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Favero V, Eller-Vainicher C, Morelli V, Cairoli E, Salcuni AS, Scillitani A, Corbetta S, Casa SD, Muscogiuri G, Persani L, Chiodini I. Increased Risk of Vertebral Fractures in Patients With Mild Autonomous Cortisol Secretion. J Clin Endocrinol Metab 2024; 109:e623-e632. [PMID: 37738555 PMCID: PMC10795935 DOI: 10.1210/clinem/dgad560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/07/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023]
Abstract
CONTEXT The risk of vertebral fractures (VFx) in patients with adrenal incidentalomas (AI) and mild autonomous cortisol secretion (MACS) is debated. OBJECTIVE To evaluate the VFx prevalence and incidence in patients with AI and MACS. METHODS This cross-sectional and longitudinal study using retrospective data from 4 Italian endocrinology units included 444 patients (cross-sectional arm) and 126 patients (longitudinal arm, 24.9 ± 5.3 months follow-up) to evaluate prevalent and incident VFx, respectively, in patients with MACS (MACS-yes) and without MACS (MACS-no). The main outcome measures were serum cortisol after a 1-mg dexamethasone test (F-1mgDST), bone mineral density (BMD) by dual-energy x-ray absorptiometry at spine (LS) and femur (FN), and VFx presence by x-ray. RESULTS Cross-sectional arm: 214 and 230 patients were MACS-yes and MACS-no, respectively, based on F-1mgDST >1.8 µg/dL (50 nmol/L). Patients with MACS had higher VFx prevalence (62.6%) than those without MACS (22.9%, P < .001); MACS was associated with prevalent VFx (odds ratio, 5.203; 95% CI, 3.361-8.055; P < .001; relative risk [RR] 2.07), regardless of age, body mass index, gender distribution, LS-BMD, and presence of type 2 diabetes mellitus (T2D). Longitudinal arm: 66 and 60 patients were MACS-no and MACS-yes, respectively. Patients without MACS showed higher number of incident VFx (36.4%) than patients without MACS (10.0%, P < .001); MACS was associated with the presence of an incident VFx (RR 4.561; 95% CI, 1.600-13.003; P = .005) regardless of age, LS-BMD, gender distribution, presence of prevalent VFx, and T2D. Results were confirmed in women and men when separately evaluated. CONCLUSION Women and men with AI and MACS are at higher risk of VFx.
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Affiliation(s)
- Vittoria Favero
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
| | - Cristina Eller-Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, 20100 Milan, Italy
| | - Valentina Morelli
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Elisa Cairoli
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Antonio Stefano Salcuni
- Unit of Endocrinology and Metabolism, University-Hospital S. Maria Della Misericordia, 33100 Udine, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology, “Casa Sollievo della Sofferenza,” Hospital, IRCCS, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Sabrina Corbetta
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20100 Milan, Italy
| | - Silvia Della Casa
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00100 Rome, Italy
| | - Giovanna Muscogiuri
- Dipartimento di Medicina Clinica e Chirurgia, Unità di Endocrinologia, Andrologia e Diabetologia - University of Naples “Federico II”, 80131 Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, 80131 Naples, Italy
| | - Luca Persani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
- Unit of Endocrinology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
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Trandafir AI, Stanciu M, Albu SE, Stoian VR, Ciofu I, Persu C, Nistor C, Carsote M. Management of Adrenal Cortical Adenomas: Assessment of Bone Status in Patients with (Non-Functioning) Adrenal Incidentalomas. J Clin Med 2023; 12:4244. [PMID: 37445279 DOI: 10.3390/jcm12134244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Our aim is to analyse the bone profile in adults with (non-functioning) adrenal incidentalomas (AIs), specifically addressing the impact of autonomous cortisol secretion (ACS). This narrative review, based on a PubMed search from inception to February 2023 (case reports, non-ACS, and other secondary causes of osteoporosis were excluded), included 40 original studies, a total of 3046 patients with female prevalence (female:male ratio of 1921:1125), aged between 20.5 and 95.5 years old. This three decade-based analysis showed that 37 studies provided dual-energy X-ray absorptiometry (DXA) information; another five studies reports results on bone micro-architecture, including trabecular bone score (TBS), spinal deformity index, and high-resolution peripheral quantitative computed tomography; 20 cohorts included data on bone turnover markers (BTMs), while four longitudinal studies followed subjects between 1 and 10.5 years old (surgical versus non-adrenalectomy arms). Post-dexamethasone suppression test (DST) cortisol was inversely associated with bone mineral density (BMD). TBS predicted incidental vertebral fractures (VFx) regardless of BMD, being associated with post-DST cortisol independently of age and BMD. Low BTMs were identified in ACS, but not all studies agreed. An increased prevalence of ACS-related osteoporosis was confirmed in most studies (highest prevalence of 87.5%), as well as of VFx, including in pre-menopause (42.5%), post-menopause (78.6%), and male patients (72.7%) depending on the study, with a 10-fold increased incidental VFx risk up to a 12-fold increased risk after a 2-year follow-up. No specific medication against osteoporosis is indicated in ACS, but adrenalectomy (according to four studies) should be part of the long-term strategy. This bone profile case sample-based study (to our knowledge, one of the largest of its kind) showed that AIs, including the subgroup designated as having ACS, embraces a large panel of osseous complications. The level of evidence remains far from generous; there are still no homogenous results defining ACS and identifying skeletal involvement, which might be a consequence of different investigation clusters underling adrenal and bone assessments over time. However, bone status evaluations and associated therapy decisions remain an essential element of the management of adults with AIs-ACS.
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Affiliation(s)
- Alexandra-Ioana Trandafir
- Department of Endocrinology, C.I. Parhon National Institute of Endocrinology & Carol Davila Doctoral School, 011863 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550024 Sibiu, Romania
| | - Simona Elena Albu
- Department of Obstetrics and Gynaecology, Carol Davila University of Medicine and Pharmacy & University Emergency Hospital, 050474 Bucharest, Romania
| | - Vasile Razvan Stoian
- Department 10-Surgery, General Surgery Department 3, Carol Davila University of Medicine and Pharmacy & University Emergency Hospital, 050474 Bucharest, Romania
| | - Irina Ciofu
- Department of Obstetrics and Gynaecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Cristian Persu
- Department of Urology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy & Thoracic Surgery Department, "Dr. Carol Davila" Central Emergency University Military Hospital, 010825 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011863 Bucharest, Romania
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Remde H, Kranz S, Morell SM, Altieri B, Kroiss M, Detomas M, Fassnacht M, Deutschbein T. Clinical course of patients with adrenal incidentalomas and cortisol autonomy: a German retrospective single center cohort study. Front Endocrinol (Lausanne) 2023; 14:1123132. [PMID: 37223045 PMCID: PMC10200872 DOI: 10.3389/fendo.2023.1123132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/01/2023] [Indexed: 05/25/2023] Open
Abstract
Background Adrenal incidentalomas with cortisol autonomy are associated with increased cardiovascular morbidity and mortality. Specific data on the clinical and biochemical course of affected patients are lacking. Methods Retrospective study from a tertiary referral centre in Germany. After exclusion of overt hormone excess, malignancy and glucocorticoid medication, patients with adrenal incidentalomas were stratified according to serum cortisol after 1 mg dexamethasone: autonomous cortisol secretion (ACS), >5.0; possible ACS (PACS), 1.9-5.0; non-functioning adenomas (NFA), ≤1.8 µg/dl. Results A total of 260 patients were enrolled (147 women (56.5%), median follow-up 8.8 (2.0-20.8) years). At initial diagnosis, median age was 59.5 (20-82) years, and median tumour size was 27 (10-116) mm. Bilateral tumours were more prevalent in ACS (30.0%) and PACS (21.9%) than in NFA (8.1%). Over time, 40/124 (32.3%) patients had a shift of their hormonal secretion pattern (NFA to PACS/ACS, n=15/53; PACS to ACS, n=6/47; ACS to PACS, n=11/24; PACS to NFA, n=8/47). However, none of the patients developed overt Cushing's syndrome. Sixty-one patients underwent adrenalectomy (NFA, 17.9%; PACS, 24.0%; ACS, 39.0%). When non-operated patients with NFA were compared to PACS and ACS at last follow-up, arterial hypertension (65.3% vs. 81.9% and 92.0%; p<0.05), diabetes (23.8% vs. 35.6% and 40.0%; p<0.01), and thromboembolic events (PACS: HR 3.43, 95%-CI 0.89-13.29; ACS: HR 5.96, 95%-CI 1.33-26.63; p<0.05) were significantly less frequent, along with a trend towards a higher rate of cardiovascular events in case of cortisol autonomy (PACS: HR 2.23, 95%-CI 0.94-5.32; ACS: HR 2.60, 95%-CI 0.87-7.79; p=0.1). Twenty-five (12.6%) of the non-operated patients died, with higher overall mortality in PACS (HR 2.6, 95%-CI 1.0-4.7; p=0.083) and ACS (HR 4.7, 95%-CI 1.6-13.3; p<0.005) compared to NFA. In operated patients, prevalence of arterial hypertension decreased significantly (77.0% at diagnosis to 61.7% at last follow-up; p<0.05). The prevalence of cardiovascular events and mortality did not differ significantly between operated and non-operated patients, whereas thromboembolic events were significantly less frequent in the surgical treatment group. Conclusion Our study confirms relevant cardiovascular morbidity in patients with adrenal incidentalomas (especially those with cortisol autonomy). These patients should therefore be monitored carefully, including adequate treatment of typical cardiovascular risk factors. Adrenalectomy was associated with a significantly decreased prevalence of hypertension. However, more than 30% of patients required reclassification according to repeated dexamethasone suppression tests. Thus, cortisol autonomy should ideally be confirmed before making any relevant treatment decision (e.g. adrenalectomy).
