging diagnostics. Management requires evaluation of the malignant nature and hormonal activity. The aim of the present study is to assess possible clinical abnormalities in 132 AI patients both at baseline and during follow-up (mean 48.6 ± 12.5 months). In all patients, demographic, anthropometric data, biochemical, metabolic and hormonal data, and 24-h ambulatory blood pressure monitoring were assessed. Mild autonomous cortisol secretions (MACS) were diagnosed in patients without signs and symptoms of overt Cushing's syndrome and post dexamethasone (DXM) plasma cortisol concentration > 50 nmol/L (>1.8 μg/dL). Patients with overnight DXM-1 mg test positive showed higher values of diastolic blood pressure, glycemia and uric acid levels compared to patients with negative DXM test at baseline. During follow-up, the potential development of MACS in patients with nonfunctional AI showed a prevalence of 29%, though the cardiovascular and metabolic alterations were less pronounced compared to those diagnosed with MACS at baseline. Therefore, follow-ups with AI patients are useful for observing changes in clinical features.

Mild autonomous cortisol secretion: pathophysiology, comorbidities and management approaches

The majority of incidentally discovered adrenal tumours are benign adrenocortical adenomas and the prevalence of adrenocortical adenomas is around 1-7% on cross-sectional abdominal imaging. These can be non-functioning adrenal tumours or they can be associated with autonomous cortisol secretion on a spectrum that ranges from rare clinically overt adrenal Cushing syndrome to the much more prevalent mild autonomous cortisol secretion (MACS) without signs of Cushing syndrome. MACS is diagnosed (based on an abnormal overnight dexamethasone suppression test) in 20-50% of patients with adrenal adenomas. MACS is associated with cardiovascular morbidity, frailty, fragility fractures, decreased quality of life and increased mortality. Management of MACS should be individualized based on patient characteristics and includes adrenalectomy or conservative follow-up with treatment of associated comorbidities. Identifying patients with MACS who are most likely to benefit from adrenalectomy is challenging, as adrenalectomy results in improvement of cardiovascular morbidity in some, but not all, patients with MACS. Of note, diagnosis and management of patients with bilateral MACS is especially challenging. Current gaps in MACS clinical practice include a lack of specific biomarkers diagnostic of MACS-related health outcomes and a paucity of clinical trials demonstrating the efficacy of adrenalectomy on comorbidities associated with MACS. In addition, little evidence exists to demonstrate the efficacy and safety of long-term medical therapy in patients with MACS.

Are comorbidities of patients with adrenal incidentaloma tied to sex?

Background

A recent cross-sectional study showed that both comorbidities and mortality in patients with adrenal incidentaloma (AI) are tied to sex. However, few longitudinal studies evaluated the development of arterial hypertension, hyperglycemia, dyslipidemia and bone impairment in patients with AI. The aim of this study is to analyze the impact of sex in the development of these comorbidities during long-term follow-up.

Methods

We retrospectively evaluated 189 patients (120 females, 69 males) with AI, from four referral centers in Italy and Croatia. Clinical characteristics, comorbidities and cortisol after 1-mg dexamethasone suppression test (1-mg DST) were assessed at baseline and at last follow-up visit (LFUV). Median follow-up was 52 (Interquartile Range 25-86) months.

Results

The rates of arterial hypertension and hyperglycemia increased over time both in females (65.8% at baseline versus 77.8% at LFUV, p=0.002; 23.7% at baseline versus 39.6% at LFUV, p<0.001; respectively) and males (58.0% at baseline versus 69.1% at LFUV, p=0.035; 33.8% at baseline versus 54.0% at LFUV, p<0.001; respectively). Patients were stratified in two groups using 1.8 µg/dl as cut-off of cortisol following 1-mg DST: non-functional adrenal tumors (NFAT) and tumors with mild autonomous cortisol secretion (MACS). In the NFAT group (99 patients, females 62.6%), at baseline, we did not observe any difference in clinical characteristics and comorbidities between males and females. At LFUV, males showed a higher frequency of hyperglycemia than females (57.6% versus 33.9%, p=0.03). In the MACS group (89 patients, females 64.0%), at baseline, the prevalence of hypertension, hyperglycemia and dyslipidemia was similar between sexes, despite females were younger (60, IQR 55-69 versus 67.5, IQR 61-73, years; p=0.01). Moreover, females presented higher rates of bone impairment (89.3% versus 54.5%, p=0.02) than males. At LFUV, a similar sex-related pattern was observed.

Conclusion

Patients with AI frequently develop arterial hypertension and hyperglycemia and should be periodically checked for these comorbidities, regardless of sex. In patients with MACS, the lack of difference between sexes in the frequency of cardiometabolic comorbidities despite that females are younger, and the higher frequency of bone impairment in females, suggest a sex-specific effect of cortisol.

