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

Metabolic complications and clinical outcomes of non-functioning adrenal incidentalomas: a systematic review and meta-analysis

BACKGROUND

Increased detection of non-functioning adrenal incidentalomas (NFAI) due to widespread abdominal imaging may underestimate associated metabolic risks. To examine NFAI's impact on metabolic comorbidities and evaluate outcomes in surgical and non-surgical management, including changes in NFAI characteristics during follow-up.

METHODS

Meta-analysis of studies from PubMed, Embase, Cochrane Library, and Web of Science (January 2000 to May 2024). Studies focusing on patients with serum cortisol levels ≤ 50 nmol/L after 1 mg dexamethasone suppression test (DST). Prevalence of hypertension, diabetes, obesity, and lipid disorders before and after follow-up. Tumor growth (> 10 mm increase) and functional changes (1 mg DST retest) were assessed.

RESULTS

Eighteen studies met inclusion criteria (n = 2,059). In the non-surgical group, diabetes (RR: 1.33, 95% CI: 1.07-1.65) and lipid disorders (RR: 1.22, 95% CI: 1.07-1.38) increased significantly, while hypertension (RR: 1.07, 95% CI: 0.99-1.16) and obesity (RR: 1.05, 95% CI: 0.91-1.21) showed no significant change. Surgical intervention significantly improved hypertension (RR: 0.67, 95% CI: 0.52-0.86). During mean follow-up of 46.1 months, 4% (95% CI: 2%- 8%) of NFAI enlarged > 10 mm, while 8% (95% CI: 5%- 14%) became functional during 45.1 months of follow-up.

CONCLUSIONS

In patients with NFAI, subtle hormone secretion may exist despite current diagnostic criteria suggesting non-functionality. Such tumors show significant associations with metabolic disorders, particularly diabetes mellitus and dyslipidemia. Future research should focus on developing more sensitive diagnostic methods and establishing evidence-based surgical intervention criteria through prospective studies.

Diabetes Mellitus in Non-Functioning Adrenal Incidentalomas: Analysis of the Mild Autonomous Cortisol Secretion (MACS) Impact on Glucose Profile

Non-functioning adrenal incidentalomas (NFAIs) have been placed in relationship with a higher risk of glucose profile anomalies, while the full-blown typical picture of Cushing's syndrome (CS) and associated secondary (glucocorticoid-induced) diabetes mellitus is not explicitly confirmed in this instance. Our objective was to highlight the most recent data concerning the glucose profile, particularly, type 2 diabetes mellitus (T2DM) in NFAIs with/without mild autonomous cortisol secretion (MACS). This was a comprehensive review of the literature; the search was conducted according to various combinations of key terms. We included English-published, original studies across a 5-year window of publication time (from January 2020 until 1 April 2024) on PubMed. We excluded case reports, reviews, studies on T1DM or secondary diabetes, and experimental data. We identified 37 studies of various designs (14 retrospective studies as well 13 cross-sectional, 4 cohorts, 3 prospective, and 2 case-control studies) that analysed 17,391 individuals, with a female-to-male ratio of 1.47 (aged between 14 and 96 years). T2DM prevalence in MACS (affecting 10 to 30% of NFAIs) ranged from 12% to 44%. The highest T2DM prevalence in NFAI was 45.2% in one study. MACS versus (non-MACS) NFAIs (n = 16) showed an increased risk of T2DM and even of prediabetes or higher fasting plasma glucose or HbA1c (no unanimous results). T2DM prevalence was analysed in NFAI (N = 1243, female-to-male ratio of 1.11, mean age of 60.42) versus (non-tumour) controls (N = 1548, female-to-male ratio of 0.91, average age of 60.22) amid four studies, and two of them were confirmatory with respect to a higher rate in NFAIs. Four studies included a sub-group of CS compared to NFAI/MACS, and two of them did not confirm an increased rate of glucose profile anomalies in CS versus NFAIs/ACS. The longest period of follow-up with concern to the glycaemic profile was 10.5 years, and one cohort showed a significant increase in the T2DM rate at 17.9% compared to the baseline value of 0.03%. Additionally, inconsistent data from six studies enrolling 1039 individuals that underwent adrenalectomy (N = 674) and conservative management (N = 365) pinpointed the impact of the surgery in NFAIs. The regulation of the glucose metabolism after adrenalectomy versus baseline versus conservative management (n = 3) was improved. To our knowledge, this comprehensive review included one of the largest recent analyses in the field of glucose profile amid the confirmation of MACS/NFAI. In light of the rising incidence of NFAI/AIs due to easier access to imagery scans and endocrine evaluation across the spectrum of modern medicine, it is critical to assess if these patients have an increased frequency of cardio-metabolic disorders that worsen their overall comorbidity and mortality profile, including via the confirmation of T2DM.

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

BACKGROUND AND OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Is the Adrenal Incidentaloma Functionally Active? An Approach-To-The-Patient-Based Review

Adrenal incidentalomas are a common occurrence. Most of them are adrenocortical adenomas that do not cause harm and do not require surgery, but a non-negligible proportion of incidentalomas is represented by functionally active masses, including cortisol-secreting adenomas (12%), pheochromocytomas (3–6%), aldosterone-secreting adenomas (2–3%), as well as malignant nodules, such as adrenocortical carcinomas (2–5%), which can be either functioning or non-functioning. All patients with an adrenal incidentaloma should undergo a few biochemical screening and confirmatory tests to exclude the presence of a functionally active mass. In this approach-to-the-patient-based review, we will summarize current recommendations on biochemical evaluation and management of functionally active adrenal incidentalomas. For this purpose, we will present four case vignettes, whereby we will describe how patients were managed, then we will review and discuss additional considerations tied to the diagnostic approach, and conclude with practical aspects of patient perioperative management. To improve the perioperative management of patients with functional adrenal incidentalomas, multidisciplinary meetings are advocated.