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Delivanis DA, Andrade Hurtado MD, Cortes T, Athimulam S, Khanna A, Atkinson E, McKenzie T, Takahashi N, Moynagh MR, Bancos I. Abnormal body composition in patients with adrenal adenomas. Eur J Endocrinol 2021; 185:653-662. [PMID: 34406976 PMCID: PMC8511231 DOI: 10.1530/eje-21-0458] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/18/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Increased visceral fat and sarcopenia are cardiovascular risk factors that may explain increased cardiovascular morbidity and frailty in patients with adrenal adenomas. Our objective was to compare body composition measurement of patients with adrenal adenomas to referent subjects without adrenal disease. DESIGN Cross-sectional study, 2014-2018. METHODS Participants were adults with nonfunctioning adrenal tumor (NFAT), mild autonomous cortisol secretion (MACS), and Cushing syndrome (CS) and age, sex, and BMI 1:1 matched referent subjects without adrenal disorders. Main outcome measures were body composition measurements calculated from abdominal CT imaging. Intra-abdominal adipose tissue and muscle mass measurements were performed at the third lumbar spine level. RESULTS Of 227 patients with adrenal adenomas, 20 were diagnosed with CS, 76 with MACS, and 131 with NFAT. Median age was 56 years (range: 18-89), and 67% were women. When compared to referent subjects, patients with CS, MACS, and NFAT demonstrated a higher visceral fat (odds ratio (OR): 2.2 (95% CI: 0.9-6.5), 2.0 (1.3-3.2), and 1.8 (1.2-2.7) and a lower skeletal muscle area (OR: 0.01 (95% CI: 0-0.09), 0.31 (0.18-0.49), and 0.3 (1.2-2.7)) respectively. For every 1 µg/dL cortisol increase after overnight dexamethasone, visceral fat/muscle area ratio increased by 2.3 (P = 0.02) and mean total skeletal muscle area decreased by 2.2 cm2 (P = 0.03). CONCLUSION Patients with adrenal adenomas demonstrate a lower muscle mass and a higher proportion of visceral fat when compared to referent subjects, including patients with NFAT. Even a subtle abnormality in cortisol secretion may impact health of patients with adenomas.
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Affiliation(s)
- Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Maria D. Andrade Hurtado
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic Health System, La Crosse, WI, USA
| | - Tiffany Cortes
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, MI, USA
| | - Aakanksha Khanna
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Atkinson
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Travis McKenzie
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
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Chevalier B, Vantyghem MC, Espiard S. Bilateral Adrenal Hyperplasia: Pathogenesis and Treatment. Biomedicines 2021; 9:biomedicines9101397. [PMID: 34680514 PMCID: PMC8533142 DOI: 10.3390/biomedicines9101397] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 01/06/2023] Open
Abstract
Bilateral adrenal hyperplasia is a rare cause of Cushing’s syndrome. Micronodular adrenal hyperplasia, including the primary pigmented micronodular adrenal dysplasia (PPNAD) and the isolated micronodular adrenal hyperplasia (iMAD), can be distinguished from the primary bilateral macronodular adrenal hyperplasia (PBMAH) according to the size of the nodules. They both lead to overt or subclinical CS. In the latter case, PPNAD is usually diagnosed after a systematic screening in patients presenting with Carney complex, while for PBMAH, the diagnosis is often incidental on imaging. Identification of causal genes and genetic counseling also help in the diagnoses. This review discusses the last decades’ findings on genetic and molecular causes of bilateral adrenal hyperplasia, including the several mechanisms altering the PKA pathway, the recent discovery of ARMC5, and the role of the adrenal paracrine regulation. Finally, the treatment of bilateral adrenal hyperplasia will be discussed, focusing on current data on unilateral adrenalectomy.
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Affiliation(s)
- Benjamin Chevalier
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, F-59000 Lille, France; (B.C.); (M.-C.V.)
| | - Marie-Christine Vantyghem
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, F-59000 Lille, France; (B.C.); (M.-C.V.)
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1190, European Genomic Institute for Diabetes (EGID), CHU Lille, F-59000 Lille, France
| | - Stéphanie Espiard
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, F-59000 Lille, France; (B.C.); (M.-C.V.)
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1190, European Genomic Institute for Diabetes (EGID), CHU Lille, F-59000 Lille, France
- Correspondence:
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Nishiyama M, Karashima T, Iwasaki Y, Terada Y, Fujimoto S. Unilateral adrenalectomy partially improved hyperglycemia in a patient with primary bilateral macronodular adrenal hyperplasia. Diabetol Int 2021; 12:480-484. [PMID: 34567928 DOI: 10.1007/s13340-021-00503-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/28/2021] [Indexed: 11/27/2022]
Abstract
Primary bilateral macronodular adrenal hyperplasia (PBMAH) is characterized by bilateral multiple adrenal macro-nodules that often cause mild over-secretion of cortisol in the form of subclinical Cushing's syndrome. We herein describe a case, wherein unilateral adrenalectomy partially improved hyperglycemia in a patient with PBMAH and suggest the usefulness and limitations of this surgical strategy. A 64-year-old woman with type 2 diabetes had an incidental diagnosis of bilateral adrenal lesions. She had a family history of type 2 diabetes, and her HbA1c level was 8.9% under insulin therapy. She did not present with any symptoms associated with Cushing's syndrome. The basal cortisol level was in the normal range (12.0 μg/dL); however, the adrenocorticotropic hormone (ACTH) level was suppressed (2.1 pg/mL) and the serum cortisol level was not suppressed in the dexamethasone test. Computed tomography and magnetic resonance imaging showed bilateral adrenal macro-nodules and 131I-adosterol accumulated in the bilateral adrenal lesions. Collectively, she was diagnosed with subclinical Cushing's syndrome due to PBMAH complicated with diabetes mellitus, hypertension, and dyslipidemia. Laparoscopic left adrenalectomy was performed, and the pathologic findings were consistent with PBMAH. After unilateral adrenalectomy, serum cortisol levels decreased, and hypertension improved. Both HbA1c levels and insulin requirement also decreased, but insulin therapy was continuously needed. It should be noted that hyperglycemia may not be cured after successful surgery in a patient with PBMAH. Additional operation or medical therapy should be considered if unilateral adrenalectomy is unable to correct hypercortisolism in PBMAH patients.
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Affiliation(s)
- Mitsuru Nishiyama
- Health Care Center, Kochi University, 1-5-2, Akebono-cho, Kochi-City, Kochi 780-8520 Japan.,Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, 1-185, Kohasu, Okoh-cho, Nankoku-City, Kochi 783-8505 Japan
| | - Takashi Karashima
- Department of Urology, Kochi Medical School, Kochi University, 1-185, Kohasu, Okoh-cho, Nankoku-City, Kochi 783-8505 Japan
| | - Yasumasa Iwasaki
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, 1-185, Kohasu, Okoh-cho, Nankoku-City, Kochi 783-8505 Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, 1-185, Kohasu, Okoh-cho, Nankoku-City, Kochi 783-8505 Japan
| | - Shimpei Fujimoto
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, 1-185, Kohasu, Okoh-cho, Nankoku-City, Kochi 783-8505 Japan
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Chiodini I, Gennari L. Grand Challenge in Adrenal Endocrinology: Is the Legacy of the Past a Challenge for the Future of Precision Medicine? Front Endocrinol (Lausanne) 2021; 12:747006. [PMID: 34539585 PMCID: PMC8446680 DOI: 10.3389/fendo.2021.747006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 08/09/2021] [Indexed: 01/06/2023] Open
Affiliation(s)
- 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
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Corwin MT, Lan C, Wilson M, Loehfelm TW, Campbell MJ. Can abdominal CT features predict autonomous cortisol secretion in patients with adrenal nodules? Abdom Radiol (NY) 2021; 46:4338-4344. [PMID: 33963418 DOI: 10.1007/s00261-021-03110-y] [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: 02/10/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine if CT features of adrenal nodules and of the remainder of the abdomen can predict autonomous cortisol secretion (ACH) in patients with adrenal nodules, and to identify a nodule size threshold below which ACH is unlikely. METHODS Retrospective review of adult patients with adrenal nodules who underwent CT of abdomen and 1-mg Dexamethasone suppression test within 1 year of each other. Patients were considered to have no ACH if serum cortisol was ≤ 1.8 µg/dL after the 1-mg dexamethasone suppression test and to have possible or definite autonomous cortisol secretion if serum cortisol was > 1.8 µg/dL. The following CT features were assessed: Adrenal nodule length, nodule width, unenhanced nodule attenuation, contralateral adrenal gland thickness, visceral and subcutaneous adipose tissue area, skeletal muscle area and density, and unenhanced liver attenuation. RESULTS 29 patients had no autonomous cortisol secretion and 29 patients had possible or definite autonomous cortisol secretion. Nodule length and width were the only two variables that significantly differed between patients with nonfunctional nodules and those with possibly or definitely functional nodules. Using a threshold nodule length of 1.5 cm, the sensitivity and specificity for predicting possible or definite autonomous cortisol secretion was 93.1% and 37.9%, respectively. CONCLUSION Autonomous cortisol secretion in patients with adrenal nodules correlates with increasing nodule size. A nodule length threshold of 1.5 cm provides 93.1% sensitivity for predicting possible or definite ACH based on the 1-mg Dexamethasone suppression test.