Dexamethasone Suppression Testing in a Contemporary Cohort with Adrenal Incidentalomas in Two U.S. Integrated Healthcare Systems

Autonomous cortisol secretion (ACS) from an adrenal adenoma can increase the risk for comorbidities and mortality. The dexamethasone suppression test (DST) is the standard method to diagnose ACS. A multi-site, retrospective cohort of adults with diagnosed adrenal tumors was used to understand patient characteristics associated with DST completion and ACS. Time to DST completion was defined using the lab value and result date; follow-up time was from the adrenal adenoma diagnosis to the time of completion or censoring. ACS was defined by a DST > 1.8 µg/dL (50 nmol/L). The Cox proportional hazards regression model assessed associations between DST completion and patient characteristics. In patients completing a DST, a logistic regression model evaluated relationships between elevated ACS and covariates. We included 24,259 adults, with a mean age of 63.1 years, 48.1% obese, and 28.7% with a Charlson comorbidity index ≥ 4. Approximately 7% (n = 1768) completed a DST with a completion rate of 2.36 (95% CI 2.35, 2.37) per 100 person-years. Fully adjusted models reported that male sex and an increased Charlson comorbidity index were associated with a lower likelihood of DST completion. Current or former smoking status and an increased Charlson comorbidity index had higher odds of a DST > 1.8 μg/dL. In conclusion, clinical policies are needed to improve DST completion and the management of adrenal adenomas.

Epidemiology and Management of Hypertension and Diabetes Mellitus in Patients with Mild Autonomous Cortisol Secretion: A Review

Mild autonomous cortisol secretion (MACS) is associated with a higher cardiometabolic risk than that observed in patients with nonfunctioning adrenal adenomas and in the general population. In patients with MACS, the excess of glucocorticoids affects various metabolic pathways, leading to different manifestations of metabolic syndrome and other comorbidities. Hypertension and diabetes mellitus are two of the most common cardiometabolic comorbidities associated with MACS, reaching a prevalence of up to 80% and up to 40%, respectively. In addition, they are the comorbidities that experienced a greater improvement after adrenalectomy in patients with MACS. Hypertension pathogenesis is multifactorial, including the coexistence of comorbidities such as obesity or diabetes and the role of the different polymorphisms of the glucocorticoid receptor gene, among others. Glucocorticoid-induced diabetes mellitus is mainly related to the detrimental effects of glucocorticoids on insulin-dependent glucose uptake in peripheral tissues, gluconeogenesis and insulin secretion. There are no specific recommendations for hypertension and diabetes treatment in patients with MACS. Thus, considering the similar underlying pathogenesis of hypertension and diabetes mellitus in overt and mild hypercortisolism, our recommendation is to follow this general stepwise approach: surgically remove the adrenal culprit lesion to induce remission from hypercortisolism; control hypercortisolism with steroidogenesis inhibitors; and treat elevated blood pressure or high glucose levels using carefully selected anti-hypertensives and glucose-lowering medications if blood pressure and glucose levels remain uncontrolled, respectively. In this review, we summarize the epidemiology, physiopathology and management of diabetes mellitus and hypertension in patients with MACS.

Could the presence of adrenal incidentaloma negatively affect COVID 19 outcomes?

BACKGROUND AND OBJECTIVE

Adrenal incidentalomas (AIs) are lesions larger than 1 cm that are incidentally detected in the adrenal glands. Chest computed tomography (CCT) is widely used in the first evaluation of patients with suspected coronavirus disease (COVID-19) that resulted in many incidental findings in the thorax and upper abdomen. In this study, we aimed to investigate the frequency of AI and their effects on the course and outcome of COVID-19 regardless of functional status.

MATERIAL AND METHODS

We included 2493 patients aged between 18 and 99 years and whose adrenal glands were clearly visible in CCT images. They were divided into two groups: those with AI (AI group) and without AI (Control group).

RESULTS

AI was detected in 148 (5.93%) patients and 80 (54.1%) of them were male. There was no difference in sex distribution between the groups, but the median age of patients with AI was significantly higher than those without AI [54.5 (20-94 years) vs. 42 (18-99 years); p < 0.001)]. In addition, in the AI group, both hospitalizations due to COVID-19-related conditions (30.4 vs. 21.2%, p = 0.008) and the mortality rate experienced during this time was significantly higher (14.7 vs. 7%, p < 0.001) diseases. The AI group had a significantly higher comorbidity rate than the control group (61.5 vs. 41.9%, p < 0.001). The most common comorbid diseases were hypertension, cardiovascular diseases, diabetes mellitus, respiratory system diseases, and hyperlipidaemia. Advanced age and male gender in terms of mortality, advanced age and covid 19 positivity in terms of hospitalization were determined as significant risk factors.

CONCLUSIONS

The presence of AI may increase the morbidity and mortality rates associated with COVID-19, regardless of their functional status. Therefore, patients subjected to CCT imaging for COVID-19-related lung diseases should also be evaluated for AI. Careful follow-up of patients with COVID-19 and AI is necessary to monitor the progression of COVID-19.

Comorbidities in mild autonomous cortisol secretion and the effect of treatment: systematic review and meta-analysis

OBJECTIVE

To assess (1) comorbidities associated with and (2) treatment strategies for patients with adrenal incidentalomas and mild autonomous cortisol secretion (MACS; > 1.8 µg/dL (>50 nmol/L) cortisol level cut-off following the 1 mg dexamethasone suppression test).

DESIGN

Systematic review and meta-analysis.

METHODS

Seven databases were searched up to July 14, 2022. Eligible studies were (randomized) trials, cohort studies, and cross-sectional studies assessing comorbidities potentially attributable to cortisol excess or mortality in patients with adrenal incidentaloma with or without MACS or the effects of conservative or surgical management of MACS. Random-effects meta-analysis was performed to estimate pooled proportions (with 95% CIs).