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Affiliation(s)
- Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Stefanie Kranz
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Dermatology and Allergology, University Hospital Augsburg, Augsburg, Germany
| | - Sarah Maria Morell
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Nephrology, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine IV, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
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Bertherat J, Bourdeau I, Bouys L, Chasseloup F, Kamenicky P, Lacroix A. Clinical, pathophysiologic, genetic and therapeutic progress in Primary Bilateral Macronodular Adrenal Hyperplasia. Endocr Rev 2022:6957368. [PMID: 36548967 DOI: 10.1210/endrev/bnac034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) usually present bilateral benign adrenocortical macronodules at imaging and variable levels of cortisol excess. PBMAH is a rare cause of primary overt Cushing's syndrome, but may represent up to one third of bilateral adrenal incidentalomas with evidence of cortisol excess. The increased steroidogenesis in PBMAH is often regulated by various G-protein coupled receptors aberrantly expressed in PBMAH tissues; some receptor ligands are ectopically produced in PBMAH tissues creating aberrant autocrine/paracrine regulation of steroidogenesis. The bilateral nature of PBMAH and familial aggregation, led to the identification of germline heterozygous inactivating mutations of the ARMC5 gene, in 20-25% of the apparent sporadic cases and more frequently in familial cases; ARMC5 mutations/pathogenic variants can be associated with meningiomas. More recently, combined germline mutations/pathogenic variants and somatic events inactivating the KDM1A gene were specifically identified in patients affected by GIP-dependent PBMAH. Functional studies demonstrated that inactivation of KDM1A leads to GIP-receptor (GIPR) overexpression and over or down-regulation of other GPCRs. Genetic analysis is now available for early detection of family members of index cases with PBMAH carrying identified germline pathogenic variants. Detailed biochemical, imaging, and co-morbidities assessment of the nature and severity of PBMAH is essential for its management. Treatment is reserved for patients with overt or mild cortisol/aldosterone or other steroid excesses taking in account co-morbidities. It previously relied on bilateral adrenalectomy; however recent studies tend to favor unilateral adrenalectomy, or less frequently, medical treatment with cortisol synthesis inhibitors or specific blockers of aberrant GPCR.
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Affiliation(s)
- Jerôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Fanny Chasseloup
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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Bengoa-Rojano N, Fernández-Argüeso M, Botella-Carretero J, Pascual-Corrales E, Araujo-Castro M. Prevalencia y fenotipo de la hiperplasia suprarrenal macronodular bilateral primaria con secreción autónoma de cortisol: un estudio de 98 pacientes. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bengoa-Rojano N, Fernández-Argüeso M, Botella-Carretero JI, Pascual-Corrales E, Araujo-Castro M. Prevalence and phenotype of primary bilateral macronodular adrenal hyperplasia with autonomous cortisol secretion: a study of 98 patients. Rev Clin Esp 2022; 222:458-467. [PMID: 35597729 DOI: 10.1016/j.rceng.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/22/2022] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- N Bengoa-Rojano
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Fernández-Argüeso
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J I Botella-Carretero
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biosanitaria en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Madrid. Spain
| | - E Pascual-Corrales
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Araujo-Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Facultad de Medicina, Universidad de Alcalá, Alcalá de Henares (Madrid). Spain.
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Ceccato F, Barbot M, Scaroni C, Boscaro M. Frequently asked questions and answers (if any) in patients with adrenal incidentaloma. J Endocrinol Invest 2021; 44:2749-2763. [PMID: 34160793 PMCID: PMC8572215 DOI: 10.1007/s40618-021-01615-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 06/14/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Adrenal incidentalomas (AIs) are incidentally discovered adrenal masses, during an imaging study undertaken for other reasons than the suspicion of adrenal disease. Their management is not a minor concern for patients and health-care related costs, since their increasing prevalence in the aging population. The exclusion of malignancy is the first question to attempt, then a careful evaluation of adrenal hormones is suggested. Surgery should be considered in case of overt secretion (primary aldosteronism, adrenal Cushing's Syndrome or pheochromocytoma), however the management of subclinical secretion is still a matter of debate. METHODS The aim of the present narrative review is to offer a practical guidance regarding the management of AI, by providing evidence-based answers to frequently asked questions. CONCLUSION The clinical experience is of utmost importance: a personalized diagnostic-therapeutic approach, based upon multidisciplinary discussion, is suggested.
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Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy.
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy.
- Department of Neuroscience DNS, University of Padova, Padova, Italy.
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - M Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
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Araujo-Castro M, Robles Lázaro C, Parra Ramírez P, García Centeno R, Gracia Gimeno P, Fernández-Ladreda MT, Sampedro Núñez MA, Marazuela M, Escobar-Morreale HF, Valderrabano P. Maximum adenoma diameter, regardless of uni- or bilaterality, is a risk factor for autonomous cortisol secretion in adrenal incidentalomas. J Endocrinol Invest 2021; 44:2349-2357. [PMID: 33683661 DOI: 10.1007/s40618-021-01539-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/17/2021] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- M Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition. Hospital, Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS. Madrid, Madrid, Spain.
| | - C Robles Lázaro
- Department of Endocrinology and Nutrition, Hospital Virgen de la Concha, Zamora, Spain
| | - P Parra Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario la Paz, Madrid, Spain
| | - R García Centeno
- Department of Endocrinology and Nutrition, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - P Gracia Gimeno
- Department of Endocrinology and Nutrition, Hospital Royo Villanova, Zaragoza, Spain
| | - M T Fernández-Ladreda
- Department of Endocrinology and Nutrition, Hospital Universitario de Puerto Real, Cádiz, Spain
| | - M A Sampedro Núñez
- Department of Endocrinology and Nutrition, Hospital Universitario de la Princesa, Madrid, Spain
| | - M Marazuela
- Department of Endocrinology and Nutrition, Hospital Universitario de la Princesa, Madrid, Spain
| | - H F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, University of Alcalá, Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - P Valderrabano
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
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Favero V, Cremaschi A, Falchetti A, Gaudio A, Gennari L, Scillitani A, Vescini F, Morelli V, Aresta C, Chiodini I. Management and Medical Therapy of Mild Hypercortisolism. Int J Mol Sci 2021; 22:ijms222111521. [PMID: 34768949 PMCID: PMC8584167 DOI: 10.3390/ijms222111521] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/30/2022] Open
Abstract
Mild hypercortisolism (mHC) is defined as an excessive cortisol secretion, without the classical manifestations of clinically overt Cushing's syndrome. This condition increases the risk of bone fragility, neuropsychological alterations, hypertension, diabetes, cardiovascular events and mortality. At variance with Cushing's syndrome, mHC is not rare, with it estimated to be present in up to 2% of individuals older than 60 years, with higher prevalence (up to 10%) in individuals with uncontrolled hypertension and/or diabetes or with unexplainable bone fragility. Measuring cortisol after a 1 mg overnight dexamethasone suppression test is the first-line test for searching for mHC, and the degree of cortisol suppression is associated with the presence of cortisol-related consequences and mortality. Among the additional tests used for diagnosing mHC in doubtful cases, the basal morning plasma adrenocorticotroph hormone, 24-h urinary free cortisol and/or late-night salivary cortisol could be measured, particularly in patients with possible cortisol-related complications, such as hypertension and diabetes. Surgery is considered as a possible therapeutic option in patients with munilateral adrenal incidentalomas and mHC since it improves diabetes and hypertension and reduces the fracture risk. In patients with mHC and bilateral adrenal adenomas, in whom surgery would lead to persistent hypocortisolism, and in patients refusing surgery or in whom surgery is not feasible, medical therapy is needed. Currently, promising though scarce data have been provided on the possible use of pituitary-directed agents, such as the multi-ligand somatostatin analog pasireotide or the dopamine agonist cabergoline for the-nowadays-rare patients with pituitary mHC. In the more frequently adrenal mHC, encouraging data are available for metyrapone, a steroidogenesis inhibitor acting mainly against the adrenal 11-βhydroxylase, while data on osilodrostat and levoketoconazole, other new steroidogenesis inhibitors, are still needed in patients with mHC. Finally, on the basis of promising data with mifepristone, a non-selective glucocorticoid receptor antagonist, in patients with mild cortisol hypersecretion, a randomized placebo-controlled study is ongoing for assessing the efficacy and safety of relacorilant, a selective glucocorticoid receptor antagonist, for patients with mild adrenal hypercortisolism and diabetes mellitus/impaired glucose tolerance and/or uncontrolled systolic hypertension.
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Affiliation(s)
- Vittoria Favero
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
| | - Arianna Cremaschi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
| | - Alberto Falchetti
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy;
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy;
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology “Casa Sollievo della Sofferenza” Hospital, IRCCS, 71013 San Giovanni Rotondo (FG), Italy;
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. M. Misericordia of Udine, 33100 Udine, Italy;
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
- Correspondence: ; Tel.: +39-02-61911-2738
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
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Bouys L, Chiodini I, Arlt W, Reincke M, Bertherat J. Update on primary bilateral macronodular adrenal hyperplasia (PBMAH). Endocrine 2021; 71:595-603. [PMID: 33587256 DOI: 10.1007/s12020-021-02645-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/21/2021] [Indexed: 01/05/2023]
Abstract
Primary bilateral macronodular adrenal hyperplasia (PBMAH), characterized by bilateral benign adrenal macronodules (>1 cm) potentially responsible for variable levels of cortisol excess, is a rare and heterogeneous disease. However, its frequency increases due to incidentally diagnosed cases on abdominal imaging carried out for reasons other than suspected adrenal disease. Mostly isolated, it can also be associated with dominantly inherited genetic conditions in rare cases. Considering the bilateral nature of adrenal involvement and the description of familial cases, the search of a genetic predisposition has led to the identification of germline heterozygous inactivating mutations of the putative tumor suppressor gene ARMC5, causing around 25% of the apparent sporadic cases. Rigorous biochemical and imaging assessment are key elements in the management of this challenging disease in terms of diagnosis. Treatment is reserved for symptomatic patients with overt or subclinical Cushing syndrome, and was historically based on bilateral adrenalectomy, which nowadays tends to be replaced by unilateral adrenalectomy or lifelong treatment with cortisol synthesis inhibitors.