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Giovanelli L, Aresta C, Favero V, Bonomi M, Cangiano B, Eller-Vainicher C, Grassi G, Morelli V, Pugliese F, Falchetti A, Gennari L, Scillitani A, Persani L, Chiodini I. Hidden hypercortisolism: a too frequently neglected clinical condition. J Endocrinol Invest 2021; 44:1581-1596. [PMID: 33394454 DOI: 10.1007/s40618-020-01484-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/07/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Classic Cushing's syndrome (CS) is a severe disease characterized by central obesity, hypertension, easy bruising, striae rubrae, buffalo hump, proximal myopathy and hypertricosis. However, several CS cases have also been reported with unusual or camouflaged manifestations. In recent years, several authors investigated the prevalence of "hidden hypercortisolism" (HidHyCo) among subjects affected with bone fragility, hypertension and type 2 diabetes mellitus (DM2). The prevalence of the HidHyCo is estimated to be much higher than that of classic CS. However, similarly to classic CS, HidHyCo is known to increase the risk of fractures, cardiovascular disease and mortality. METHODS We reviewed all published cases of unusual presentations of hypercortisolism and studies specifically assessing the HidHyCo prevalence in diabetic, osteoporotic and hypertensive patients. RESULTS We found 49 HidHyCo cases, in whom bone fragility, hypertension and diabetes were the presenting manifestations of an otherwise silent hypercortisolism. Amongst these cases, 34.7%, 32.7%, 6.1% and 19.0%, respectively, had bone fragility, hypertension, DM2 or hypertension plus DM2 as the sole clinical manifestations of HidHyCo. Overall, 25% of HidHyCo cases were of pituitary origin, and bone fragility was the very prevalent first manifestation among them. In population studies, it is possible to estimate that 1-4% of patients with apparent primary osteoporosis has a HidHyCo and the prevalence of this condition among diabetics ranges between 3.4 and 10%. CONCLUSION These data indicate that patients with resistant or suddenly worsening hypertension or DM2 or unexplainable bone fragility should be screened for HidHyCo using the most recently approved sensitive cut-offs.
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Affiliation(s)
- L Giovanelli
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Aresta
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - V Favero
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Bonomi
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - B Cangiano
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Eller-Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - G Grassi
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - F Pugliese
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, FG, Italy
| | - A Falchetti
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
| | - L Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - A Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, FG, Italy
| | - L Persani
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - I Chiodini
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Aresta C, Soranna D, Giovanelli L, Favero V, Parazzoli C, Gennari L, Persani L, Scillitani A, Blevins LS, Brown D, Einhorn D, Pivonello R, Pantalone KM, Jørgensen JOL, Zambon A, Chiodini I. When to suspect hidden hypercortisolism in type 2 diabetes: a meta-analysis. Endocr Pract 2021; 27:1216-1224. [PMID: 34325041 DOI: 10.1016/j.eprac.2021.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Among patients with type 2 diabetes (T2D), the prevalence of hidden hypercortisolism (HidHyCo, formally called subclinical hypercortisolism or mild autonomous cortisol secretion) was estimated to be 2.2-12.1%. The aim of this study was to investigate whether the available literature helps to identify the characteristics of T2D patients more frequently associated with HidHyCo. METHODS A meta-analysis was performed using studies that assessed both the prevalence of HidHyCo in patients with T2D and the characteristics of these patients with and without HidHyCo. The DerSimonian and Laird (DSL) and the Hartung, Knapp, Sidik and Jonkman (HKSJ) methods were utilized. RESULTS Among the 18 available studies, 6 studies provided the necessary data. The association between HidHyCo and advanced T2D (based on the patients' description given in each study in presence of micro/ microvascular complications, or insulin treatment plus hypertension, or hypertension treated with ≥2 drugs), hypertension, insulin treatment and dyslipidemia was reported in 5 (2184 patients), 6 (2283 patients), 3 (1440 patients), and 3 (987 patients) studies, respectively. HidHyCo was associated with advanced T2D as assessed with both DSL (odds ratio, OR, 3.47, 95% Confidence Interval, 95%CI, 2.12-5.67) and HKSJ method (OR 3.60, 95%CI 2.03-6.41) and with the prevalence of hypertension or of insulin treatment as assessed by the DSL approach (OR 1.92, 95%CI 1.05-3.50 and OR 2.29, 95%CI 1.07-4.91, respectively), but not as assessed with HKSJ method. CONCLUSIONS Patients with advanced T2D have a higher prevalence of HidHyCo. These data inform about the selection of T2D patients for HidHyCo screening.
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Affiliation(s)
- Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico Italiano, Biostatistic Unit, Milan, Italy
| | - Luca Giovanelli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Vittoria Favero
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Chiara Parazzoli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy
| | - Lewis S Blevins
- Department of Neurosurgery, University of California San Francisco, California Center for Pituitary Disorders, San Francisco, California
| | | | - Dan Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, CA, USA
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Staff of UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | | | | | - Antonella Zambon
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy; Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Iacopo Chiodini
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy.
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Huayllas MKP, Smith LM, Gallagher JC, Netzel BC, Singh RJ, Kater CE. Steroidogenesis in patients with adrenal incidentalomas: Extended steroid profile measured by liquid chromatography-mass spectrometry after ACTH stimulation and dexamethasone suppression. Clin Endocrinol (Oxf) 2021; 95:29-40. [PMID: 33598999 DOI: 10.1111/cen.14445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Describe the secretion and profile of adrenal steroids in patients with adrenal incidentalomas compared to control subjects. DESIGN, SETTING AND PARTICIPANTS A prospective study, 73 patients with adrenal incidentalomas, 21 bilateral and 52 unilateral and 34 matched controls in University Hospital. METHODS Collect fasting blood sample before and 60 min after ACTH test (250 µg IV). One week later, perform overnight 1 mg dexamethasone test. The following steroids were measured by liquid chromatography-mass spectrometry (LC-MS): pregnenolone, 17-OH pregnenolone, 17-OH progesterone, 11-deoxycorticosterone, 11-deoxyortisol, 21-deoxycortisol, corticosterone, cortisol, androstenedione and aldosterone. RESULTS Mean baseline serum cortisol was higher in incidentalomas, bilateral 361 ± 124, (range 143-665) nmol/L,(p < .0001), unilateral 268 ± 89 3.2 (range 98-507) nmol/L (p < .019) compared to controls 207 ± 100 (range 72-502) nmol/L. ACTH stimulation showed significantly higher levels in bilateral and unilateral cases compared to controls. After dexamethasone, mean serum cortisol levels suppressed in bilaterals 89 ± 69 (range 30-3) nmol/L (p < .0001), 58 ± 52 (range 16-323) nmol/L in unilateral (p < .01) compared to 26 ± 9 (range 7-46) nmol/L in controls. Mean baseline serum corticosterone was higher in bilateral 9.3 ± 4.8 (range 2.4-18.4) nmol/L (p < .005) and unilateral 7.3 ± 5.7 (range 0.1-30.3) nmol/L (p < .01) compared to controls 4.2 ± 2.4 (range 1.1-10.2) nmol/L, after ACTH stimulation significantly increased to higher levels in bilateral (p < .0002) and unilateral cases (p < .044) compared to controls. After dexamethasone, mean levels were 2.5 ± 2.6 (range 0.5-12.5) nmol/L in bilateral (p < .0006), 1.5 ± 1.6 (range 0.3-9.3) nmol/L in unilateral (p < .09) and 0.75 ± 0.46 (range 0.1-2.1) nmol/L in controls. Mean baseline serum 11-deoxycorticosterone (DOC) was higher in bilaterals 0.32 ± 0.23 (range 0.08-1.1) nmol/L (p < .03) compared to controls 0.15 ± 0.21 (range 0.08-1.1) nmol/L. ACTH stimulation increased levels to 3.27 ± 1.72 (range 0.5-7.4) nmol/L in bilateral cases compared to controls 1.369 ± 1.53 (range 0.1-7.1) nmol/L (p < .0001). Dexamethasone decreased levels to baseline (p ns). There were significant differences in serum 21-deoxycortisol (p < .0002) and serum pregnenolone (p < .004) only after ACTH stimulation. CONCLUSIONS There is increased activity in several steroid biosynthesis pathways and higher steroid levels in bilateral compared to unilateral cases and evidence of hypercortisolism in 30% unilateral and 62% of bilateral incidentalomas.