RESULTS

In 30 cross-sectional and 16 cohort studies (n = 17 156 patients in total), patients with MACS had a higher prevalence of diabetes (relative risk [RR] 1.44 [1.23-1.69]), hypertension (RR = 1.24 [1.16-1.32]), and dyslipidemia (RR = 1.23 [1.13-1.34]). All-cause mortality (adjusted for confounders) in patients with MACS, assessed in 4 studies (n = 5921), was increased (hazard ratio [HR] = 1.54 [1.27-1.81]). Nine observational studies (n = 856) and 2 randomized trials (n = 107) suggest an improvement in glucometabolic control (RR = 7.99 [2.95-21.90]), hypertension (RR = 8.75 [3.99-19.18]), and dyslipidemia (RR = 3.24 [1.19-8.82]) following adrenalectomy.

CONCLUSIONS

The present systematic review and meta-analysis highlight the relevance of MACS, since both cardiometabolic morbidities and mortality appeared to have increased in patients with MACS compared to patients with non-functioning incidentalomas. However, due to heterogeneous definitions, various outcomes, selective reporting, and missing data, the reported pooled estimates need to be interpreted with caution. The small number of patients in randomized trials prevents any strong conclusion on the causality between MACS and these comorbidities.

Characterisation of the urinary steroid profile of patients with nonfunctioning adrenal incidentalomas: A matched controlled cross-sectional study

AIM

To identify alterations in steroid metabolism in patients with nonfunctioning adrenal incidentalomas (NFAIs) through the analysis of their urinary steroid profile (USP).

METHODS

Cross-sectional study with one study group (NFAIs, cortisol post dexamethasone suppression test [DST] ≤ 1.8 µg/dl [49.7 nmol/L]) and 2 control groups: patients with autonomous cortisol secretion (ACS group, cortisol post-DST > 1.8 µg/dl (49.7 nmol/L) and patients without adrenal tumours (healthy-adrenal group). Twenty-four-hour urine collections for USP measurement (total and free fraction of 51 24 h-urine specimens) were obtained from 73 participants (24 with NFAIs, 24 without AIs, and 25 with ACS). USP was determined by gas chromatography coupled to mass spectrometry. Patients of the three groups were matched according to sex, age (±5 years-old) and body mass index (±5 kg/m² ).

RESULTS

Compared to healthy-adrenal controls, patients with NFAIs had a lower excretion of androgen metabolites (230.5 ± 190.12 vs. 388.7 ± 328.58 µg/24 h, p = .046) and a higher excretion of urinary free cortisol (UFC) (54.3 ± 66.07 vs. 25.4 ± 11.16 µg/24 h, p = .038). UFC was above the reference range in 20.8% of patients in the NFAI, compared to 0% in the healthy-adrenal group (p = .018). Patients with ACS had a higher prevalence of hypertension, dyslipidemia, and diabetes than patients with NFAIs or the control group. A lower excretion of androgen metabolites (218.4 ± 204.24 vs. 231 ± 190 µg/24 h, p = .041) and a nonsignificant higher excretion of glucocorticoid metabolites (2129.6 ± 1195.96 vs. 1550.8 ± 810.03 µg/24 h, p = .180) was found in patients with ACS compared to patients with NFAIs.

CONCLUSION

NFAIs seem to secrete a subtle, yet clinically relevant, excess of glucocorticoids. Future studies are needed to confirm our findings; and to identify metabolic alterations associated with an increased cardiometabolic risk.

Adrenal incidentaloma: Do patients with apparently nonfunctioning mass or autonomous cortisol secretion have similar or different clinical and metabolic features?

OBJECTIVE

Although there is growing evidence associating nonfunctioning adrenal incidentalomas (NFAI) with cardiovascular risk factors, there are limited data whether NFAI and autonomous cortisol secretion (ACS) groups have similar or different clinical and metabolic features. The aim of this study is to compare cardiometabolic clinic parameters among patients with ACS and NFAI, as well as controls.

DESIGN

Cross-sectional study.

PATIENTS

Eighty nine NFAI, 58 ACS and 64 controls were evaluated.

MEASUREMENTS

Diagnosis of NFAI (1 mg dexamethasone suppression test [1 mg-DST] ≤50 nmol/L [≤1.8 μg/dl]) and ACS (1 mg-DST > 50 nmol/L [> 1.8 μg/dl]) was established according to current guidelines. The control group was selected based on a normal adrenal imaging exam.

RESULTS

There were no differences between groups regarding age, gender, ethnicity, menopause or body mass index. Patients with adrenal incidentaloma presented higher frequency of hypertension (74.1 vs. 57.8%; p = .02), resistant hypertension (45.4 vs. 9.4%; p < .001), dyslipidemia (80.1 vs. 63.9%; p = .01), as well as metabolic syndrome (84.2 vs. 61.7%; p = .001) compared to the controls, respectively. NFAI and ACS patients presented similar frequency of arterial hypertension (70.8 vs. 79.3%) and resistant hypertension (41.3 vs. 51.1%), dyslipidemia (79.3 vs. 81.5%) and metabolic syndrome (83.3 vs. 85.7%); also, levels of HbA1c were similar between the groups. Binary logistic regression showed that NFAI (p = .004) and ACS (p = .001) were independent predictors for resistant hypertension (p = .003); also, ACS was an independent predictor for metabolic syndrome (p = .04).

CONCLUSIONS

NFAI and ACS presented a higher frequency of cardiometabolic morbidities in comparison with individuals with normal adrenal glands. Additionally, we demonstrated that both ACS and NFAI groups have similar cardiometabolic conditions.