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Affiliation(s)
- Lucas Bouys
- Institut Cochin, Université de Paris, Inserm U1016, CNRS UMR8104, 24 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, ENDO-ERN HCP, University of Milan, Milan, Italy
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, ENDO-ERN HCP, University of Birmingham, Birmingham, B15 2TT, UK
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, ENDO-ERN HCP, Klinikum der Universität, Ludwig-Maximilians-Universität München, Ziemssenstraße 1, 80336, Munich, Germany
| | - Jérôme Bertherat
- Institut Cochin, Université de Paris, Inserm U1016, CNRS UMR8104, 24 rue du Faubourg Saint-Jacques, 75014, Paris, France.
- Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, ENDO-ERN HCP, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
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11
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Aresta C, Favero V, Morelli V, Giovanelli L, Parazzoli C, Falchetti A, Pugliese F, Gennari L, Vescini F, Salcuni A, Scillitani A, Persani L, Chiodini I. Cardiovascular complications of mild autonomous cortisol secretion. Best Pract Res Clin Endocrinol Metab 2021; 35:101494. [PMID: 33814301 DOI: 10.1016/j.beem.2021.101494] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adrenal incidentalomas (AI) may be associated with a mild autonomous cortisol secretion (MACS) in up to one third of cases. There is growing evidence that MACS patients actually present increased risk of cardiovascular disease and higher mortality rate, driven by increased prevalence of known cardiovascular risk factors, as well as accelerated cardiovascular remodelling. Adrenalectomy seems to have cardiometabolic beneficial effects in MACS patients but their management is still a debated topic due to the lack of high-quality studies. Several studies suggested that so called "non-functioning" AI may be actually "functioning" with an associated increased cardiovascular risk. Although the individual cortisol sensitivity and peripheral activation have been recently suggested to play a role in influencing the cardiovascular risk even in apparently eucortisolemic patients, to date the degree of cortisol secretion, as mirrored by the cortisol levels after dexamethasone suppression test remains the best predictor of an increased cardiovascular risk in AI patients. However, whether or not the currently used cut-off set at 50 nmol/L for cortisol levels after dexamethasone suppression could be considered completely reliable in ruling out hypercortisolism remains unclear.
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Affiliation(s)
- Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Vittoria Favero
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy.
| | - Luca Giovanelli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Chiara Parazzoli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Alberto Falchetti
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Flavia Pugliese
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy.
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy.
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy.
| | - Antonio Salcuni
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy.
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy.
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Iacopo Chiodini
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
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12
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Vukomanovic V, Matovic M, Djukic A, Ignjatovic V, Vuleta K, Djukic S, Simic Vukomanovic I. THE ROLE OF TUMOR-SEEKING RADIOPHARMACEUTICALS IN THE DIAGNOSIS AND MANAGEMENT OF ADRENAL TUMORS. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:316-323. [PMID: 33363653 DOI: 10.4183/aeb.2020.316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Context The variety of tumor-seeking radiopharmaceuticals, which are currently in clinical use, may have a potential role as imaging agents for adrenal gland tumors, due to physiological characteristics of this organ. Objective The purpose of this study was to evaluate the diagnostic potential of 99mTc-HYNIC-TOC, 99mTc(V)-DMSA, and 99mTc-MIBI in the assessment of adrenal tumors, by correlating with imaging findings and histopathologic results. Design The research is designed as a cross-sectional prospective study. Patients and method The study included 50 patients with adrenal tumors (19 hormone-secreting and 31 nonfunctioning) and 23 controls without adrenal involvement. In all patients, single-photon emission computed tomography (SPECT) was performed, using qualitative and semiquantitative analysis. The tumor to non-tumor tracer uptake was conducted by using a region-of-interest technique. Adrenal to background (A/B) ratio was calculated in all cases. Results 99mTc-HYNIC-TOC scintigraphy showed a high statistical significance between A/B ratios, while other two tracers resulted in a lower sensitivity, specificity and accuracy. Futhermore, 99mTc-HYNIC-TOC could have a high diagnostic yield to detect adrenal tumors (the receiver-operating-characteristic curve analysis, A/B ratio cut-off value of 8.40). Conclusion A semiquantitative SPECT analysis showed that 99mTc-HYNIC-TOC is a highly sensitive tumor-seeking agent for the accurate localization of adrenal tumors.
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Affiliation(s)
- V Vukomanovic
- Clinical Center Kragujevac - Nuclear Medicine Department, University of Kragujevac, Faculty of Medical Sciences - Kragujevac, Serbia.,Department of Nuclear Medicine and Oncology, Kragujevac, Serbia
| | - M Matovic
- Clinical Center Kragujevac - Nuclear Medicine Department, University of Kragujevac, Faculty of Medical Sciences - Kragujevac, Serbia
| | - A Djukic
- Clinical Center Kragujevac - Nuclear Medicine Department, University of Kragujevac, Faculty of Medical Sciences - Kragujevac, Serbia.,Department of Pathophysiology, Kragujevac, Serbia
| | - V Ignjatovic
- Clinical Center Kragujevac - Nuclear Medicine Department, University of Kragujevac, Faculty of Medical Sciences - Kragujevac, Serbia.,Department of Nuclear Medicine and Oncology, Kragujevac, Serbia
| | - K Vuleta
- Clinical Center Kragujevac - Nuclear Medicine Department, University of Kragujevac, Faculty of Medical Sciences - Kragujevac, Serbia
| | - S Djukic
- Department of Internal Medicine, Kragujevac, Serbia
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13
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Sherlock M, Scarsbrook A, Abbas A, Fraser S, Limumpornpetch P, Dineen R, Stewart PM. Adrenal Incidentaloma. Endocr Rev 2020; 41:bnaa008. [PMID: 32266384 PMCID: PMC7431180 DOI: 10.1210/endrev/bnaa008] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup, and clinical symptoms and signs are required in every case. Adrenocortical carcinoma remains a real concern but is restricted to <2% of all cases. Functional adrenal incidentaloma lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Afroze Abbas
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Sheila Fraser
- Department of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Padiporn Limumpornpetch
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Rosemary Dineen
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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14
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Moraes AB, de Paula MP, de Paula Paranhos-Neto F, Cavalari EMR, de Morais FFC, Curi DSC, Lima LFC, de Mendonça LMC, Farias MLF, Madeira M, Vieira Neto L. Bone Evaluation by High-Resolution Peripheral Quantitative Computed Tomography in Patients With Adrenal Incidentaloma. J Clin Endocrinol Metab 2020; 105:5837655. [PMID: 32413110 DOI: 10.1210/clinem/dgaa263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/08/2020] [Indexed: 12/23/2022]
Abstract
CONTEXT Data regarding high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with adrenal incidentaloma (AI) are unknown. PURPOSE To evaluate the areal bone mineral density (aBMD), microstructure, and fractures in patients with nonfunctioning AI (NFAI) and autonomous cortisol secretion (ACS). METHODS We evaluated 45 patients with NFAI (1 mg dexamethasone suppression test [DST] ≤1.8 µg/dL) and 30 patients with ACS (1 mg DST 1.9-5.0 µg/dL). aBMD was measured using dual-energy X-ray absorptiometry; vertebral fracture by spine X-ray; and bone geometry, volumetric bone mineral density (vBMD), and microstructure by HR-pQCT. RESULTS Patients with ACS showed lower aBMD values at the spine, femoral neck, and radius 33% than those with NFAI. Osteoporosis was frequent in both groups: NFAI (64.9%) and ACS (75%). Parameters at the distal radius by HR-pQCT were decreased in patients with ACS compared to those with NFAI: trabecular vBMD (Tb.vBMD, P = 0.03), inner zone of the trabecular region (Inn.Tb.vBMD, P = 0.01), the bone volume/tissue volume ratio (BV/TV, P = 0.03) and trabecular thickness (P = 0.04). As consequence, a higher ratio of the outer zone of the trabecular region/inner zone vBMD (Meta/Inn.vBMD, P = 0.003) was observed. A correlation between the cortisol levels after 1 mg DST and Meta/Inn.vBMD ratio was found (r = 0.29; P = 0.01). The fracture frequency was 73.7% in patients with ACS vs 55.6% in patients with NFAI (P = 0.24). CONCLUSION Our findings point to an association between trabecular bone microarchitectural derangement at the distal radius and ACS. Our data suggest that AI have a negative impact on bone when assessed by HR-pQCT, probably associated to subclinical hypercortisolism.