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Affiliation(s)
- Martha K P Huayllas
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, UNIFESP- EPM, Federal University of São Paulo, São Paulo, Brasil
| | - Lynette M Smith
- Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Brian C Netzel
- Laboratory and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ravinder J Singh
- Laboratory and Pathology, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Claudio E Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, UNIFESP- EPM, Federal University of São Paulo, São Paulo, Brasil
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Impact of Adrenalectomy on Morbidity in Patients with Non-Functioning Adrenal Cortical Tumours, Mild Hypercortisolism and Cushing's Syndrome as Assessed by National and Quality Registries. World J Surg 2021; 45:3099-3107. [PMID: 34180008 PMCID: PMC8408086 DOI: 10.1007/s00268-021-06214-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 01/06/2023]
Abstract
Background The impact of adrenalectomy on morbidity in patients with mild hypercortisolism and non-functioning adrenocortical adenoma is unclear. The present study evaluated morbidity before and after adrenalectomy in patients with benign adrenocortical tumour with Cushing´s syndrome (CS), autonomous cortisol secretion (ACS) and non-functioning adrenocortical adenoma as assessed by national and quality registries. Methods Patients registered in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009–2017 with CS, ACS or non-functioning adrenocortical adenoma, were included in this retrospective study and analysed with age- and sex-matched controls, 1:3. Morbidity associated with CS was assessed pre- and postoperatively by analysing data from the Swedish National Patient Register and the Swedish Prescribed Drug Register. Results Some 271 patients were included, CS (127), ACS (45) and non-functioning adrenocortical adenoma (99), with 813 matched controls. The frequency of hypertension was almost 50% in all tumour groups. Antihypertensive medication preoperatively was more frequent in all tumour groups compared with controls. No preoperative differences in medication were detected between patients with CS and ACS. A decrease in the use of hypertensive drugs was noticed annually for all patient groups after adrenalectomy. Conclusions Hypertension is common in patients with benign adrenocortical tumours regardless of cortisol hypersecretion. The use of antihypertensive drugs in patients with CS, ACS and non-functioning adrenocortical adenoma was reduced after adrenalectomy. These findings highlight the need for a randomized controlled trial to investigate the impact of adrenalectomy on morbidity in patients with mild hypercortisolism. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06214-0.
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Hamidi O. Cardiovascular and metabolic consequences in patients with asymptomatic adrenal adenomas. Curr Opin Endocrinol Diabetes Obes 2021; 28:277-282. [PMID: 33764928 DOI: 10.1097/med.0000000000000628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The incidence of adrenal tumors has increased over the past 20 years, most of which are incidentally discovered nonfunctioning adenomas (NFA) and tumors with mild autonomous cortisol secretion (MACS). This review aimed to summarize recent progress in understanding cardiometabolic risk in patients with NFA and MACS and to provide updates on the effect of treatment on improving outcomes in this population. RECENT FINDINGS NFA and MACS are associated with adverse cardiovascular risk factors and metabolic derangements, which are likely mediated by excessive glucocorticoid secretion. Recent studies showed significantly higher prevalence of hypertension, impaired glucose metabolism, obesity, and dyslipidemia in patients with NFA and MACS. Adrenalectomy may improve comorbidities in selected patients. SUMMARY Asymptomatic adrenal adenomas are common and are associated with adverse cardiometabolic changes. In selected patients, adrenalectomy may reduce cardiometabolic risk and improve clinical outcomes.
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Affiliation(s)
- Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Ivović M, Marina LV, Šojat AS, Tančić-Gajić M, Arizanović Z, Kendereški A, Vujović S. Approach to the Patient with Subclinical Cushing's Syndrome. Curr Pharm Des 2021; 26:5584-5590. [PMID: 32787757 DOI: 10.2174/1381612826666200813134328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/08/2020] [Indexed: 01/07/2023]
Abstract
A growing number of patients with adrenal incidentalomas and subclinical Cushing's syndrome (SCS) led to an increasing number of different guidelines, and diagnostic and treatment recommendations. Excess cortisol secretion in patients with SCS is associated with several comorbidities, such as hypertension, dyslipidemia, type 2 diabetes mellitus, and obesity, which in the long-term increase mortality of these patients. Subtle cortisol secretion affects bone health, quality of life and causes depression, but due to the unapparent clinical features, patients with SCS are often at risk between over and under treatment. This narrative review aimed to summarize the latest recommendations on the approach to the patient with subclinical Cushing's syndrome.
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Affiliation(s)
- Miomira Ivović
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Ljiljana V Marina
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Antoan S Šojat
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Milina Tančić-Gajić
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Zorana Arizanović
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Aleksandra Kendereški
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Svetlana Vujović
- Department for Obesity, Metabolic and Reproductive Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
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Li D, Kaur RJ, Zhang CD, Ebbehoj A, Singh S, Atkinson EJ, Achenbach SJ, Rocca W, Khosla S, Bancos I. Risk of bone fractures after the diagnosis of adrenal adenomas: a population-based cohort study. Eur J Endocrinol 2021; 184:597-606. [PMID: 33606665 PMCID: PMC7974392 DOI: 10.1530/eje-20-1396] [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: 12/05/2020] [Accepted: 02/19/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Several small studies reported increased prevalence and incidence of asymptomatic vertebral fractures in patients with non-functioning adrenal adenomas and adenomas with mild autonomous cortisol secretion. However, the risk of symptomatic fractures at vertebrae, and at other sites remains unknown. Our objective was to determine the prevalence and incidence of symptomatic site-specific fractures in patients with adrenal adenomas. DESIGN Population-based cohort study, Olmsted County, Minnesota, USA, 1995-2017. METHODS Participants were the patients with adrenal adenoma and age/sex-matched referent subjects. Patients with overt hormone excess were excluded. Main outcomes measures were prevalence and incidence of bone fractures. RESULTS Of 1004 patients with adrenal adenomas, 582 (58%) were women, and median age at diagnosis was 63 years (20-96). At the time of diagnosis, patients had a higher prevalence of previous fractures than referent subjects (any fracture: 47.9% vs 41.3%, P = 0.003, vertebral fracture: 6.4% vs 3.6%, P = 0.004, combined osteoporotic sites: 16.6% vs 13.3%, P = 0.04). Median duration of follow-up was 6.8 years (range: 0-21.9 years). After adjusting for age, sex, BMI, tobacco use, prior history of fracture, and common causes of secondary osteoporosis, patients with adenoma had hazard ratio of 1.27 (95% CI: 1.07-1.52) for developing a new fracture during follow up when compared to referent subjects. CONCLUSIONS Patients with adrenal adenomas have higher prevalence of fractures at the time of diagnosis and increased risk to develop new fractures when compared to referent subjects.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ravinder Jeet Kaur
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Catherine D. Zhang
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Andreas Ebbehoj
- Department of Clinical Medicine, Department of Endocrinology and Diabetes, Aarhus University, Aarhus, Denmark
| | - Sumitabh Singh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth J. Atkinson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara J. Achenbach
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter Rocca
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Women’s Health Research Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Sundeep Khosla
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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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: 20] [Impact Index Per Article: 6.7] [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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Raj R, Kern PA, Ghanta N, Uy EM, Asadipooya K. Adrenal Vein Cortisol to Metanephrine Ratio for Localizing ACTH-Independent Cortisol-Producing Adenoma: A Case Report. J Endocr Soc 2021; 5:bvab009. [PMID: 33644621 DOI: 10.1210/jendso/bvab009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Indexed: 11/19/2022] Open
Abstract
Context Finding the source of adrenocorticotropic hormone (ACTH)-independent cortisol-producing adenoma in the patients with subclinical Cushing syndrome (SCS) and bilateral adrenal nodules is sometimes challenging. Computed tomography (CT) and positron emission tomography are helpful, but adrenal venous sampling (AVS) is the gold standard approach. However, interpretation of AVS is important to improve the accuracy of decision-making for surgery. We report a case and review of the literature to assess the benefit of using adrenal vein cortisol to metanephrine ratio to determine the source of cortisol production in SCS and bilateral nodules. Evidence Acquisition Three authors searched PubMed for data on patients with SCS who had AVS procedure and measurements of cortisol and catecholamines. Case Description A 51-year-old woman with SCS and hypertension crisis presented to our clinic. Paraclinical investigations revealed that she had an ACTH-independent cortisol-producing adenoma and her CT scan showed bilateral adrenal nodules. After AVS, cortisol (high to low) lateralization ratio could not determine the source of cortisol production but the cortisol to metanephrine ratio localized the source to the left side, which included the larger nodule according to CT measurements. Left adrenalectomy led to clinical and paraclinical improvement. Conclusion There is a possibility of co-secretion of other steroids accompanied with cortisol in the setting of ACTH-independent SCS. Moreover, cortisol measurement alone and interpretation of AVS results based on cortisol values may not help lateralizing the source of cortisol production with bilateral adrenal nodules. Therefore, we suggest applying cortisol to metanephrine ratio with the same gradient (gradient > 2.3, highest to lowest concentration) when the source of cortisol production cannot be determined by cortisol lateralization ratio.