Cardiometabolic profile and urinary metabolomic alterations in non-functioning adrenal incidentalomas: A review

BACKGROUND

The incidence of adrenal incidentalomas (AIs) has increased over the last 20 years, most of which are apparently non-functioning adrenal adenomas. However, increased evidence supports the existence of an association between non-functioning adrenal incidentalomas (NFAI) and an unfavourable cardio-metabolic profile.

METHODS

This study offers a comprehensive review of the available evidence supporting a higher cardiometabolic risk in NFAIs compared to controls without adrenal tumours. Moreover, it summarises the studies focused on the differential urinary metabolomic profile of NFAI and controls without adrenal lesions.

RESULTS

This adverse metabolic profile of patients with NFAI includes a higher prevalence of insulin resistance, obesity, hypertension, hyperglycaemia, dyslipidaemia, and cardiovascular alterations and mortality compared to healthy controls without adrenal tumours. Although the pathophysiology that explains the association between NFAI and the parameters of metabolic syndrome and cardiovascular risk is a relatively unexplored field of study, some evidence supports that there are a series of incipient alterations in cortisol metabolism not detected with the classical tests that led to this detrimental profile. These alterations may be potentially detected by a comprehensive metabolomics approach. Several studies detected a shift towards an increase of urinary cortisol metabolites excretion in NFAIs compared to controls without adrenal tumours.

CONCLUSION

In view of the higher cardiometabolic risk in NFAI than in controls without adrenal tumours, and the detected alterations in metabolomics profile of NFAI, I propose that the term of NFAI should be changed for another term that best fits to its linked cardiometabolic profile.

Adrenalectomy improves blood pressure control in nonfunctioning adrenal incidentalomas and glycemic and lipid control in patients with autonomous cortisol secretion

PURPOSE

To compare the evolution of the cardiometabolic parameters in patients with nonfunctioning adrenal incidentalomas (NFAI) and autonomous cortisol secretion (ACS) who underwent adrenalectomy and those who were conservatively managed.

METHODS

A retrospective study of all patients with NFAI and ACS submitted to surgery or in follow-up in our center between January 2011-October 2020. NFAI was defined as an adrenal incidentaloma with cortisol post-dexamethasone suppression test (DST) ≤ 50 nmol/L and ACS as values >50 nmol/L without specific clinical signs of overt Cushing´s syndrome.

RESULTS

A total of 486 patients with NFAI (16 in the surgical group and 470 in the control group) and 259 with ACS (42 in the surgical group and 217 in the control group) were included. At baseline, patients with ACS were older than those with NFAI (P = 0.010). After adjusting by age, patients with ACS had a higher prevalence of hypertension (adjusted OR = 1.9 [1.36-2.60]) and higher levels of fasting plasma glucose and HbA1c (adjusted β = 6.9 [2.05-11.83] and adjusted β = 0.4 [0.12-0.63]) than NFAI. During follow-up, ACS patients who underwent adrenalectomy had a greater decrease in glucose levels (-16.6 ± 45.07 vs. -1.0 ± 26.92 mg/dL, P = 0.035) and in triglycerides (-20.21 ± 55.97 vs. 1.3 ± 59.23 mg/dL, P = 0.029) than ACS patients conservatively managed. NFAI patients who underwent surgery experienced an improvement in systolic blood pressure compared to NFAI of the conservative group (-11.1 ± 15.94 vs 1.0 ± 17.54 mmHg, P = 0.009).

CONCLUSION

The benefits of adrenalectomy in the cardiometabolic profile in adrenal incidentalomas are not limited only to the group of patients with ACS, an improvement in blood pressure control is also observed in NFAI patients after surgery.

Tumour size in adrenal tumours: its importance in the indication of adrenalectomy and in surgical outcomes-a single-centre experience

OBJECTIVE

To evaluate the relevance of tumour size in adrenal tumours in the estimation of malignancy risk and in the outcomes of adrenalectomy.

METHODS

We evaluate the histological results and surgical outcomes (intraoperative and postsurgical complications) in a retrospective single-centre cohort of patients without history of active extraadrenal malignancy with adrenal tumours consecutively operated in our centre during January 2010 and December 2020. We compared these results in lesions smaller and larger than 40, 50, and 60 mm.

RESULTS

Of 131 patients with adrenal tumours who underwent adrenalectomy, 76 (58.0%) had adrenal masses measuring ≥ 40 mm; 47 were > 50 mm and 28 > 60 mm. The final diagnosis was adrenocortical carcinoma (ACC) in 7 patients, pheochromocytoma in 35, and benign lesions in the remaining. All patients with ACC had adrenal masses > 50 mm, with Hounsfield units > 40 and low lipidic content in the CT. The risk of ACC and pheochromocytoma increased as tumour size did. The diagnostic accuracy of tumour size was quite good for the prediction of ACC (AUC-ROC 0.883). Nevertheless, when only adrenal tumours with HU < 40 were considered, the risk of ACC was 0% independent of tumour size. For pheochromocytomas, the risk was of 8.6% independent of tumour size for lesions with < 20HU. The risk of intraoperative and postoperative complications was independent of tumour size.

CONCLUSION

Risk of malignancy and of pheochromocytoma increased as tumour size increased, but, in the presurgical estimation of malignancy risk and of pheochromocytoma, not only tumour size, also lipidic content and other radiological features, should be considered. The risk of complications was independent of tumour size, but hospital stay was longer in patients with complication or open approach.