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Affiliation(s)
- Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Marcela Pessoa de Paula
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Francisco de Paula Paranhos-Neto
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Emanuela Mello Ribeiro Cavalari
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Felipe Fernandes Cordeiro de Morais
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Daniel Silva Carvalho Curi
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Luis Felipe Cardoso Lima
- Nuclear Instrumentation Laboratory, COPPE-PEN, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Laura Maria Carvalho de Mendonça
- Department of Internal Medicine and Rheumatology Unit, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Maria Lucia Fleiuss Farias
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Miguel Madeira
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
- Endocrinology Unit, Bonsucesso Federal Hospital, Rio de Janeiro, RJ, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
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15
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Zhang Z, Wang L, Chen J, Li X, Liu D, Cao T, Yang X, Huang H, Wang X, Song X, Yang D, Wang J. Clinical analysis of adrenal lesions larger than 5 cm in diameter (an analysis of 251 cases). World J Surg Oncol 2019; 17:220. [PMID: 31842905 PMCID: PMC6916431 DOI: 10.1186/s12957-019-1765-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/02/2019] [Indexed: 12/17/2022] Open
Abstract
Background To describe the pathological distribution, imaging manifestations, and surgical managements and prognosis of large adrenal tumors (LATs) ≥ 5 cm Methods A total of 251 patients with LATs were analyzed on the basis of pathological or clinical diagnosis. Regarding surgery, open adrenalectomy was performed on 89 patients, and laparoscopic adrenalectomy was performed on 89 patients. Thirty-two patients with bilateral tumors were analyzed in terms of clinical characteristics. The survival rate was determined for 43 patients with adrenal metastases and 29 patients with primary adrenal malignancies. The CT characteristics including tumor diameter, shape, edge, heterogeneity, necrosis, calcification, pre-contrast attenuation, and contrast attenuation were analyzed for 117 patients. Results The majority of LATs were still benign, but they had a higher probability to be malignant. Benign LATs made up 68.13% of all cases, mainly adrenal cysts (19.52%), pheochromocytoma (18.73%), benign adenoma (16.73%), and myelolipoma (7.17%). Malignant LATs accounted for 28.69% of cases, mainly including adrenocortical carcinoma (8.76%) and metastases (17.13%). Laparoscopic surgery was found to involve less trauma than open surgery. It was also safer and postoperative recovery was faster, but it had drawbacks and could not completely replace open surgery. CT features had obvious specificity for the diagnosis of benign and malignant tumors. For example, benign adenomas had a smaller pre-contrast (< 10 Hu) whereas malignant adrenal tumors had, on the contrary, higher attenuation. Regarding adrenal malignant carcinoma, adrenal primary malignant tumors showed a better prognosis than adrenal metastases (mean survival of 19.17 months vs 9.49 months). Primary adrenal cortical carcinoma without metastasis had a better prognosis than primary adrenal cortical carcinoma metastasis (mean survival of 23.71 months vs 12.75 months), and adrenal solitary metastasis had a better prognosis than general multiple metastatic carcinoma (mean survival of 14.95 months vs 5.17 months). Conclusion LATs were more likely to be benign; however, they still had a high probability of being a malignant tumor. Understanding the clinicopathological characteristics of LATs can facilitate selection of more effective clinical treatment options.
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Affiliation(s)
- Zongzong Zhang
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lina Wang
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jing Chen
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiunan Li
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dikuan Liu
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Tianyu Cao
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xuehan Yang
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hongwei Huang
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xuejian Wang
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xishuang Song
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Deyong Yang
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.
| | - Jianbo Wang
- Department of Urology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.
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Clinical Usefulness of 99mTc-HYNIC-TOC and 131I-MIBG Scintigraphy in the Evaluation of Adrenal Tumors. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2018-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Disorders and morphological abnormalities affecting the adrenal gland, could lead to profound clinical consequences, owing to its biochemical structure-activity and morphological characteristics.
The recent focus on theranostic approach has led to a need for tumors characterization and early diagnosis at the molecular level. Many radiotracers have been developed with specific imaging characteristics for the adrenal tumors, by exploiting different physiological mechanisms of uptake and metabolism.
The aim of present study is to provide a prospective confirmation of 131I-MIBG and 99mTc-HYNIC-TOC scintigraphy, for the evaluation of patients with known or suspected tumors of the adrenal region.
The research is designed as a cross-sectional observational study of the clinical correlates and diagnostic accuracy of radionuclide-based imaging methods in relation to in vitro analysis, clinical manifestations and morphological characteristics of these tumors. Furthermore, the present study also evaluates the usefulness and the clinical impact of each radiopharmaceutical for the detection and management of tumors, and functional imaging modality as well.
Visual scintigraphic appearance of an increased focal tracer uptake in the suspected tumor site revealed that 99mTc-HYNIC-TOC is highly sensitive and reliable tumor-seeking radiotracer for adrenal tumors, but does not distinguish between adenoma and pheochromocytoma, and the existence of hormone secreting adrenocortical tumor cells. However, 131IMIBG scintigraphy is highly sensitive and specific method only in differentiating catecholamine-secreting adrenal tumors.
Clinical significance of this research is in the accurate localization of adrenal tumors, and is of paramount importance for an algorithmic diagnostic approach and management, and provide the rationale to different therapeutic possibilities.
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Simsek FS, Arslan M, Dag Y. An exceptional group of non-small cell lung cancer difficult to diagnose: Evaluation of lipid-poor adrenal lesions. Bosn J Basic Med Sci 2019; 19:195-200. [PMID: 30997878 DOI: 10.17305/bjbms.2019.3837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/02/2019] [Indexed: 12/25/2022] Open
Abstract
In some non-small cell lung cancer (NSCLC) patients, lipid-poor adrenal adenomas cannot be adequately differentiated from metastases using imaging methods. Invasive diagnostic procedures also have a low negative predictive value (NPV) in such cases. The current study aims to establish a specific and clinically practical metabolic parameter for lipid-poor adrenal lesions (ALs) in NSCLC patients. This diagnostic approach may prevent unnecessary abdominal enhanced computed tomography (CT), magnetic resonance imaging, or invasive diagnostic procedures. Sixty-four NSCLC patients with 69 lipid-poor ALs and 28 control patients with 30 benign lipid-poor ALs, who underwent FDG-PET/CT, were retrospectively reviewed. Two morphological and four metabolic parameters were analyzed in FDG-PET/CT images of NSCLC and control patients. Baseline and post-chemotherapy images of 64 NSCLC patients were re-evaluated according to the PERCIST 1.0. In cases where ALs could not be differentiated, follow-up FDG-PET/CT images were re-examined. The receiver operating characteristic (ROC) curve method was used for the evaluation of diagnostic parameters. Out of 69 ALs, 39 were determined as metastatic lesions (adrenal metastasis), while 30 lesions were considered non-metastatic (adrenal adenomas). The mean attenuation value, SUVmax AL/SUVmax primary tumor, SUVmax, SUVmax AL/liver, and SUVmax AL/SUVmean liver were significantly different between metastatic and benign ALs from NSCLC patients. The SUVmax AL/SUVmean liver ≥1.81 had the best positive (PPV, 94.3%) and negative (NPV, 82.4%) predictive values, and the highest specificity (93.3%), sensitivity (84.6%) and accuracy (86.9%). Lipid-poor ALs with SUVmax AL/SUVmean liver ≥1.81 can be accepted as malignant in NSCLC. However, if SUVmax AL/SUVmean liver is <1.81, a pathologic examination is required. Utilizing this cut-off value to decide on adrenal core biopsy may prevent its unnecessary use. Moreover, this diagnostic approach can save time and reduce the healthcare costs.
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Affiliation(s)
- Fikri Selcuk Simsek
- Nuclear Medicine Department, Firat University Medical Faculty, Elazığ, Turkey.
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Altieri B, Muscogiuri G, Paschou SA, Vryonidou A, Della Casa S, Pontecorvi A, Fassnacht M, Ronchi CL, Newell-Price J. Adrenocortical incidentalomas and bone: from molecular insights to clinical perspectives. Endocrine 2018; 62:506-516. [PMID: 30073456 DOI: 10.1007/s12020-018-1696-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/24/2018] [Indexed: 12/21/2022]
Abstract
Adrenal incidentalomas constitute a common clinical problem with an overall prevalence of around 2-3%, but are more common with advancing age being present in 10% of those aged 70 years. The majority of these lesions are benign adrenocortical adenomas (80%), characterized in 10-40% of the cases by autonomous cortisol hypersecretion, and in 1-10% by aldosterone hypersecretion. Several observational studies have shown that autonomous cortisol and aldosterone hypersecretion are more prevalent than expected in patients with osteopenia and osteoporosis: these patients have accelerated bone loss and an increased incidence of vertebral fractures. In contrast to glucocorticoid action, the effects of aldosterone on bone are less well understood. Recent data, demonstrating a concomitant co-secretion of glucocorticoid metabolites in patients with primary aldosteronism, could explain some of the metabolic abnormalities seen in patients with aldosterone hypersecretion. In clinical practice, patients with unexplained osteoporosis, particularly when associated with other features such as impaired glucose tolerance or hypertension, should be investigated for the possible presence of autonomous cortisol or aldosterone secretion due to an adrenal adenoma. Randomized intervention studies are needed, however, to investigate the optimum interventions for osteoporosis and other co-morbidities in these patients.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Wuerzburg, Wuerzburg, Germany.