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Affiliation(s)
- Rishi Raj
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Pikeville Medical Center, Pikeville, KY, USA
| | - Philip A Kern
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, KY, USA
| | - Neelima Ghanta
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, KY, USA
| | - Edilfavia M Uy
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Highlands Appalachian Regional Health Care Medical Center, Prestonsburg, KY, USA
| | - Kamyar Asadipooya
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, KY, USA
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Yozamp N, Vaidya A. Assessment of mild autonomous cortisol secretion among incidentally discovered adrenal masses. Best Pract Res Clin Endocrinol Metab 2021; 35:101491. [PMID: 33593680 DOI: 10.1016/j.beem.2021.101491] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Incidentally discovered adrenal masses are common and mostly benign and non-functioning adenomas. However, evolving evidence suggests that a notable proportion of these adrenal adenomas may demonstrate mild autonomous cortisol secretion (MACS), which has been associated with an increased risk for hypertension, hyperglycemia, obesity, dyslipidemia, vertebral fractures, adverse cardiovascular events, and mortality. Therefore, it is advised that all patients with an incidentally discovered adrenal mass be tested for MACS. When there is convincing evidence for MACS, surgical adrenalectomy has been associated with an improvement in certain metabolic parameters and a reduction in vertebral fractures; however, conclusive evidence demonstrating decreased cardiovascular outcomes or mortality are not yet available. Future studies with adequate randomization and follow-up to assess adverse clinical endpoints are needed to determine the optimal management and follow-up of patients with MACS.
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Affiliation(s)
- Nicholas Yozamp
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Athimulam S, Grebe S, Bancos I. Steroid profiling in the diagnosis of mild and overt Cushing's syndrome. Best Pract Res Clin Endocrinol Metab 2021; 35:101488. [PMID: 33589355 PMCID: PMC8164982 DOI: 10.1016/j.beem.2021.101488] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In this review, we provide a comprehensive overview of the utility of steroid profiling for diagnosis of management of overt Cushing syndrome and mild autonomous cortisol secretion. A diagnosis of Cushing syndrome is made through a multistep process that includes confirmation of endogenous hypercortisolism, followed by determination of its cause. Steroid metabolomic testing applied to serum or urine steroids and their metabolites can provide additional and novel insights into alterations of steroid biosynthesis and metabolism and its causes. In particular, increased availability and advances in mass spectrometry-based steroid analysis, coupled with machine learning-based algorithms, have facilitated the development of tailored diagnostic and subtyping approaches for autonomous cortisol secretion and might be useful for detecting low grade autonomous glucocorticoid secretion and in predicting and monitoring of disease severity and associated comorbidities.
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Affiliation(s)
- Shobana Athimulam
- Department of Medicine, Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, MI, USA.
| | - Stefan Grebe
- Department of Laboratory Medicine and Pathology, Division of Clinical Biochemistry and Immunology, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
| | - Irina Bancos
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
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Miller BS, Auchus RJ. Evaluation and Treatment of Patients With Hypercortisolism. JAMA Surg 2020; 155:1152-1159. [DOI: 10.1001/jamasurg.2020.3280] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Barbra S. Miller
- Division of Endocrine Surgery, University of Michigan, Ann Arbor
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor
- now with Division of Surgical Oncology, The Ohio State University, Columbus
| | - Richard J. Auchus
- Division of Endocrine Surgery, University of Michigan, Ann Arbor
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor
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Ueland GÅ, Grinde T, Methlie P, Kelp O, Løvås K, Husebye ES. Diagnostic testing of autonomous cortisol secretion in adrenal incidentalomas. Endocr Connect 2020; 9:963-970. [PMID: 33032259 PMCID: PMC7576642 DOI: 10.1530/ec-20-0419] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Autonomous cortisol secretion (ACS) is a condition with ACTH-independent cortisol overproduction from adrenal incidentalomas (AI) or adrenal hyperplasia. The hypercortisolism is often mild, and most patients lack typical clinical features of overt Cushing's syndrome (CS). ACS is not well defined and diagnostic tests lack validation. METHODS Retrospective study of 165 patients with AI evaluated clinically and by assay of morning plasma ACTH, late-night saliva cortisol, serum DHEA sulphate (DHEAS), 24-h urine-free cortisol, and cortisol after dexamethasone suppression. RESULTS Patients with AI (n = 165) were diagnosed as non-functioning incidentalomas (NFI) (n = 82) or ACS (n = 83) according to current European guidelines. Late-night saliva cortisol discriminated poorly between NFI and ACS, showing a high rate of false-positive (23/63) and false-negative (38/69) results. The conventional low-dose dexamethasone suppression test (LDDST) did not improve the diagnostic specificity, compared with the 1 mg overnight DST. Receiver operating characteristic curve analysis of DHEAS in the two cohorts demonstrated an area under the curve of 0.76 (P < 0.01) with a sensitivity for ACS of 58% and a specificity of 80% using the recommended cutoff at 1.04 µmol/L (40 µg/dL). CONCLUSION We here demonstrate in a large retrospective cohort of incidentaloma patients, that neither DHEAS, late-night saliva cortisol nor 24-h urine free cortisol are useful to discriminate between non-functioning adrenal incidentalomas and ACS. The conventional LDDST do not add further information compared with the 1 mg overnight DST. Alternative biomarkers are needed to improve the diagnostic workup of ACS.
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Affiliation(s)
- Grethe Å Ueland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Correspondence should be addressed to G Å Ueland:
| | - Thea Grinde
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- K. G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Oskar Kelp
- Department of Medicine, Akershus University Hospital, Nordbyhagen, Norway
| | - Kristian Løvås
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- K. G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- K. G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
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Singh S, Atkinson EJ, Achenbach SJ, LeBrasseur N, Bancos I. Frailty in Patients With Mild Autonomous Cortisol Secretion is Higher Than in Patients with Nonfunctioning Adrenal Tumors. J Clin Endocrinol Metab 2020; 105:5867964. [PMID: 32628749 PMCID: PMC7382051 DOI: 10.1210/clinem/dgaa410] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Mild autonomous cortisol secretion (MACS) affects up to 50% of patients with adrenal adenomas. Frailty is a syndrome characterized by the loss of physiological reserves and an increase in vulnerability, and it serves as a marker of declining health. OBJECTIVE To compare frailty in patients with MACS versus patients with nonfunctioning adrenal tumors (NFAT). DESIGN Retrospective study, 2003-2018. SETTING Referral center. PATIENTS Patients >20 years of age with adrenal adenoma and MACS (1 mg overnight dexamethasone suppression (DST) of 1.9-5 µg/dL) and NFAT (DST <1.9 µg/dL). MAIN OUTCOME MEASURE Frailty index (range 0-1), calculated using a 47-variable deficit model. RESULTS Patients with MACS (n = 168) demonstrated a higher age-, sex-, and body mass index-adjusted prevalence of hypertension (71% vs 60%), cardiac arrhythmias (50% vs 40%), and chronic kidney disease (25% vs 17%), but a lower prevalence of asthma (5% vs 14%) than patients with NFAT (n = 275). Patients with MACS reported more symptoms of weakness (21% vs 11%), falls (7% vs 2%), and sleep difficulty (26% vs 15%) as compared with NFAT. Age-, sex- and BMI-adjusted frailty index was higher in patients with MACS vs patients with NFAT (0.17 vs 0.15; P = 0.009). Using a frailty index cutoff of 0.25, 24% of patients with MACS were frail, versus 18% of patients with NFAT (P = 0.028). CONCLUSION Patients with MACS exhibit a greater burden of comorbid conditions, adverse symptoms, and frailty than patients with NFAT. Future prospective studies are needed to further characterize frailty, examine its responsiveness to adrenalectomy, and assess its influence on health outcomes in patients with MACS.