A retrospective study on the association between urine metanephrines and cardiometabolic risk in patients with nonfunctioning adrenal incidentaloma

Several studies argued that cardiovascular evaluation of patients with nonfunctioning adrenal incidentaloma is of particular importance. Therefore, we aimed to evaluate the possibility of stratifying the cardiometabolic risk using metanephrine levels in this setting of patients. A retrospective cross-sectional study was designed, collecting data of metanephrine values in 828 patients with nonfunctioning adrenal incidentaloma, referred to our Division within the University of Turin between 2007 and 2021. The univariate analysis showed associations between urine metanephrines and cardiometabolic variables/parameters, particularly considering the noradrenaline metabolite. At the univariate regression, normetanephrine was associated with metabolic syndrome (OR = 1.13, p = 0.002), hypertensive cardiomyopathy (OR = 1.09, p = 0.026), microalbuminuria (OR = 1.14, p = 0.024), and eGFR < 60 mL/min/1.73 m2 (OR = 1.11, p = 0.013), while metanephrine was associated with microalbuminuria (OR = 1.50, p = 0.008). At multivariate regression, considering all major cardiovascular risk factors as possible confounders, normetanephrine retained a significant association with metabolic syndrome (OR = 1.10, p = 0.037). Moreover, metanephrine retained a significant association with the presence of microalbuminuria (OR = 1.66, p = 0.003). The present study showed a further role for metanephrines in the cardiovascular risk stratification of patients with nonfunctioning adrenal incidentaloma. Individuals with high levels of these indirect markers of sympathetic activity should be carefully monitored and may benefit from an aggressive treatment to reduce their additional cardiometabolic burden.

Prevalence and phenotype of primary bilateral macronodular adrenal hyperplasia with autonomous cortisol secretion: a study of 98 patients

AIM

This study evaluated prevalence of primary bilateral macronodular adrenal hyperplasia (PBMAH). It also analyzed the differential phenotype of patients with PBMAH compared to other bilateral adrenal lesions that do not meet the definition of PBMAH.

METHODS

We reviewed the medical records of 732 patients diagnosed with an adrenal incidentaloma at our center. Ninety-eight patients with subclinical hypercortisolism were included in the analysis. We defined PBMAH as the presence of plasma cortisol > 1.8 μg/dL after an over-night 1-mg dexamethasone test, bilateral adrenal hyperplasia, and bilateral adrenal nodules > 1 cm.

RESULTS

A total of 31 patients had PBMAH. Patients with PBMAH showed greater prevalence of autonomous cortisol secretion (plasma cortisol > 5.0 μg/dL after an overnight 1-mg dexamethasone test) than patients without PBMAH (OR 4.1, 95%CI 1.38-12.09, p = 0.010). Tumor size and total adenomatous mass were significantly greater in patients with PBMAH compared to patients without PBMAH (30.2 ± 12.16 vs. 24.3 ± 8.47 mm, p = 0.010 and 53.9 ± 20.8 vs. 43.3 ± 14.62 mm, p = 0.023), respectively. A greater proportion of patients with PBMAH had diabetes compared to patients without PBMAH (45.2% vs. 25.4%, p = 0.05).

CONCLUSION

PBMAH is present in one-third of patients with adrenal incidentaloma and subclinical hypercortisolism. Patients with PBMAH showed greater autonomous cortisol secretion, bigger tumor size, and higher rates of diabetes than those without PBMAH.

Accuracy of the dexamethasone suppression test for the prediction of autonomous cortisol secretion-related comorbidities in adrenal incidentalomas

PURPOSE

The aim of this study was to evaluate the diagnostic accuracy of the 1 mg dexamethasone suppression test (DST) for the prediction of autonomous cortisol secretion (ACS)-related comorbidities in patients with adrenal incidentalomas (AIs).

METHODS

This was a retrospective multicenter study. We recruited patients with AI/s ≥ 1 cm, excluding those who, during the study, were found during the extension study of an extra-adrenal cancer, with a known diagnosis of hereditary syndromes characterized by adrenal tumors, those presenting with overt hormonal excess syndromes, and those in whom the DST results were missing.

RESULTS

A total of 823 patients met the inclusion criteria. Based on the 1.8, 3.0, and 5.0 µg/dl post-DST cortisol thresholds, the prevalence of ACS was 33.5%, 13.7%, and 5.6%, respectively. The prevalence of hypertension (OR = 1.8, 95% CI = 1.3-2.4), diabetes (OR = 1.6, 95% CI = 1.2-2.2), and dyslipidemia (OR = 1.4, 95% CI = 1.0-1.9) was higher with cortisol post-DST ≥ 1.8 µg/dl; the prevalence of hypertension (OR = 2.1, 95% CI = 1.4-3.3) and diabetes (OR = 1.7, 95% CI = 1.1-2.6) was higher with values ≥ 3.0 µg/dl; and the prevalence of hypertension (OR = 2.0, 95% CI = 1.0-3.7) was higher with levels ≥ 5.0 µg/dl. However, the diagnostic accuracy of the DST for the prediction of cardiometabolic comorbidities in patients with AIs was poor, with areas under the ROC curve < 0.61.

CONCLUSIONS

The DST is a poor predictor of cardiometabolic comorbidities in patients with AIs regardless of the cortisol cut-off values applied. This finding suggests that the diagnosis of ACS should not be based solely on the results of the DST. Other clinical, metabolic, or imaging markers showing a better performance for the prediction of the development and progression of cardiometabolic comorbidities in AIs need to be identified.