- Division of Endocrinology and Metabolic Diseases, Institute of Medical Pathology, Catholic University of the Sacred Heart, Rome, Italy.
| | - Giovanna Muscogiuri
- Department of Clinical Medicine and Surgery, University "Federico II", Naples, Italy
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athens, Greece
| | - Silvia Della Casa
- Division of Endocrinology and Metabolic Diseases, Institute of Medical Pathology, Catholic University of the Sacred Heart, Rome, Italy
| | - Alfredo Pontecorvi
- Division of Endocrinology and Metabolic Diseases, Institute of Medical Pathology, Catholic University of the Sacred Heart, Rome, Italy
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Cristina L Ronchi
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Wuerzburg, Wuerzburg, Germany
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
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Hurtado MD, Cortes T, Natt N, Young WF, Bancos I. Extensive clinical experience: Hypothalamic-pituitary-adrenal axis recovery after adrenalectomy for corticotropin-independent cortisol excess. Clin Endocrinol (Oxf) 2018; 89:721-733. [PMID: 29968420 PMCID: PMC6246804 DOI: 10.1111/cen.13803] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To identify predictors of hypothalamic-pituitary-adrenal (HPA) axis recovery interval and severity of glucocorticoid withdrawal symptoms (GWS) in patients undergoing adrenalectomy for corticotropin-independent cortisol excess. DESIGN This is a retrospective study of patients with mild autonomous cortisol excess (MACE), moderate and severe Cushing syndrome (CS) who developed adrenal insufficiency after unilateral adrenalectomy between 1998 and 2017. RESULTS Adrenalectomy was performed in 81 patients (79% women, median age 52 years [IQR 42-62]). HPA axis recovery occurred at a median of 4.3 months (IQR 1.6-11.4) after adrenalectomy (severe CS vs moderate CS vs MACE: median 11.4 vs 2.8 vs 2.1 months, P < 0.01). Main predictors of HPA axis recovery interval included: preoperative serum cortisol concentration after 1-mg overnight dexamethasone suppression test >10 μg/dL or >276 nmol/L (9.7 vs 1.3 months if cortisol ≤10 μg/dL or ≤276 nmol/L, P < 0.01); body mass index (for every 3 kg/m2 decrease, glucocorticoid taper increased by 1 month, P < 0.05); age <45 (11.4 vs 2.3 months if ≥45 years, P < 0.05); duration of symptoms prior to diagnosis >1 year (11.4 vs 2.8 months if ≤1 year); moon facies (11.4 vs 2.2 months if no rounding of the face); and myopathy (13.1 vs 2.7 months if no myopathy, P < 0.05). Patients with severe CS had a higher incidence of GWS compared to patients with MACE (66.7% vs 40.0%, P < 0.05) with a median of 1 and 0 events/patient, respectively. CONCLUSIONS The HPA axis recovery interval was the longest for patients with severe CS. Surprisingly, patients with moderate CS recovered their HPA axis as quickly as those with MACE. Glucocorticoid withdrawal symptoms were observed in all groups, with more events in patients with severe CS. This study emphasizes the need to counsel patients on expectations for HPA axis recovery and address intervention for GWS based on individual preoperative parameters.
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Affiliation(s)
- Maria Daniela Hurtado
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN
| | - Tiffany Cortes
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN
| | - Neena Natt
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN
| | - William F. Young
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN
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Bourdeau I, El Ghorayeb N, Gagnon N, Lacroix A. MANAGEMENT OF ENDOCRINE DISEASE: Differential diagnosis, investigation and therapy of bilateral adrenal incidentalomas. Eur J Endocrinol 2018; 179:R57-R67. [PMID: 29748231 DOI: 10.1530/eje-18-0296] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/10/2018] [Indexed: 01/11/2023]
Abstract
The investigation and management of unilateral adrenal incidentalomas have been extensively considered in the last decades. While bilateral adrenal incidentalomas represent about 15% of adrenal incidentalomas (AIs), they have been less frequently discussed. The differential diagnosis of bilateral incidentalomas includes metastasis, primary bilateral macronodular adrenal hyperplasia and bilateral cortical adenomas. Less frequent etiologies are bilateral pheochromocytomas, congenital adrenal hyperplasia (CAH), Cushing's disease or ectopic ACTH secretion with secondary bilateral adrenal hyperplasia, primary malignancies, myelolipomas, infections or hemorrhage. The investigation of bilateral incidentalomas includes the same hormonal evaluation to exclude excess hormone secretion as recommended in unilateral AI, but diagnosis of CAH and adrenal insufficiency should also be excluded. This review is focused on the differential diagnosis, investigation and treatment of bilateral AIs.
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Affiliation(s)
- Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - Nada El Ghorayeb
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - Nadia Gagnon
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
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21
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Ceccato F, Barbot M, Albiger N, Antonelli G, Zilio M, Todeschini M, Regazzo D, Plebani M, Lacognata C, Iacobone M, Mantero F, Boscaro M, Scaroni C. Daily salivary cortisol and cortisone rhythm in patients with adrenal incidentaloma. Endocrine 2018; 59:510-519. [PMID: 28956262 DOI: 10.1007/s12020-017-1421-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIM Impaired cortisol rhythm is a characteristic feature of Cushing's Syndrome, nevertheless late night salivary cortisol (LNSC) is not suitable to detect subclinical hypercortisolism in patients with adrenal incidentaloma (AI). We studied daily salivary cortisol (F) and cortisone (E) rhythm in patients with AI. MATERIALS AND METHODS Six saliva samples were collected from awakening to night in 106 patients with AI and 40 controls. F and E were measured with LC-MS/MS and daily F exposure was calculated with the area under the curve (AUC). RESULTS Patients with serum cortisol after dexamethasone suppression test (DST) > 50 nmol/L showed higher morning F (15.5 ± 14.5 vs. 8.6 ± 5.5 nmol/L, p = 0.001), suppressed corticotropin levels (76 vs. 35%, p < 0.001) and increased daily F exposure (3795 ± 1716 vs. 2898 ± 1478, p = 0.012), especially in the morning (2035 ± 1267 vs. 1365 ± 777, p = 0.003), otherwise LNSC levels were similar. Salivary E and AUC levels were higher in patients with DST > 50 nmol/L. AUC was not correlated with urinary cortisol levels or adenoma size. F and E levels were similar among patients with unilateral or bilateral adenoma, or considering the presence of hypertension, dyslipidemia, diabetes, or cardiovascular events. CONCLUSION Daily cortisol exposure, evaluated with AUC from multiple saliva collections, is increased in AI patients with serum cortisol > 50 nmol/L after DST, especially in the morning, leading to reduced corticotropin levels. Cortisol rhythm is preserved in patients with AI, remarking that LNSC is not a screening test for subclinical hypercortisolism.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy.
| | - Mattia Barbot
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
| | - Nora Albiger
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
| | - Giorgia Antonelli
- Department of Medicine DIMED, Laboratory Medicine Unit, University-Hospital of Padova, Padova, Italy
| | - Marialuisa Zilio
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Todeschini
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
| | - Daniela Regazzo
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine DIMED, Laboratory Medicine Unit, University-Hospital of Padova, Padova, Italy
| | - Carmelo Lacognata
- Department of Medicine DIMED, Radiology Section, University-Hospital of Padova, Padova, Italy
| | - Maurizio Iacobone
- Department of Surgery, Minimally-Invasive Endocrine Surgery Unit, Oncology and Gastroenterology, University-Hospital of Padova, Padova, Italy
| | - Franco Mantero
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Department of Medicine DIMED, Endocrinology Unit, University-Hospital of Padova, Padova, Italy
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Scaroni C, Zilio M, Foti M, Boscaro M. Glucose Metabolism Abnormalities in Cushing Syndrome: From Molecular Basis to Clinical Management. Endocr Rev 2017; 38:189-219. [PMID: 28368467 DOI: 10.1210/er.2016-1105] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 03/15/2017] [Indexed: 12/13/2022]
Abstract
An impaired glucose metabolism, which often leads to the onset of diabetes mellitus (DM), is a common complication of chronic exposure to exogenous and endogenous glucocorticoid (GC) excess and plays an important part in contributing to morbidity and mortality in patients with Cushing syndrome (CS). This article reviews the pathogenesis, epidemiology, diagnosis, and management of changes in glucose metabolism associated with hypercortisolism, addressing both the pathophysiological aspects and the clinical and therapeutic implications. Chronic hypercortisolism may have pleiotropic effects on all major peripheral tissues governing glucose homeostasis. Adding further complexity, both genomic and nongenomic mechanisms are directly induced by GCs in a context-specific and cell-/organ-dependent manner. In this paper, the discussion focuses on established and potential pathologic molecular mechanisms that are induced by chronically excessive circulating levels of GCs and affect glucose homeostasis in various tissues. The management of patients with CS and DM includes treating their hyperglycemia and correcting their GC excess. The effects on glycemic control of various medical therapies for CS are reviewed in this paper. The association between DM and subclinical CS and the role of screening for CS in diabetic patients are also discussed.
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Affiliation(s)
- Carla Scaroni
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
| | - Michelangelo Foti
- Department of Cell Physiology & Metabolism, Centre Médical Universitaire, 1 Rue Michel Servet, 1211 Genèva, Switzerland
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
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Li L, Yang G, Zhao L, Dou J, Gu W, Lv Z, Lu J, Mu Y. Baseline Demographic and Clinical Characteristics of Patients with Adrenal Incidentaloma from a Single Center in China: A Survey. Int J Endocrinol 2017; 2017:3093290. [PMID: 28848603 PMCID: PMC5564109 DOI: 10.1155/2017/3093290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/14/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022] Open
Abstract
AIM To investigate the clinical and endocrinological characteristics of patients with adrenal incidentaloma (AI). MATERIALS AND METHODS This retrospective study enrolled 1941 AI patients hospitalized at the Department of Endocrinology, Chinese PLA General Hospital, Beijing, China, between January 1997 and December 2016. The patient gender, age at visits, imaging features, functional status, and histological results were analyzed. RESULTS Of the 1941 patients, 984 (50.70%) were men. The median age was 52 years (interquartile range: 44-69 years). 140 cases had bilateral AI. Endocrine evaluation showed that 1411 (72.69%) patients had nonfunctional tumor, 152 (7.83%) had subclinical Cushing syndrome (SCS), and 82 (4.33%) had primary hyperaldosteronism. A total of 925 patients underwent operation for removal of 496 cortical adenomas (53.62%), 15 adrenal cortical carcinomas (1.62%), and 172 pheochromocytomas (18.59%). The bilateral group had a higher proportion of SCS (18.57% versus 7.10%, P < 0.001, P = 0.006). A mass size of 46 mm was of great value in distinguishing malignant tumors from the benign tumors, with sensitivity of 88.2% and specificity of 95.5%. CONCLUSIONS We reported the baseline demographic and clinical characteristics of patients with AI in a large series from a single center in China.