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Affiliation(s)
- Sumitabh Singh
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth J Atkinson
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Sara J Achenbach
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Nathan LeBrasseur
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
- Correspondence and Reprint Requests: Irina Bancos, MD, Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905. E-mail:
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Foster T, Bancos I, McKenzie T, Dy B, Thompson G, Lyden M. Early assessment of postoperative adrenal function is necessary after adrenalectomy for mild autonomous cortisol secretion. Surgery 2020; 169:150-154. [PMID: 32693952 DOI: 10.1016/j.surg.2020.05.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/26/2020] [Accepted: 05/27/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The diagnostic threshold for mild autonomous cortisol secretion using low dose, overnight, dexamethasone suppression testing is recognized widely as a serum cortisol ≥1.8 mcg/dL. The degree to which these patients require postoperative glucocorticoid replacement is unknown. METHODS We reviewed adult patients with corticotropin (ACTH)-independent hypercortisolism who underwent unilateral laparoscopic adrenalectomy for benign disease with a dexamethasone suppression testing ≥1.8 mcg/dL at our institution from 1996 to 2018. Patients with a dexamethasone suppression testing of 1.8 to 5 mcg/dL were compared with those with a dexamethasone suppression testing >5 mcg/dL. RESULTS We compared 68 patients with a preoperative dexamethasone suppression testing of 1.8 to 5 mcg/dL to 53 patients with a preoperative dexamethasone suppression testing >5 mcg/dL. Preoperative serum ACTH (mean 10.0 vs 9.2 pg/mL), adenoma size (mean 3.4 vs 3.5 cm), and side of adrenalectomy (37 and 47% right) were similar between groups (P > .05 each). Patients with a dexamethasone suppression testing 1.8 to 5 mcg/dL were older (mean values 58 ± 11 vs 52 ± 16 years ; P = .01), less likely to be female (63 vs 81%; P = .03), had greater body mass indexes (33.1 ± 8.4 vs 29.1 ± 5.6; P = .01), and had lesser 24 hour preoperative urine cortisol excretions (32.6 ± 26.7 vs 76.1 ± 129.4 mcg; P = .03). Postoperative serum cortisol levels were compared in 22 patients with a dexamethasone suppression testing of 1.8 to 5 mcg/dL to 14 patients with a dexamethasone suppression testing >5 mcg/dL. Those with dexamethasone suppression testing 1.8 to 5 mcg/dL had greater postoperative serum cortisol levels (8.0 ± 5.7 vs 5.0 ± 2.6 mcg/dL; P = .03), were less likely to be discharged on glucocorticoid replacement (59% vs 89%; P = .003), and had a decreased duration of treatment (4.4 ± 3.8 vs 10.7 ± 18.0 months; P = .04). CONCLUSION Assessment of early postoperative adrenal function with mild autonomous cortisol secretion is necessary to minimize unnecessary glucocorticoid replacement.
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Affiliation(s)
| | - Irina Bancos
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Benzon Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
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Vaduva P, Bonnet F, Bertherat J. Molecular Basis of Primary Aldosteronism and Adrenal Cushing Syndrome. J Endocr Soc 2020; 4:bvaa075. [PMID: 32783015 PMCID: PMC7412855 DOI: 10.1210/jendso/bvaa075] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
This review reports the main molecular alterations leading to development of benign cortisol- and/or aldosterone-secreting adrenal tumors. Causes of adrenal Cushing syndrome can be divided in 2 groups: multiple bilateral tumors or adenomas secreting cortisol. Bilateral causes are mainly primary pigmented nodular adrenocortical disease, most of the time due to PRKAR1A germline-inactivating mutations, and primary bilateral macronodular adrenal hyperplasia that can be caused in some rare syndromic cases by germline-inactivating mutations of MEN1, APC, and FH and of ARMC5 in isolated forms. PRKACA somatic-activating mutations are the main alterations in unilateral cortisol-producing adenomas. In primary hyperaldosteronism (PA), familial forms were identified in 1% to 5% of cases: familial hyperaldosteronism type I (FH-I) due to a chimeric CYP11B1/CYP11B2 hybrid gene, FH-II due to CLCN-2 germline mutations, FH-III due to KCNJ5 germline mutations, FH-IV due to CACNA1H germline mutations and PA, and seizures and neurological abnormalities syndrome due to CACNA1D germline mutations. Several somatic mutations have been found in aldosterone-producing adenomas in KCNJ5, ATP1A1, ATP2B3, CACNA1D, and CTNNB1 genes. In addition to these genetic alterations, genome-wide approaches identified several new alterations in transcriptome, methylome, and miRnome studies, highlighting new pathways involved in steroid dysregulation.
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Affiliation(s)
- Patricia Vaduva
- Reference Center for Rare Adrenal Diseases, Department of Endocrinology, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France
| | - Fideline Bonnet
- Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France.,Hormonal Biology Laboratory, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Jérôme Bertherat
- Reference Center for Rare Adrenal Diseases, Department of Endocrinology, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris University, Paris, France
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72
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Eller-Vainicher C, Morelli V, Aresta C, Salcuni AS, Falchetti A, Carnevale V, Persani L, Scillitani A, Chiodini I. Defining Nonfunctioning Adrenal Adenomas on the Basis of the Occurrence of Hypocortisolism after Adrenalectomy. J Endocr Soc 2020; 4:bvaa079. [PMID: 32699828 PMCID: PMC7365697 DOI: 10.1210/jendso/bvaa079] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/12/2020] [Indexed: 01/06/2023] Open
Abstract
Background In patients with adrenal incidentalomas (AIs), there is uncertainty on how to rule out hypercortisolism. The occurrence of postsurgical (unilateral adrenalectomy) hypocortisolism (PSH) has been proposed as a proof of the presence of presurgical hypercortisolism in AI patients. The aim of this study was to define the thresholds of cortisol level after the 1 mg overnight dexamethasone suppression test (F-1mgDST), urinary free cortisol (UFC), midnight serum cortisol (MSC), and adrenocorticotropin (ACTH) to predict the absence of PSH in AI patients undergoing surgery. Methods In 60 patients who underwent AI excision, cortisol secretion was assessed by a low-dose corticotropin stimulation test or insulin tolerance test when needed. We searched for the lowest presurgical value of F-1mgDST, UFC, and MSC and the highest value for ACTH in AI patients with PSH as indexes of normal cortisol secretion. Results The lowest values of F-1mgDST, UFC, and MSC and the highest value for ACTH in PSH patients were 1.2 µg/dL (33 nmol/L), 10.4 µg/24 hours (29 nmol/24 hours), 1.2 µg/dL (33 nmol/L), and 26.9 pg/mL (6 pmol/L), respectively, but only F-1mgDST <1.2 µg/dL (33 nmol/L) was able to predict the absence of PSH. Among AI patients with F-1mgDST <1.2 µg/dL (33 nmol/L) no subjects had diabetes mellitus and/or metabolic syndrome, and these subjects tended to have a better metabolic profile than those with F-1mgDST ≥1.2 µg/dL (33 nmol/L). Conclusion In AI patients a F-1mgDST <1.2 µg/dL (33 nmol/L) rules out PSH and could be used to exclude hypercortisolism in AI patients.
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Affiliation(s)
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico Milan, Italy
| | - Carmen Aresta
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy.,Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
| | - Antonio Stefano Salcuni
- Endocrinology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy
| | - Vincenzo Carnevale
- Unit of Internal Medicine, Ospedale "Casa Sollievo della soffererenza" IRCCS, San Giovanni Rotondo (FG), Italy
| | - Luca Persani
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy.,Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
| | - Alfredo Scillitani
- Endocrinology and Diabetology, Ospedale "Casa Sollievo della soffererenza" IRCCS, San Giovanni Rotondo (FG), Italy
| | - Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy.,Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
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73
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Abstract
The European society of endocrinology, in association with the European network for the study of adrenal tumors, published recommendations for the diagnosis and treatment of adrenal incidentalomas in 2016. A thorough and critical analysis of the literature was performed to establish evidence-based recommendations and expert suggestions with the aim of avoiding 'over-diagnosis' and 'over-treatment' and to reduce unnecessary investigations, surgery and follow-up. The purpose of this review is to reconsider several recommendations that are open to debate, such as imaging of adrenal incidentalomas, diagnosis of pheochromocytoma, diagnosis and treatment of autonomous cortisol-secreting tumors, investigations of bilateral AI and follow-up of non-operated AIs, based on studies published after the release of the recommendations.
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Affiliation(s)
- Sophie Cambos
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, 33604 Pessac, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, 33604 Pessac, France; Inserm U1215, Neurocentre Magendie, University of Bordeaux, 146 Rue Leo Saignat, 33076 Bordeaux Cedex, France.