[Cardiometabolic risk in patients with primary aldosteronism and autonomous cortisol secretion. Case-control study]

OBJECTIVE

To analyse the differences in the cardio-metabolic profile of patients with primary aldosteronism (PA) and autonomous cortisol secretion (ACS) matched by age and sex.

METHODS

Case-control study; cases of PA without associated ACS and as controls patients with ACS (dexamethasone suppression test ≥ 1.8 μg/dL in the absence of specific hypercortisolism clinical data), matched by age and sex. Comorbidities of hypertension, diabetes, obesity, dyslipidaemia, chronic kidney failure, and cardiovascular and cerebrovascular events were analysed, as well as their degree of control.

RESULTS

57 patients with PA and 57 with ACS were included. On diagnosis, in addition to a higher prevalence of hypertension in the PA patients (100 vs. 52.7%, p < .0001) and higher systolic blood pressure levels (143.2 (2.5) vs. 135.3 (2.6) mmHg, p = .032) than in the ACS patients, no other differences were detected in the prevalence of other cardio-metabolic comorbidities. Nevertheless, the patients with ACS had higher HbA1c levels (p = .028) than the PA patients. After a median follow-up of 2.25 years, the patients with PA presented a greater deterioration in kidney function (Average decrease in glomerular filtration rate (MDRD-4) -17.4 (3.0) vs. -2.3 (4.4) mL/min/1.73 m^2, p = .005) and lipid profile (Δtriglycerides of 34.5 (15.8) vs. -6.7 (11.3) mg/dL, p = .038) than the ACS patients.

CONCLUSIONS

Despite the higher prevalence of hypertension in the patients with PA than in the patients with ACS matched by age and sex, no differences were detected in the prevalence of other cardio-metabolic comorbidities. However, the PA patients showed a greater deterioration in kidney function and lipid profile throughout the follow-up than the ACS patients.

Predictors of Tumour Growth and Autonomous Cortisol Secretion Development during Follow-Up in Non-Functioning Adrenal Incidentalomas

PURPOSE

To assess the risk of developing autonomous cortisol secretion (ACS) and tumour growth in non-functioning adrenal incidentalomas (NFAIs).

METHODS

Multicentre retrospective observational study of patients with NFAIs. ACS was defined as serum cortisol >1.8 µg/dL after 1 mg-dexamethasone suppression test (DST) without specific data on Cushing's syndrome. Tumour growth was defined as an increase in maximum tumour diameter >20% from baseline; and of at least 5 mm.

RESULTS

Of 654 subjects with NFAIs included in the study, both tumour diameter and DST were re-evaluated during a follow-up longer than 12 months in 305 patients. After a median follow-up of 41.3 (IQR 24.7-63.1) months, 10.5% of NFAIs developed ACS. The risk for developing ACS was higher in patients with higher serum cortisol post-DST levels (HR 6.45 for each µg/dL, p = 0.001) at diagnosis. Significant tumour growth was observed in 5.2% of cases. The risk of tumour growth was higher in females (HR 10.7, p = 0.004).

CONCLUSIONS

The frequency of re-evaluation with DST in NFAIs during the initial 5 years from diagnosis can probably be tailored to the serum cortisol post-DST level at presentation. Re-evaluation of NFAIs with imaging studies, on the other hand, seems unnecessary in most cases, particularly if the initial imaging demonstrates features specific to typical adenoma, given the low rate of significant tumour growth.

Maximum adenoma diameter, regardless of uni- or bilaterality, is a risk factor for autonomous cortisol secretion in adrenal incidentalomas

PURPOSE

To evaluate differences between patients with unilateral and bilateral adrenal incidentalomas (AIs) in the prevalence of autonomous cortisol secretion (ACS) and related comorbidities.

METHODS

In this multicentre retrospective study, AIs ≥ 1 cm without overt hormonal excess were included in the study. ACS was defined by a post-dexamethasone suppression test (DST) serum cortisol ≥ 5.0 µg/dl, in the absence of signs of hypercortisolism. For the association of ACS with the prevalence of comorbidities, post-DST serum cortisol was also analysed as a continuous variable.

RESULTS

Inclusion criteria were met by 823 patients, 66.3% had unilateral and 33.7% bilateral AIs. ACS was demonstrated in 5.7% of patients. No differences in the prevalence of ACS and related comorbidities were found between bilateral and unilateral AIs (P > 0.05). However, we found that tumour size was a good predictor of ACS (OR = 1.1 for each mm, P < 0.001), and the cut-off of 25 mm presented a good diagnostic accuracy to predict ACS (sensitivity of 69.4%, specificity of 74.1%). During a median follow-up time of 31.2 (IQR = 14.4-56.5) months, the risk of developing dyslipidaemia was increased in bilateral compared with unilateral AIs (HR = 1.8, 95% CI = 1.1-3.0 but, this association depended on the tumour size observed at the end of follow-up (HR adjusted by last visit-tumour size = 0.9, 95% CI = 0.1-16.2).

CONCLUSIONS

Tumour size, not bilaterality, is associated with a higher prevalence of ACS. During follow-up, neither tumour size nor bilaterality were associated with the development of new comorbidities, yet a larger tumour size after follow-up explained the association of bilateral AIs with the risk of dyslipidaemia.

Higher risk of chronic kidney disease and progressive kidney function impairment in primary aldosteronism than in essential hypertension. Case-control study

PURPOSE

To study the differences in the prevalence, risk, and grade of control of different cardiometabolic comorbidities in patients with primary aldosteronism (PA) and essential hypertension (EH) matched by age, sex, and blood pressure levels at diagnosis.