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Affiliation(s)
- Lele Li
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Guoqing Yang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Ling Zhao
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
- *Jingtao Dou:
| | - Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Juming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
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Chiodini I, Vainicher CE, Morelli V, Palmieri S, Cairoli E, Salcuni AS, Copetti M, Scillitani A. MECHANISMS IN ENDOCRINOLOGY: Endogenous subclinical hypercortisolism and bone: a clinical review. Eur J Endocrinol 2016; 175:R265-R282. [PMID: 27412441 DOI: 10.1530/eje-16-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/13/2016] [Indexed: 01/11/2023]
Abstract
In recent years, the condition of subclinical hypercortisolism (SH) has become a topic of growing interest. This is due to the fact that SH prevalence is not negligible (0.8-2% in the general population) and that, although asymptomatic, this subtle cortisol excess is not harmless, being associated with an increased risk of complications, in particular of osteoporosis and fragility fractures. As specific symptoms of hypercortisolism are absent in SH, the SH diagnosis relies only on biochemical tests and it is a challenge for physicians. As a consequence, even the indications for the evaluation of bone involvement in SH patients are debatable and guidelines are not available. Finally, the relative importance of bone density, bone quality and glucocorticoid sensitivity in SH is a recent field of research. On the other hand, SH prevalence seems to be increased in osteoporotic patients, in whom a vertebral fracture may be the presenting symptom of an otherwise asymptomatic cortisol excess. Therefore, the issue of who and how to screen for SH among the osteoporotic patients is widely debated. The present review will summarize the available data regarding the bone turnover, bone mineral density, bone quality and risk of fracture in patients with endogenous SH. In addition, the role of the individual glucocorticoid sensitivity in SH-related bone damage and the problem of diagnosing and managing the bone consequences of SH will be reviewed. Finally, the issue of suspecting and screening for SH patients with apparent primary osteoporosis will be addressed.
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Affiliation(s)
- I Chiodini
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Eller Vainicher
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - S Palmieri
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - E Cairoli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - A S Salcuni
- Endocrine UnitDepartment of Medical Sciences, University of Cagliari, Cagliari, Italy
| | | | - A Scillitani
- Unit of Endocrinology"Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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Ognjanović S, Macut D, Petakov M, Elezović Kovačević V, Isailović T, Bozić Antić I, Ilić D, Popović B, Bogavac T, Pekmezović T, Damjanović S. The Occurrence of Subclinical Hypercortisolism and Osteoporosis in Patients with Incidentally Discovered Unilateral and Bilateral Adrenal Tumors. J Med Biochem 2016; 35:401-409. [PMID: 28670192 PMCID: PMC5471635 DOI: 10.1515/jomb-2016-0020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/06/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Adrenal incidentalomas (AI) are clinically silent adrenal masses that are detected incidentally during imaging procedures performed for unrelated diseases. The aim of this study was to investigate the prevalence of sub-clinical hypercortisolism (SH) and associated co-morbidities in patients with unilateral AI (UAI) and bilateral AI (BAI). METHODS We evaluated 152 patients, 105 (69.1%) with UAI and 47 (30.9%) with BAI. SH was diagnosed in the presence of serum cortisol levels after 1 mg dexamethasone suppression test (DST) or after 2-day low-dose DST (LDDST) > 50 nmol/L with at least one of the following parameters: midnight serum cortisol > 208 nmol/L, 24-h urinary free cortisol > 245 nmol/24 h, or ACTH < 10 ng/L. Bone mineral density (BMD) was measured at lumbar spine (LS) and femoral neck (FN). RESULTS Age, BMI, and waist circumference were comparable, and diabetes, hypertension and dyslipidemia occurred with similar frequency in both groups. The overall prevalence of SH was 20.5% based on post-1 mg DST, and 20.0% based on post-LDDST cortisol levels, and it was more prevalent in BAI than UAI patients (31.1% vs 15.2%, respectively, p=0.026). LS BMD was lower in BAI than in UAI patients (0.96±0.14 vs 0.87±0.15, p=0.002). There were no differences in FN BMD. The prevalence of osteoporosis was higher in BAI compared to UAI patients (37.1% vs 15.9%, respectively, p=0.011). CONCLUSIONS Patients with BAI had higher prevalence of SH and osteoporosis than those with UAI. Frequency of other co-morbidities was similar. This may be due to the higher degree of autonomous cortisol secretion or different tissue-specific sensitivity to glucocorticoids.
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Affiliation(s)
- Sanja Ognjanović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Djuro Macut
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Petakov
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Tatjana Isailović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Bozić Antić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Dušan Ilić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Bojana Popović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Tamara Bogavac
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Tatjana Pekmezović
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Svetozar Damjanović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Adrenal (131)I-6β-iodomethylnorcholesterol scintigraphy in choosing the side for adrenalectomy in bilateral adrenal tumors with subclinical hypercortisolemia. ACTA ACUST UNITED AC 2016; 40:2453-60. [PMID: 26041277 PMCID: PMC4584114 DOI: 10.1007/s00261-015-0452-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose Adrenal scintigraphy with 131I-6β-iodomethylnorcholesterol is considered by several authors the gold standard for assessing tumors with subclinical hypercortisolemia. However, most of the described series consist mainly of cases with unilateral lesions. The aim of our study was to assess whether scintigraphy is useful in choosing the adrenalectomy side in the case of bilateral adrenal tumors with subclinical hypercortisolemia. Methods The study focused on 15 consecutive patients with benign bilateral adrenal tumors and subclinical hypercortisolemia. The scintigraphy with 131I-6β-iodomethylnorcholesterol was performed. Fourteen patients underwent unilateral adrenalectomy; the gland with predominant uptake on scintigraphy was removed. Cortisol and ACTH concentrations were measured one and six months after surgery. Post-dexamethasone cortisolemia was assessed six months after surgery. To date, the patients have been under postoperative observation for 1–4 years. Results Four patients showed unilateral uptake of radiotracer, and nine patients showed predominant accumulation of radiotracer in one of the adrenal glands. The smaller tumor was predominant in 2 cases. Percentage of activity on the predominant side correlates positively with the difference between tumors’ diameters. Unilateral uptake of radiotracer predicts long-lasting postoperative insufficiency of the second adrenal gland. Excision of predominating tumor led to cessation of hypercortisolemia in all patients. Conclusions The corticoadrenal scintigraphy is useful in choosing the side for operation in the case of bilateral adrenal tumors with subclinical hypercortisolemia.
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Paschou SA, Kandaraki E, Dimitropoulou F, Goulis DG, Vryonidou A. Subclinical Cushing's syndrome in patients with bilateral compared to unilateral adrenal incidentalomas: a systematic review and meta-analysis. Endocrine 2016; 51:225-35. [PMID: 26498946 DOI: 10.1007/s12020-015-0776-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/15/2015] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to systematically review the literature for studies that have investigated possible differences in the prevalence of subclinical Cushing's syndrome (SCS) and related clinical implications between patients with unilateral (UAI) and bilateral adrenal incidentalomas (BAI) and to meta-analyze the best evidence available. Electronic databases PubMed and EMBASE were systematically searched. Main study outcome was the prevalence of SCS in patients with UAI and BAI. Secondary outcomes were the prevalence of obesity, diabetes, glucose intolerance, hypertension, dyslipidemia, and osteoporosis in patients with UAI and BAI. Risk differences (RD) or mean differences (MD) and 95 % confidence intervals (CIs) were calculated. Meta-analysis was conducted using Review Manager (RevMan 5.3). Six studies were included in the meta-analysis involving in total 1239 patients, 968 with UAI, and 271 with BAI. Patients with UAI had lower prevalence of SCS compared with those with BAI [RD (95 % CI) -0.13 (-0.22 to -0.05), I (2) = 42 %]. The mass diameter of UAI did not differ from BAI (the size of the largest lesion) [MD (95 % CI) -0.45 (-1.09 to 0.19), I (2) = 91 %]. The prevalence of obesity [MD (95 % CI) 0.42 (-0.53 to 1.37), I (2) = 4 %], diabetes [RD (95 % CI) -0.04 (-0.11 to 0.04), I (2) = 0 %], hypertension [RD (95 % CI) 0.00 (-0.18 to 0.18), I (2) = 75 %], and dyslipidemia [RD (95 % CI) -0.02 (-0.16 to 0.13), I (2) = 50 %] did not differ between UAI and BAI. The present meta-analysis provided evidence that patients with BAI present a higher prevalence of SCS compared to patients with UAI.
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Affiliation(s)
- Stavroula A Paschou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athanasaki 1, 11526, Athens, Greece.
| | - Eleni Kandaraki
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athanasaki 1, 11526, Athens, Greece
| | - Fotini Dimitropoulou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athanasaki 1, 11526, Athens, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athanasaki 1, 11526, Athens, Greece
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Baltzer P, Clauser P, Klatte T, Walz J. Work-up of the Incidental Adrenal Mass. Eur Urol Focus 2015; 1:217-222. [PMID: 28723390 DOI: 10.1016/j.euf.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 12/07/2015] [Indexed: 12/26/2022]
Abstract
CONTEXT Incidental adrenal masses (or adrenal incidentalomas [AI]) are a common finding during imaging and are present in up to 5% of the computed tomography (CT) scans performed on the general population. The best way to manage these lesions is still under discussion. OBJECTIVE To evaluate recent literature and available guidelines regarding the work-up of AIs. EVIDENCE ACQUISITION We used a medical search engine to identify studies published in the past 5 yr regarding AIs. We also evaluated current guidelines and the most relevant papers published before 2010. EVIDENCE SYNTHESIS Unenhanced and contrast-enhanced CT, with laboratory tests to exclude functional lesions, are the most sensitive and specific methods currently available for the characterisation of adrenal masses. Magnetic resonance imaging, positron emission tomography-CT and fine-needle aspiration biopsy can be used as adjunct diagnostic tools in indeterminate lesions but are rarely indicated. In a relatively high number of indeterminate nodules, follow-up or surgery is suggested, although most of these lesions turn out to be benign. CONCLUSIONS Various imaging modalities, with CT being most important, are available to diagnose malignant and functional lesions in AIs. An improved identification of benign lesions is warranted to reduce the number of unnecessary surgeries and follow-up examinations in patients with benign lesions. PATIENT SUMMARY We performed a review of the literature on and guidelines for the management of incidental adrenal masses. It is possible to detect the presence of lesions that require surgery in the majority of cases. Follow-up is required for lesions that are not treated surgically.