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74
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Practical guide on the initial evaluation, follow-up, and treatment of adrenal incidentalomas Adrenal Diseases Group of the Spanish Society of Endocrinology and Nutrition. ACTA ACUST UNITED AC 2020; 67:408-419. [PMID: 32349941 DOI: 10.1016/j.endinu.2020.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/03/2020] [Indexed: 12/16/2022]
Abstract
Initial evaluation of adrenal incidentalomas should be aimed at ruling out malignancy and functionality. For this, a detailed clinical history should be taken, and an adequate radiographic assessment and a complete blood chemistry and hormone study should be performed. The most controversial condition, because of the lack of consensus in its definition, is autonomous cortisol secretion. Our recommendation is that, except when cortisol levels <1.8μg/dL in the dexamethasone suppression test rule out diagnosis and levels ≥5μg/dL establish the presence of autonomous cortisol secretion, diagnosis should be based on a combined definition of dexamethasone suppression test ≥3μg/dL and at least one of the following: elevated urinary free cortisol, ACTH level <10 pg/mL, or elevated nocturnal cortisol (in serum and/or saliva). During follow-up, dexamethasone suppression test should be repeated, usually every year, on an individual basis depending on the results of prior tests and the presence of comorbidities potentially related to hypercortisolism. The initial radiographic test of choice for characterization of adrenal incidentalomas is a computed tomography scan without contrast, but there is no unanimous agreement on subsequent monitoring. Our general recommendation is a repeat imaging test 6-12 months after diagnosis (based on the radiographic characteristics of the lesion). If the lesion remains stable and there are no indeterminate characteristics, no additional radiographic studies would be needed. We think that patients with autonomous cortisol secretion with comorbidities potentially related to hypercortisolism, particularly if they are young and there is a poor control, may benefit from unilateral adrenalectomy. The indication for unilateral adrenalectomy is clear in patients with overt hormonal syndromes or suspected malignancy. In conclusion, adrenal incidentalomas require a comprehensive evaluation that takes into account the possible clinical signs and comorbidities related to hormonal syndromes or malignancy; a complete hormone profile (taking into account the conditions that may lead to falsely positive and negative results); and an adequate radiographic study. Monitoring and/or treatment will be decided based on the results of the initial evaluation.
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75
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Correlation Between Size and Function of Unilateral and Bilateral Adrenocortical Nodules: An Observational Study. AJR Am J Roentgenol 2020; 214:800-807. [PMID: 32069079 DOI: 10.2214/ajr.19.21753] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE. Adrenal incidentalomas occur in 5% of adults and can produce autonomous cortisol secretion that increases the risk of metabolic syndrome and cardiovascular disease. The objective of our study was to evaluate the relationship between adrenal nodule size measured on CT and autonomous cortisol secretion. SUBJECTS AND METHODS. In a prospective study of 73 patients 22-87 years old with incidentalomas, unilateral in 52 patients and bilateral in 21 patients, we measured maximum nodule diameter on CT and serum cortisol levels at 8:00 am, 60 minutes after the adrenocorticotropic hormone stimulation test, and after the dexamethasone suppression test. We also studied 34 age-, sex-, and body mass index-matched control subjects. Statistics used were Spearman correlation coefficients, t tests, ANOVA test, and multivariate analysis. RESULTS. The mean maximum diameter of unilateral nodules measured on CT was larger on the right (2.47 ± 0.98 [SD] cm) than on the left (2.04 ± 0.86 cm) (p = 0.01). In the bilateral cases, the mean diameter of the right nodules was 2.69 ± 0.93 cm compared with 2.13 ± 0.89 cm on the left (p = 0.06). Mean baseline serum cortisol level was significantly higher in the patients with incidentalomas (bilateral, 13.1 ± 4.5 mcg/dL [p < 0.001]; unilateral, 9.7 ± 3.2 mcg/dL [p = 0.019]) than in the control subjects (7.5 ± 3.6 mcg/dL). After dexamethasone suppression test, serum cortisol levels were suppressed to less than 1.8 mcg/dL in 100% of control subjects, 33% of patients with bilateral incidentalomas, and 62% of patients with unilateral incidentalomas (p < 0.001). There were significant correlations between maximum nodule diameter on CT and serum cortisol levels after the dexamethasone suppression test (ρ = 0.500; p < 0.001) and at baseline (ρ = 0.373; p = 0.003). CONCLUSION. Increasing size of adrenal nodules is associated with more severe hyper-cortisolism and less dexamethasone suppression; these cases need further evaluation and possibly surgery because of increased risks of metabolic syndrome and cardiovascular mortality.
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76
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Szychlińska M, Baranowska-Jurkun A, Matuszewski W, Wołos-Kłosowicz K, Bandurska-Stankiewicz E. Markers of Subclinical Cardiovascular Disease in Patients with Adrenal Incidentaloma. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E69. [PMID: 32050625 PMCID: PMC7074127 DOI: 10.3390/medicina56020069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 01/19/2023]
Abstract
Due to the growing availability of imaging examinations the percentage of patients with incidentally diagnosed adrenal tumors has increased. The vast majority of these lesions are benign, non-functioning adenomas, although according to various estimates even up to 30%-50% of patients with adrenal incidentaloma may present biochemical hypercortisolemia, without typical clinical features of Cushing's syndrome. Adrenal adenomas secreting small amounts of glucocorticoids may cause morphological and functional changes in the myocardium and blood vessels. Early stages of cardiovascular remodeling may be observed among asymptomatic patients with adrenal adenoma. Vascular changes precede the development of cardiovascular diseases and can increase morbidity and mortality in patients with adrenal incidentaloma. This risk may result not only from the traditional risk factors. Seemingly hormonally inactive adrenal tumors can indeed produce small amounts of glucocorticoids that have metabolic implications. Therefore, evaluation of patients with incidental adrenal findings presenting with subclinical cardiovascular disease seems of particular importance.
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Affiliation(s)
- Magdalena Szychlińska
- Clinic of Endocrinology, Diabetology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-900 Olsztyn, Poland; (A.B.-J.); (W.M.); (K.W.-K.); (E.B.-S.)
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77
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Li D, El Kawkgi OM, Henriquez AF, Bancos I. Cardiovascular risk and mortality in patients with active and treated hypercortisolism. Gland Surg 2020; 9:43-58. [PMID: 32206598 DOI: 10.21037/gs.2019.11.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with hypercortisolism demonstrate high cardiovascular morbidity and mortality, especially if diagnosis is delayed. Hypercortisolism-induced cardiovascular and metabolic comorbidities include hypertension, impaired glucose metabolism, dyslipidemia, and obesity. High prevalence of cardiovascular risk factors leads to increased rate of cardiovascular events and mortality. This risk is reduced, albeit not reversed even after successful treatment of hypercortisolism. In this review we will describe prevalence and mechanisms of cardiovascular comorbidities in patients with hypercortisolism. In addition, we will summarize the effect of therapy on cardiovascular risk factors, events, as well as mortality.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Omar M El Kawkgi
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Andres F Henriquez
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
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78
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Kelsall A, Iqbal A, Newell-Price J. Adrenal incidentaloma: cardiovascular and metabolic effects of mild cortisol excess. Gland Surg 2020; 9:94-104. [PMID: 32206602 DOI: 10.21037/gs.2019.11.19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the vast majority of cases adrenal incidentalomas (AI) are benign adrenocortical adenomas. They are present in up to 10% of the population over 70 years, with incidence increasing with age. Mild cortisol excess (MCE) in the context of AI is defined as autonomous cortisol secretion (ACS) in the absence of the classical clinical features of Cushing's syndrome. MCE has been reported in up to at least one third of patients with AI. Numerous studies have shown that MCE in AI is associated with increased cardiovascular events and mortality, likely to be consequent upon both hemodynamic changes and inflammatory pathways, and a worse metabolic phenotype characterized by: pancreatic β-cell dysfunction, insulin resistance, visceral obesity and dyslipidemia. There is currently no level 3 evidence from large intervention randomized controlled trials to guide management of MCE in AI, and there is a lack of predictive tools to allow stratification to intervention of only those patients who would benefit in terms of improved metabolic and cardiovascular end-points. Here, we describe the mal-effects of cortisol on cardiovascular and metabolic tissues and discuss management strategies based on current largely observational data.