METHODS

Case-control study of a secondary base (PA patients in follow-up in a tertiary hospital between 2018 and 2020). Controls were patients with non-functioning adrenal incidentalomas and EH, matched by age, sex, and baseline diastolic blood pressure (DBP) and systolic blood pressure (SBP).

RESULTS

Fifty patients with PA and 50 controls were enrolled in the study. At diagnosis, PA patients had a higher prevalence of chronic kidney disease (CKD) than controls (18.4% vs. 2.1%, P = 0.008). No differences were detected in the prevalence of other cardiometabolic comorbidities nor in their degree of control (P > 0.05). All patients received antihypertensive medical treatment and 10 PA patients underwent unilateral laparoscopic adrenalectomy. After a median follow-up of 31.9 [IQR = 1.0-254.8] months, PA patients presented a greater degree of declination of kidney function than controls (average decrease in glomerular filtration rate (MDRD-4) -17.6 ± 3.1 vs. -2.8 ± 1.8 ml/min/1.73 m², P < 0.001). There were no differences in the grade of SBP (P = 0.840) and DBP control (P = 0.191), nor in the risk of developing other comorbidities or in their degree of control.

CONCLUSIONS

PA patients have a higher prevalence of CKD at the time of diagnosis when compared to EH matched by age, sex, and blood pressure levels. Furthermore, the risk of kidney function impairment throughout the follow-up is significantly greater in PA patients and is independent of the degree of blood pressure control.

Impact of Adrenalectomy on Morbidity in Patients with Non-Functioning Adrenal Cortical Tumours, Mild Hypercortisolism and Cushing's Syndrome as Assessed by National and Quality Registries

Background

The impact of adrenalectomy on morbidity in patients with mild hypercortisolism and non-functioning adrenocortical adenoma is unclear. The present study evaluated morbidity before and after adrenalectomy in patients with benign adrenocortical tumour with Cushing´s syndrome (CS), autonomous cortisol secretion (ACS) and non-functioning adrenocortical adenoma as assessed by national and quality registries.

Methods

Patients registered in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009–2017 with CS, ACS or non-functioning adrenocortical adenoma, were included in this retrospective study and analysed with age- and sex-matched controls, 1:3. Morbidity associated with CS was assessed pre- and postoperatively by analysing data from the Swedish National Patient Register and the Swedish Prescribed Drug Register.

Results

Some 271 patients were included, CS (127), ACS (45) and non-functioning adrenocortical adenoma (99), with 813 matched controls. The frequency of hypertension was almost 50% in all tumour groups. Antihypertensive medication preoperatively was more frequent in all tumour groups compared with controls. No preoperative differences in medication were detected between patients with CS and ACS. A decrease in the use of hypertensive drugs was noticed annually for all patient groups after adrenalectomy.

Conclusions

Hypertension is common in patients with benign adrenocortical tumours regardless of cortisol hypersecretion. The use of antihypertensive drugs in patients with CS, ACS and non-functioning adrenocortical adenoma was reduced after adrenalectomy. These findings highlight the need for a randomized controlled trial to investigate the impact of adrenalectomy on morbidity in patients with mild hypercortisolism.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06214-0.

Cardiovascular and metabolic consequences in patients with asymptomatic adrenal adenomas

PURPOSE OF REVIEW

The incidence of adrenal tumors has increased over the past 20 years, most of which are incidentally discovered nonfunctioning adenomas (NFA) and tumors with mild autonomous cortisol secretion (MACS). This review aimed to summarize recent progress in understanding cardiometabolic risk in patients with NFA and MACS and to provide updates on the effect of treatment on improving outcomes in this population.

RECENT FINDINGS

NFA and MACS are associated with adverse cardiovascular risk factors and metabolic derangements, which are likely mediated by excessive glucocorticoid secretion. Recent studies showed significantly higher prevalence of hypertension, impaired glucose metabolism, obesity, and dyslipidemia in patients with NFA and MACS. Adrenalectomy may improve comorbidities in selected patients.

SUMMARY

Asymptomatic adrenal adenomas are common and are associated with adverse cardiometabolic changes. In selected patients, adrenalectomy may reduce cardiometabolic risk and improve clinical outcomes.

Cardiovascular and metabolic risk factors in patients with subclinical Cushing

PURPOSE

Adrenal incidentalomas (AI) are discovered after work-up unrelated to adrenal gland diseases; up to 30% of AI show subclinical endogenous cortisol excess (SH), frequently associated to hypertension, obesity, metabolic disorders and increased incidence of cardiovascular events (CVEs).

METHODS

We analysed 628 AI patients divided into two groups: 471 non-functional adrenal adenoma (NFA) and 157 SH. All patients underwent complete examinations, 24-h ambulatory blood pressure monitoring, biohumoral parameters and vascular damage markers, such as c-IMT and ankle brachial index. After long-term follow-up, we registered newly onset of CVEs such as myocardial infarction (MI), percutaneous stenting and surgical bypass (PTA/CABG), stroke, overall/cardiovascular mortality. Moreover, SH patients underwent to surgical (SSH) or pharmacological treatment (MSH).