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Affiliation(s)
- Pascal Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
| | - Paola Clauser
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Klatte
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Jochen Walz
- Institut Paoli-Calmettes, Service de chirurgie urologique, Marseille, France
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Perogamvros I, Vassiliadi DA, Karapanou O, Botoula E, Tzanela M, Tsagarakis S. Biochemical and clinical benefits of unilateral adrenalectomy in patients with subclinical hypercortisolism and bilateral adrenal incidentalomas. Eur J Endocrinol 2015; 173:719-25. [PMID: 26330465 DOI: 10.1530/eje-15-0566] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 09/01/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The treatment of subclinical hypercortisolism in patients with bilateral adrenal incidentalomas (AI) is debatable. We aimed to compare the biochemical and clinical outcome of unilateral adrenalectomy vs a conservative approach in these patients. DESIGN Retrospective study. METHODS The study included 33 patients with bilateral AI; 14 patients underwent unilateral adrenalectomy of the largest lesion (surgical group), whereas 19 patients were followed up (follow-up group). At baseline and at each follow-up visit, we measured 0800 h plasma ACTH, midnight serum cortisol (MSF), 24-h urinary-free cortisol (UFC) and serum cortisol following a standard 2-day low-dose-dexamethasone-suppression test (LDDST). We evaluated the following comorbidities: arterial hypertension, impaired glucose tolerance or diabetes mellitus, dyslipidemia and osteoporosis. RESULTS Baseline demographic, clinical characteristics and the duration of follow-up (53.9±21.3 vs 51.8±20.1 months, for the surgical vs the follow-up group) were similar between groups. At the last follow-up visit the surgical group had a significant reduction in post-LDDST cortisol (2.4±1.6 vs 6.7±3.9 μg/dl, P=0.002), MSF (4.3±2 vs 8.8±4.6 μg/dl, P=0.006) and 24-h UFC (50.1±21.1 vs 117.9±42.4 μg/24 h, P=0.0007) and a significant rise in mean±s.d. morning plasma ACTH levels (22.2±9.6 vs 6.9±4.8 pg/ml, P=0.002). Improvement in co-morbidities was seen only in the surgical group, whereas no changes were noted in the follow-up group. CONCLUSIONS Our early results show that removal of the largest lesion offers significant improvement both to cortisol excess and its metabolic consequences, without the debilitating effects of bilateral adrenalectomy. A larger number of patients, as well as a longer follow-up, are required before drawing solid conclusions.
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Affiliation(s)
| | - D A Vassiliadi
- Department of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, 106 76 Athens, GreeceEndocrine UnitSecond Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Center, Attiko University Hospital, 12462 Athens, Greece
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Di Dalmazi G, Pasquali R, Beuschlein F, Reincke M. Subclinical hypercortisolism: a state, a syndrome, or a disease? Eur J Endocrinol 2015; 173:M61-71. [PMID: 26282599 DOI: 10.1530/eje-15-0272] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/23/2015] [Indexed: 01/11/2023]
Abstract
Subclinical hypercortisolism (SH), defined as alterations of the hypothalamus-pituitary-adrenal axis in the absence of clinical signs or symptoms related to cortisol secretion, is a common finding in patients with adrenal incidentalomas. The clinical correlates of this pathological condition have become clearer over the last few years. The aim of this review is to summarize the co-morbidities and the clinical outcomes of patients with SH. According to the analysis of the results of the studies published within the last 15 years, hypertension and type 2 diabetes are a common finding in patients with SH, occurring roughly in 2/3 and 1/3 of the patients respectively. Moreover, several additional cardiovascular and metabolic complications, like endothelial damage, increased visceral fat accumulation and impaired lipid metabolism have been shown to increase the cardiovascular risk of those patients. Accordingly, recent independent reports investigating the natural history of the disease in a long-term follow-up setting have shown that patients with SH have a higher incidence of cardiovascular events and related mortality. Moreover, longitudinal studies have also shown increased incidence of osteoporotic vertebral fractures. Future research is needed to improve the diagnostic performance of hormonal tests, by assessment of the complete steroid profile with more accurate assays, and to define the efficacy of surgical vs medical treatment in a randomized-controlled setting.
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Affiliation(s)
- Guido Di Dalmazi
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstrasse 1, D-80336 München, GermanyEndocrinology UnitDepartment of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, 40138 Bologna, Italy
| | - Renato Pasquali
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstrasse 1, D-80336 München, GermanyEndocrinology UnitDepartment of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, 40138 Bologna, Italy
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstrasse 1, D-80336 München, GermanyEndocrinology UnitDepartment of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, 40138 Bologna, Italy
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ziemssenstrasse 1, D-80336 München, GermanyEndocrinology UnitDepartment of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, 40138 Bologna, Italy
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Jia AH, Du HQ, Fan MH, Li YH, Xu JL, Niu GF, Bai J, Zhang GZ, Ren YB. Clinical and pathological analysis of 116 cases of adult adrenal cortical adenoma and literature review. Onco Targets Ther 2015; 8:1251-7. [PMID: 26064059 PMCID: PMC4455871 DOI: 10.2147/ott.s81831] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The aim of this study is to investigate origin, gross features, microscopic features, immunohistochemical properties, and differential diagnosis of adrenal cortical adenoma (ACA) in patients ≥20 years old. METHODS The clinicopathological features of 116 cases of ACA and the immunohistochemical features of 50 cases of ACA were evaluated, and the relevant literature was reviewed. RESULTS In our cohort, 76.72% (89/116) of the cases were functional, and 27 cases had non-functional, benign adrenal adenomas. ACA presented as an island tumor with an envelope, and the mean tumor size was 3.6 cm (range 1-5 cm), with a mean tumor weight of 9.28 g (range 5-113 g). The shape of the tumor cells was consistent, and mitosis was rarely observed. Forty of the 46 patients with cortisol-secreting ACA had tumors containing granule cells. Primary aldosteronism was observed in 43 cases. Thirty-eight cases had endoscopically visible tumors, with clear cells and lipid-rich cytoplasm arranged in irregular patches or strips. Cortisol-producing ACAs were associated with atrophy of the non-tumorous cortex. Adrenocortical adenomas displayed positive immunohistochemical staining for MELAN-A, Syn (46 of 50 cases of ACA), NSE (44 of 50 cases of ACA), Vim (42 of 50 cases of ACA) and Ki-67 <5% (24 of 50 cases of ACA; the remaining 26 cases were negative for Ki-67). CONCLUSION Prediction of endocrine syndrome in functional ACA was possible based on its structure and morphologic features, which could prevent an unanticipated postoperative crisis. However, a clinical study is needed to validate these findings.
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Affiliation(s)
- Ai-Hua Jia
- Department of Pathology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Hong-Quan Du
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Min-Hua Fan
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Yu-Hong Li
- Department of Pathology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Jun-Long Xu
- Department of Pathology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Gui-Fen Niu
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Jie Bai
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Guang-Zhen Zhang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Yu-Bo Ren
- Department of Pathology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
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Ricciato MP, Di Donna V, Perotti G, Pontecorvi A, Bellantone R, Corsello SM. The role of adrenal scintigraphy in the diagnosis of subclinical Cushing's syndrome and the prediction of post-surgical hypoadrenalism. World J Surg 2015; 38:1328-35. [PMID: 24615601 DOI: 10.1007/s00268-014-2482-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Management of subclinical Cushing's syndrome (SCS) remains controversial; it is not possible to predict which patients would benefit from adrenalectomy. In the present study we aimed to evaluate the role of adrenocortical scintigraphy (ACS) in the management of patients with SCS. METHODS The medical records of 33 consecutive patients with adrenal "incidentaloma" and proven or suspected SCS who underwent (131)I-19-iodocholesterol ACS between 2004 and 2010 were reviewed. Sixteen underwent laparoscopic adrenalectomy (surgical group-S-group) and 17 were medically managed (medical group-M-group). Follow-up evaluation was obtained by outpatient consultation. RESULTS Overall 25 patients (15 in the S-group and 10 in the M-group) had concordant unilateral uptake at ACS (ACS+). In the S-group, the mean follow-up duration was 30.9 ± 16.1 months and, irrespective of the presence of hormonal diagnosis of SCS, in patients who were ACS+ adrenalectomy resulted in a significant increase in HDL cholesterol and decreases in body mass index, glycemia, and blood pressure (BP). One patient reduced antihypertensive medication and three others were able to discontinue it altogether. Prolonged postoperative hypoadrenalism (PH) occurred in 14 patients in the S-group. The overall accuracy in predicting PH was 93.7 % for ACS and 68.7 % for laboratory findings. In the M-group, the mean follow-up duration was 31.5 ± 26.3 months and no patient developed overt Cushing's syndrome, although ACS+ patients experienced a worsening in glycemia and diastolic BP. CONCLUSIONS Adrenal scintigraphy seems the most accurate diagnostic test for SCS. It is able to predict the metabolic outcome and the occurrence of PH, identifying the patients who could benefit from adrenalectomy irrespective of hormonal diagnosis.