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Affiliation(s)
- Alan Kelsall
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | - Ahmed Iqbal
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
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79
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Yasuda S, Hikima Y, Kabeya Y, Iida S, Oikawa Y, Isshiki M, Inoue I, Shimada A, Noda M. Clinical characterization of patients with primary aldosteronism plus subclinical Cushing's syndrome. BMC Endocr Disord 2020; 20:9. [PMID: 31931803 PMCID: PMC6958814 DOI: 10.1186/s12902-020-0490-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Primary aldosteronism (PA) plus subclinical Cushing's syndrome (SCS), PASCS, has occasionally been reported. We aimed to clinically characterize patients with PASCS who are poorly profiled. METHODS A population-based, retrospective, single-center, observational study was conducted in 71 patients (age, 58.2 ± 11.2 years; 24 males and 47 females) who developed PA (n = 45), SCS (n = 12), or PASCS (n = 14). The main outcome measures were the proportion of patients with diabetes mellitus (DM), serum potassium concentration, and maximum tumor diameter (MTD) on the computed tomography (CT) scans. RESULTS The proportion of DM patients was significantly greater in the PASCS group than in the PA group (50.0% vs. 13.9%, p < 0.05), without a significant difference between the PASCS and SCS groups. Serum potassium concentration was significantly lower in the PASCS group than in the SCS group (3.2 ± 0.8 mEq/L vs. 4.0 ± 0.5 mEq/L; p < 0.01), without a significant difference between the PASCS and PA groups. Among the 3 study groups of patients who had a unilateral adrenal tumor, MTD was significantly greater in the PASCS group than in the PA group (2.7 ± 0.1 cm vs. 1.4 ± 0.1 cm; p < 0.001), without a significant difference between the PASCS and SCS groups. CONCLUSIONS Any reference criteria were not obtained that surely distinguish patients with PASCS from those with PA or SCS. However, clinicians should suspect the presence of concurrent SCS in patients with PA when detecting a relatively large adrenal tumor on the CT scans.
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Affiliation(s)
- Shigemitsu Yasuda
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan.
| | - Yusuke Hikima
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Yusuke Kabeya
- Department of Home Care Medicine, Sowa Hospital, Sagamihara, Kanagawa, Japan
| | - Shinichiro Iida
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Masashi Isshiki
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Ikuo Inoue
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Mitsuhiko Noda
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
- Department of Diabetes, Metabolism and Endocrinology, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan
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80
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Dietrich CF, Correas JM, Dong Y, Nolsoe C, Westerway SC, Jenssen C. WFUMB position paper on the management incidental findings: adrenal incidentaloma. Ultrasonography 2020; 39:11-21. [PMID: 31786909 PMCID: PMC6920619 DOI: 10.14366/usg.19029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/26/2022] Open
Abstract
Focal lesions of the adrenal glands are incidentally detected in approximately 5% of cases by modern imaging techniques. Fewer than 5% of these adrenal incidentalomas are malignant and approximately 10% have endocrine activity. Reliable differentiation of malignant versus benign and hormonally active versus nonfunctional adrenal incidentalomas significantly influences therapeutic management and the outcome of affected individuals. Therefore, each adrenal incidentaloma should undergo a standardized diagnostic work-up to exclude malignancy and endocrine activity. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on the management of adrenal incidentaloma and describes efficient management strategies with particular reference to the role of ultrasound techniques.
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Affiliation(s)
- Christoph F. Dietrich
- Medical Department, Caritas-Krankenhaus, Bad Mergentheim, Germany
- Sino-German Research Center of Ultrasound in Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Germany
| | - Jean Michel Correas
- Service de Radiologie Adultes, Hôpital Necker, Université Paris Descartes, Paris, France
| | - Yi Dong
- Medical Department, Caritas-Krankenhaus, Bad Mergentheim, Germany
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Christian Nolsoe
- Ultrasound Section, Division of Surgery, Department of Gastroenterology, Herlev Hospital, Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen, Copenhagen, Denmark
| | | | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen and Brandenburg Institute for Clinical Ultrasound, Neuruppin, Germany
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81
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Thompson LH, Nordenström E, Almquist M, Bergenfelz A. Health-related quality of life in patients undergoing adrenalectomy: report from a Swedish National Audit. Langenbecks Arch Surg 2019; 404:807-814. [PMID: 31773244 PMCID: PMC6908554 DOI: 10.1007/s00423-019-01844-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 11/13/2019] [Indexed: 01/06/2023]
Abstract
Purpose The aim of the study was to examine subjective health-related quality of life (HRQoL) in patients undergoing adrenalectomy. Methods The study included patients scheduled for adrenalectomy 2014–2017 after giving informed consent. The SF-36 questionnaire was administrated before operation and 1 year postoperatively. Results were compared with published normative values in Sweden. Results Some 50 patients were included. SF-36 scores for the whole cohort improved significantly after adrenalectomy in all dimensions except for bodily pain. Compared with the general Swedish population, the patients reported a significantly reduced HRQoL before and after adrenalectomy in all domains except for bodily pain postoperatively. Patients with benign functional tumours had lower HRQoL in physical domains before adrenalectomy than patients with benign non-functional tumours; Physical Component Summary (PCS), median 33.1 (range 17.1–62.9) vs. 44.2 (20.0–66.5), p = 0.018. Postoperatively, HRQoL was similar in the two groups of patients. Patients with benign functional tumours reported significantly improved HRQoL in all dimensions after adrenalectomy: PCS 33.1 (17.1–62.9) preoperatively vs. 47.6 (19.8-57.3) postoperatively, p = 0.005; Mental Component Summary (MCS) 33.8 (11.8–62.0) preoperatively vs. 52.7 (16.4–59.8) postoperatively, p = 0.004. These improvements were not seen in patients with benign non-functional or malignant tumours. Patients with malignant tumours reported no difference in SF-36 scores before or after adrenalectomy compared with patients with benign non-functional tumours. Conclusions Adrenalectomy improved HRQoL in patients with benign functional tumours. Adrenalectomy did not improve HRQoL in patients with benign non-functional tumours or in patients with malignant tumours. Electronic supplementary material The online version of this article (10.1007/s00423-019-01844-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Erik Nordenström
- Department of Surgery, Skåne University Hospital, 22185, Lund, Sweden
| | - Martin Almquist
- Department of Surgery, Skåne University Hospital, 22185, Lund, Sweden
| | - Anders Bergenfelz
- Department of Surgery, Skåne University Hospital, 22185, Lund, Sweden
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82
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Jouinot A, Armignacco R, Assié G. Genomics of benign adrenocortical tumors. J Steroid Biochem Mol Biol 2019; 193:105414. [PMID: 31207362 DOI: 10.1016/j.jsbmb.2019.105414] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 04/25/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022]
Abstract
Benign adrenocortical adenomas and hyperplasia are relatively common and include a spectrum of distinct entities, which diagnosis depends on the macroscopic aspect and the secretion profile. Recent advances in genomics have proposed high-throughput molecular characterization of adrenal tumors, thereby improving our knowledge on the pathophysiology and tumorigenesis of these tumors. Genomic (exome and chromosome alteration profiles), epigenomic (micro-RNAs expression and methylation profiles) and transcriptomic (gene expression profiles) studies highlighted the major roles of intracellular calcium signaling in aldosterone-producing adenomas (APA), of protein kinase A (PKA)/cAMP pathway in cortisol-producing tumors, and of Wnt/beta-catenin pathway in non-secreting tumors. Exome sequencing revealed new major drivers in all tumor types, including KCNJ5, ATP1A1, ATP2B3, CACNA1D and CACNA1H mutations in APA, PRKACA mutations in cortisol-producing adenomas (CPA) and ARMC5 mutations in primary macronodular adrenocortical hyperplasia (PMAH). The clinical impact of these findings is just starting to evolve. The identification of genetic syndromes, such as germline ARMC5 mutations in PMAH, has allowed genetic counseling. Key molecular alterations could serve as a basis for the development of targeted medical treatments for benign adrenal tumors. The recent developments in genomics, including single-cell technologies, and in proteomics and metabolomics will probably offer new perspectives for characterizing benign adrenal tumorigenesis.
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Affiliation(s)
- Anne Jouinot
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France; Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France
| | - Roberta Armignacco
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France
| | - Guillaume Assié
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris Descartes University, Paris, France; Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Hôpital Cochin, Paris, France.
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83
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Delivanis DA, Athimulam S, Bancos I. Modern Management of Mild Autonomous Cortisol Secretion. Clin Pharmacol Ther 2019; 106:1209-1221. [PMID: 31206616 DOI: 10.1002/cpt.1551] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
Incidentally discovered adrenal tumors are reported in ~ 5% of adults undergoing cross-sectional imaging. Mild autonomous cortisol secretion (MACS) from the adrenal mass is demonstrated in 5-48% of patients with adrenal tumors. The diagnosis of MACS represents a challenge due to limitations of the currently used diagnostic tests, differences in the definitions of the clinically relevant MACS, and heterogeneity in an individual's susceptibility to abnormal cortisol secretion from the adrenal mass. Patients with MACS present with increased risk of cardiovascular risk factors, cardiovascular events, metabolic bone disease, and mortality. Adrenalectomy improves or reverses MACS-associated comorbidities in selected patients. The current review will address diagnostic and management challenges in the care of patients with MACS, discuss data on emerging biomarkers, and suggest future directions in the field of MACS.