RESULTS

SH patients showed higher prevalence of metabolic syndrome, diabetes mellitus, and previous CVEs respect NFA at baseline. After follow-up MSH group showed higher recurrence of major CV events compared with NFA and SSH (RR 2.27 MSH vs NFA for MI; RR 2.30 MSH vs NFA for PTA/CABG; RR 2.41 MSH vs NFA for stroke). In SSH there was a significant reduction of the number of antihypertensive medications needed to reach target blood pressure levels (2.3 ± 1.0 to 1.5 ± 0.4 drugs). None differences were found in SH patients, distinguished in relation to cortisol plasma levels after dexamethasone suppression test (1.8-5 µg/dL, above 5 µg/dL).

CONCLUSIONS

SH is linked to relevant cardiovascular and metabolic alterations, leading to worsen clinical outcomes. In eligible patients, adrenalectomy is valid and safe option to treat SH, reducing cardiometabolic abnormalities.

The prevalence and characteristics of non-functioning and autonomous cortisol secreting adrenal incidentaloma after patients' stratification by body mass index and age

BACKGROUND

The escalating prevalence of adrenal incidentaloma (AI) has been associated with the improvement of radiologic techniques and widespread imaging in aging population. It is currently unclear whether patients with obesity more likely develop AI and the current rise in the prevalence of AI could be at least partly associated with the respective rise in obesity. We compared the prevalence and characteristics of non-functional (NF) and autonomous cortisol secreting (ACS) adrenal incidentalomas (AIs) after the study population was stratified by different body mass indexes (BMI) and age groups.

METHODS

Retrospective cross-sectional study comprising of 432 patients (40.6% male, 59.4% female) with NFAI (N = 290) and ACS (N = 142), of median age 63.4 (54.0-71.6) years and median BMI 28.6 (25.5-31.7) kg/m². The data collection contained 11.132 points including demographic, anthropometric, radiologic, hormonal and metabolic parameters.

RESULTS

We observed 68-87% higher prevalence of AI across different age groups in NFAI and ACS in obese/overweight compared to normal weight subjects. Patients with ACS were older (P = 0.008), with higher basal cortisol (P < 0.001), lower basal DHEAS (P = 0.001), lower suppression DHEAS (P = 0.027) and higher aldosterone (P = 0.039). AIs with ACS were larger than NFAI (P < 0.001). Interestingly, ACS group had lower body mass (P = 0.023) and did not differ in BMI, blood pressure, heart rate, lipid profile, fasting glucose and presence of diabetes mellitus type 2 when compared to NFAI., By contrast to the similarity of metabolic profiles in ACS and NFAI, some components of adverse metabolic traits were rather associated with higher BMI and older age, in particular in NFAI.

CONCLUSION

The prevalence of NFAI and ACS were significantly higher in overweight/obese subgroup across the age distribution. Stratification by age and BMI displayed significant differences in some metabolic traits, in particular in NFAI.

Management of adrenal incidentalomas: Working through uncertainty

The European society of endocrinology, in association with the European network for the study of adrenal tumors, published recommendations for the diagnosis and treatment of adrenal incidentalomas in 2016. A thorough and critical analysis of the literature was performed to establish evidence-based recommendations and expert suggestions with the aim of avoiding 'over-diagnosis' and 'over-treatment' and to reduce unnecessary investigations, surgery and follow-up. The purpose of this review is to reconsider several recommendations that are open to debate, such as imaging of adrenal incidentalomas, diagnosis of pheochromocytoma, diagnosis and treatment of autonomous cortisol-secreting tumors, investigations of bilateral AI and follow-up of non-operated AIs, based on studies published after the release of the recommendations.

Practical guide on the initial evaluation, follow-up, and treatment of adrenal incidentalomas Adrenal Diseases Group of the Spanish Society of Endocrinology and Nutrition

Initial evaluation of adrenal incidentalomas should be aimed at ruling out malignancy and functionality. For this, a detailed clinical history should be taken, and an adequate radiographic assessment and a complete blood chemistry and hormone study should be performed. The most controversial condition, because of the lack of consensus in its definition, is autonomous cortisol secretion. Our recommendation is that, except when cortisol levels <1.8μg/dL in the dexamethasone suppression test rule out diagnosis and levels ≥5μg/dL establish the presence of autonomous cortisol secretion, diagnosis should be based on a combined definition of dexamethasone suppression test ≥3μg/dL and at least one of the following: elevated urinary free cortisol, ACTH level <10 pg/mL, or elevated nocturnal cortisol (in serum and/or saliva). During follow-up, dexamethasone suppression test should be repeated, usually every year, on an individual basis depending on the results of prior tests and the presence of comorbidities potentially related to hypercortisolism. The initial radiographic test of choice for characterization of adrenal incidentalomas is a computed tomography scan without contrast, but there is no unanimous agreement on subsequent monitoring. Our general recommendation is a repeat imaging test 6-12 months after diagnosis (based on the radiographic characteristics of the lesion). If the lesion remains stable and there are no indeterminate characteristics, no additional radiographic studies would be needed. We think that patients with autonomous cortisol secretion with comorbidities potentially related to hypercortisolism, particularly if they are young and there is a poor control, may benefit from unilateral adrenalectomy. The indication for unilateral adrenalectomy is clear in patients with overt hormonal syndromes or suspected malignancy. In conclusion, adrenal incidentalomas require a comprehensive evaluation that takes into account the possible clinical signs and comorbidities related to hormonal syndromes or malignancy; a complete hormone profile (taking into account the conditions that may lead to falsely positive and negative results); and an adequate radiographic study. Monitoring and/or treatment will be decided based on the results of the initial evaluation.