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Affiliation(s)
- Maria Pia Ricciato
- Units of Endocrinology, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Vassilatou E, Vryonidou A, Ioannidis D, Paschou SA, Panagou M, Tzavara I. Bilateral adrenal incidentalomas differ from unilateral adrenal incidentalomas in subclinical cortisol hypersecretion but not in potential clinical implications. Eur J Endocrinol 2014; 171:37-45. [PMID: 24743396 DOI: 10.1530/eje-13-0848] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate the possibility of a different prevalence of subclinical Cushing's syndrome (SCS) and potentially related morbidities between patients with unilateral adrenal incidentalomas (UAI) and bilateral adrenal incidentalomas (BAI), as existing data are few and controversial. DESIGN Prospective observational study. METHODS Clinical examination, biochemical tests, and hormonal evaluation were performed in 298 consecutive patients with adrenal incidentalomas, unilateral in 224 patients (75.2%), bilateral in 74 patients (24.8%), with apparently benign masses based on imaging characteristics and after exclusion of overt endocrine disease. The diagnosis of SCS was based on a post-dexamethasone suppression test (2 mg dexamethasone/24 h for 48 h), with serum cortisol level ≥1.8 μg/dl combined with at least one abnormal result of the other hormonal measurements. RESULTS SCS was diagnosed in 66 out of 298 (22.1%) patients, being more frequent in patients with BAI (35.1 vs 17.9%, P=0.003, for BAI and UAI respectively). Hypertension, type 2 diabetes mellitus, impaired glucose tolerance, and dyslipidemia were of a similar frequency in both groups. SCS patients with UAI and BAI did not differ in age, gender, BMI, waist circumference, and mass size. Factors related to SCS were the presence of BAI (OR, 3.24; 95% CI, 2.31-4.54) and mass size (OR, 2.63; 95% CI, 1.31-5.26). CONCLUSION BAI patients present more often with SCS when compared with UAI patients; however, morbidities potentially related to subtle cortisol hypersecretion were of a similar frequency in both groups. Further studies are needed to clarify whether this difference in hormonal activity may be related to different pathophysiologies.
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Affiliation(s)
- Evangeline Vassilatou
- Endocrine Unit2nd Department of Internal Medicine - Propaedeutic, 'Attikon' University Hospital, 1 Rimini Street, Haidari, Athens 12462, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Red Cross Hospital', Athens, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Amalia Fleming' General Hospital, Athens, Greece
| | - Andromachi Vryonidou
- Endocrine Unit2nd Department of Internal Medicine - Propaedeutic, 'Attikon' University Hospital, 1 Rimini Street, Haidari, Athens 12462, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Red Cross Hospital', Athens, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Amalia Fleming' General Hospital, Athens, Greece
| | - Dimitrios Ioannidis
- Endocrine Unit2nd Department of Internal Medicine - Propaedeutic, 'Attikon' University Hospital, 1 Rimini Street, Haidari, Athens 12462, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Red Cross Hospital', Athens, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Amalia Fleming' General Hospital, Athens, Greece
| | - Stavroula A Paschou
- Endocrine Unit2nd Department of Internal Medicine - Propaedeutic, 'Attikon' University Hospital, 1 Rimini Street, Haidari, Athens 12462, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Red Cross Hospital', Athens, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Amalia Fleming' General Hospital, Athens, Greece
| | - Maria Panagou
- Endocrine Unit2nd Department of Internal Medicine - Propaedeutic, 'Attikon' University Hospital, 1 Rimini Street, Haidari, Athens 12462, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Red Cross Hospital', Athens, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Amalia Fleming' General Hospital, Athens, Greece
| | - Ioanna Tzavara
- Endocrine Unit2nd Department of Internal Medicine - Propaedeutic, 'Attikon' University Hospital, 1 Rimini Street, Haidari, Athens 12462, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Red Cross Hospital', Athens, GreeceDepartment of EndocrinologyDiabetes and Metabolism, 'Amalia Fleming' General Hospital, Athens, Greece
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Abstract
The surgical treatment of adrenal tumours has evolved over the past century, as has our understanding of which hormones are secreted by the adrenal glands and what these hormones do. This article reviews the preoperative evaluation of patients with adrenal tumours that could be benign or malignant, including metastases. The biochemical evaluation of excess levels of hormones is discussed, as are imaging characteristics that differentiate benign tumours from malignant tumours. The options for surgical management are outlined, including the advantages and disadvantages of various open and laparoscopic approaches. The surgical management of adrenocortical carcinoma is specifically reviewed, including controversies in operative approaches as well as surgical management of invasive or recurrent disease.
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Affiliation(s)
- Barbra S Miller
- University of Michigan Health System, 1500 East Medical Center Drive, 2920F Taubman Center, Ann Arbor, MI 48109-5331, USA
| | - Gerard M Doherty
- Department of Surgery, Boston University, 75 East Newton Street, Boston, MA 02118, USA
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35
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Tabarin A. [Adrenal incidentalomas]. Presse Med 2014; 43:393-400. [PMID: 24613315 DOI: 10.1016/j.lpm.2014.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 01/20/2014] [Accepted: 01/28/2014] [Indexed: 11/30/2022] Open
Abstract
Adrenal incidentalomas are found in approximately 2-3% of abdominal CT-scan examinations. A key issue is to determine whether the incidentaloma is neoplastic or responsible for endocrine hypersecretion, two situations in which surgical excision is recommended. Candidate incidentalomas for surgery include hypersecreting tumors (pheochromocytomas, Cushing's adenoma, Conn's adenoma) and adrenocortical carcinomas. The majority of adrenal incidentalomas are non-secreting cortical adenomas and lesions to remove account for less than 5% of adrenal incidentalomes. The pathological consequences of "subclinical" cortisol-secreting adenomas responsible for mild hypercortisolism and whether or not these tumors should be removed remain debatable.
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Affiliation(s)
- Antoine Tabarin
- CHU de Bordeaux, USN Haut-Levêque, service d'endocrinologie, diabète et nutrition, 1, avenue Magellan, 33604 Pessac cedex, France.
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Szabó DR, Luconi M, Szabó PM, Tóth M, Szücs N, Horányi J, Nagy Z, Mannelli M, Patócs A, Rácz K, Igaz P. Analysis of circulating microRNAs in adrenocortical tumors. J Transl Med 2014; 94:331-9. [PMID: 24336071 DOI: 10.1038/labinvest.2013.148] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 11/01/2013] [Accepted: 11/21/2013] [Indexed: 12/28/2022] Open
Abstract
Differential diagnosis of adrenocortical adenoma (ACA) and carcinoma is of pivotal clinical relevance, as the prognosis and clinical management of benign and malignant adrenocortical tumors (ACTs) is entirely different. Circulating microRNAs (miRNAs) are promising biomarker candidates of malignancy in several tumors; however, there are still numerous technical problems associated with their analysis. The objective of our study was to investigate circulating miRNAs in ACTs and to evaluate their potential applicability as biomarkers of malignancy. We have also addressed technical questions including the choice of profiling and reference gene used. A total of 25 preoperative plasma samples obtained from patients with ACAs and carcinomas were studied by microarray and quantitative real-time PCR. None of the three miRNAs (hsa-miR-192, hsa-mir-197 and hsa-miR-1281) found as differentially expressed in plasma samples in our microarray screening could be validated by quantitative real-time PCR. In contrast, of the selected eight miRNAs reported in the literature as differentially expressed in ACT tissues, five (hsa-miR-100, hsa-miR-181b, hsa-miR-184, hsa-miR-210 and hsa-miR-483-5p) showed a statistically significant overexpression in adrenocortical cancer vs adenoma when normalized on hsa-miR-16 as a reference gene. Receiver operator characteristic analysis of data revealed that the combination of dCThsa-miR-210 - dCThsa-miR-181b and dCThsa-miR-100/dCThsa-miR-181b showed the highest diagnostic accuracy (area under curve 0.87 and 0.85, respectively). In conclusion, we have found significant differences in expression of circulating miRNAs between ACAs and carcinomas, but their diagnostic accuracy is not yet high enough for clinical application. Further studies on larger cohorts of patients are needed to assess the diagnostic and prognostic potential application of circulating miRNA markers.
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Affiliation(s)
- Diana Rita Szabó
- 2nd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Michaela Luconi
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Peter M Szabó
- Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Miklós Tóth
- 2nd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Nikolette Szücs
- 2nd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - János Horányi
- 1st Department of Surgery, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltán Nagy
- 2nd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Massimo Mannelli
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Attila Patócs
- 1] Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary [2] 'Lendület-2013' Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Károly Rácz
- 2nd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Peter Igaz
- 2nd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
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Kawate H, Kohno M, Matsuda Y, Akehi Y, Tanabe M, Horiuchi T, Ohnaka K, Nomura M, Yanase T, Takayanagi R. Long-term study of subclinical Cushing's syndrome shows high prevalence of extra-adrenal malignancy in patients with functioning bilateral adrenal tumors. Endocr J 2014; 61:1205-12. [PMID: 25223468 DOI: 10.1507/endocrj.ej14-0155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Subclinical Cushing's syndrome (SCS) is characterized by subtle autonomous cortisol secretion from adrenal tumors without specific signs and symptoms of hypercortisolism. Patients with SCS have a high prevalence of "lifestyle-related diseases," such as hypertension, diabetes mellitus, dyslipidemia, and osteoporosis. Long-term follow-up of SCS patients is reportedly indispensable for establishing indications for surgical treatment of SCS. We performed a follow-up survey of 27 patients with SCS (median: 5.3 years) and compared those who had undergone surgical treatment (n=15) with those who had not (n=12). The mean diameter of tumors was 31 mm; 16 (59%) patients had unilateral lesions and 11 (41%) carried bilateral ones. In 67% and 60% of the treatment group, respectively, hypertension and diabetes mellitus improved. We also noticed that eight of 11 (73%) SCS patients with bilateral adrenal tumors had extra-adrenal malignancies in various tissues. Interestingly, among nine SCS patients who had malignancies, eight showed bilateral adrenal uptake in ¹³¹I-aldosterol scintigraphy. The results imply that surgical treatment can reduce cardiovascular risks in SCS patients. Screening for malignancy may be necessary in patients with bilateral adrenal tumors suspected of autonomous hypersecretion of cortisol from both sides.
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Affiliation(s)
- Hisaya Kawate
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
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