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Affiliation(s)
- Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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84
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Hsieh LB, Mackinney E, Wang TS. When to Intervene for Subclinical Cushing's Syndrome. Surg Clin North Am 2019; 99:747-758. [DOI: 10.1016/j.suc.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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85
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Elhassan YS, Alahdab F, Prete A, Delivanis DA, Khanna A, Prokop L, Murad MH, O'Reilly MW, Arlt W, Bancos I. Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171:107-116. [PMID: 31234202 DOI: 10.7326/m18-3630] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Adrenal incidentalomas are mostly benign nonfunctioning adrenal tumors (NFATs) or adenomas causing mild autonomous cortisol excess (MACE), but their natural history is unclear. PURPOSE To summarize the follow-up data of adults with NFAT or MACE to determine the proportions of tumor growth, malignant transformation, and incident changes in hormone function; the prevalence of incident cardiometabolic comorbid conditions; and mortality. DATA SOURCES MEDLINE, Embase, Cochrane, and Scopus (January 1990 to February 2019) and bibliographies of identified articles, without language restriction. STUDY SELECTION Studies that included 20 or more conservatively managed patients with NFAT or MACE and reported outcomes at baseline and after at least 12 months of follow-up. DATA EXTRACTION Pairs of reviewers extracted outcomes and assessed methodological quality. DATA SYNTHESIS Thirty-two studies reported outcomes of 4121 patients with NFAT or MACE, 61.5% of whom were women; the mean age was 60.2 years, and mean follow-up was 50.2 months. Mean tumor growth was 2 mm over 52.8 months. Clinically significant tumor enlargement (≥10 mm) occurred in 2.5% of patients, and none developed adrenal cancer. Clinically overt hormone excess was unlikely to develop (<0.1%) in patients with NFAT or MACE. Only 4.3% of patients with NFAT developed MACE, and preexisting MACE was unlikely to resolve (<0.1%). Hypertension, obesity, dyslipidemia, and type 2 diabetes were highly prevalent (60.0%, 42.0%, 33.7%, and 18.1% of patients, respectively) and were more likely to develop and worsen in MACE than NFAT. New cardiovascular events were more prevalent in MACE (15.5%) than NFAT (6.4%). Mortality was 11.2% and was similar between NFAT and MACE. LIMITATION Evidence was scarce, and definitions of MACE and comorbid conditions were heterogeneous. CONCLUSION During follow-up, NFAT and MACE do not show clinically relevant changes in size or hormonal function, but they may carry an increased risk for cardiometabolic comorbid conditions. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Yasir S Elhassan
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Fares Alahdab
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Alessandro Prete
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Danae A Delivanis
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Aakanksha Khanna
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Larry Prokop
- Mayo Clinic, Rochester, Minnesota; Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota (L.P.)
| | - Mohammad H Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Michael W O'Reilly
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Wiebke Arlt
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Irina Bancos
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
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86
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Abstract
PURPOSE OF REVIEW Adrenal tumors occur in 5% of population with higher prevalence in elderly. Patients with adrenal tumors present with overt hormonal excess in up to 15% of cases, and mild autonomous cortisol secretion in 30-40% of cases. Overt Cushing syndrome, mild autonomous cortisol secretion, pheochromocytoma, and primary aldosteronism have been associated with higher cardiovascular morbidity and mortality. Increasing experimental and clinical evidence also suggests that adrenal hormone excess is detrimental to bone health. This review aims to discuss the effect of cortisol, aldosterone, and catecholamine excess on bone metabolism, secondary osteoporosis, and fragility fractures. RECENT FINDINGS Several studies have reported that patients with hormonally active adrenal tumors demonstrate increased prevalence of fragility fractures incongruous to bone density scan findings. The utility of dual absorptiometry X-ray (DXA) in diagnosing secondary osteoporosis is unclear in patients with cortisol, aldosterone, and catecholamine excess. Trabecular bone score and bone turn over markers could serve as potential diagnostic tools in assessment of severity of bone disease in patients with hormonally active adrenal tumors. SUMMARY Adrenalectomy is the mainstay of therapy in patients with overt hormone production. Appropriate case detection strategies to identify patients at risk of fragility fractures are needed in patients not treated with adrenalectomy, such as bilateral primary aldosteronism and mild autonomous cortisol secretion.
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Affiliation(s)
- Shobana Athimulam
- Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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87
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Affiliation(s)
- Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Sarantaporou 10, 54640, Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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88
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Araujo-Castro M, Sampedro Núñez MA, Marazuela M. Autonomous cortisol secretion in adrenal incidentalomas. Endocrine 2019; 64:1-13. [PMID: 30847651 DOI: 10.1007/s12020-019-01888-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/28/2019] [Indexed: 02/06/2023]
Abstract
Adrenal incidentalomas (AI) are one of the most frequent reasons for consultation in Endocrinology, as they are present in 3-10% of the general population. Up to 20% of them may have autonomous cortisol secretion (ACS), a term that refers to AI carriers with biochemical evidence of excess cortisol, but without the "specific" clinical signs of Cushing's syndrome. As ACS is associated with an increased risk of diabetes, obesity, high blood pressure (HBP), osteoporosis, cardiovascular events, and global mortality; its correct identification is of great importance. There are different laboratory assays to detect ACS, but all of them have some limitations. The dexamethasone suppression test is the most accepted for screening. However, there is no consensus on the cutoff point that should be used. Low levels of ACTH and DHEA-S and high urinary free cortisol are also associated with ACS, but in isolation they are of little value to establish the diagnosis. Considering its clinical implications and the lack of consensus in the diagnosis and in which is the most appropriate management of these patients, this review offers a quick reference guide of ACS, presenting an exhaustive review of the topic: its definition, epidemiology, diagnosis, clinical implications, treatment, and follow-up.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Miguel Antonio Sampedro Núñez
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Mónica Marazuela
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
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89
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Park J, De Luca A, Dutton H, Malcolm JC, Doyle MA. Cardiovascular Outcomes in Autonomous Cortisol Secretion and Nonfunctioning Adrenal Adenoma: A Systematic Review. J Endocr Soc 2019; 3:996-1008. [PMID: 31065617 PMCID: PMC6497919 DOI: 10.1210/js.2019-00090] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/15/2019] [Indexed: 01/06/2023] Open
Abstract
There is growing evidence that autonomous cortisol secretion (ACS), previously known as subclinical Cushing syndrome, is associated with greater prevalence of cardiovascular (CV) risk factors. However, it is unclear whether ACS is associated with greater prevalence of CV outcomes compared with nonfunctioning adrenal adenomas (NFAAs). The objective of this study is to evaluate CV outcomes and CV risk factors in patients with adrenal adenoma with ACS compared with NFAA. A literature review was performed in Embase, Medline, Cochrane Library, and reference lists within selected articles. The study protocol was registered with PROSPERO. A literature search yielded six studies that met the inclusion criteria. Studies varied in their definitions of ACS and CV outcomes. Two retrospective longitudinal studies further demonstrated higher incidence of new CV events (ACS 16.7% vs NFAA 6.7%, P = 0.04) and higher CV mortality in patients with ACS (ACS 22.6% vs 2.5%, P = 0.02). The prevalence of CV outcomes in ACS was more than three times greater than in patients with NFAA. Three of five studies found that ACS was associated with higher prevalence of diabetes and hypertension. There was no difference in dyslipidemia or body mass index demonstrated in any study. There is heterogeneity among the few studies evaluating the association between ACS and CV outcomes. Although these studies suggest a higher risk of CV outcomes in patients with ACS, many did not adjust for known confounders. Larger, high quality, prospective studies are needed to evaluate this association and to identify modifiable risk factors.
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Affiliation(s)
- Jane Park
- Western University, London, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada
| | | | - Heidi Dutton
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda
| | - Janine C Malcolm
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda
| | - Mary-Anne Doyle
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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90
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Hong N, Lee J, Ku CR, Han K, Lee CR, Kang SW, Rhee Y. Changes of computed tomography-based body composition after adrenalectomy in patients with endogenous hypercortisolism. Clin Endocrinol (Oxf) 2019; 90:267-276. [PMID: 30428502 DOI: 10.1111/cen.13902] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/23/2018] [Accepted: 11/10/2018] [Indexed: 01/24/2023]
Abstract
CONTEXT Data on longitudinal changes of computed tomography (CT)-determined visceral fat area (VFA), skeletal muscle area (SMA) and skeletal muscle radiodensity (SMD) after adrenalectomy are limited in patients with hypercortisolism. OBJECTIVE To examine the association of severity of cortisol excess and improvement of CT-based muscle and fat parameters after adrenalectomy. DESIGN Retrospective observational cohort study. PATIENTS One hundred thirty-four patients with overt Cushing's syndrome (CS; n = 39), mild autonomous cortisol excess (MACE; n = 57), or nonfunctioning adrenal tumour (NFAT; n = 38) at a tertiary endocrinology institution between 2006 and 2017 were included. MEASUREMENTS Changes in CT-determined VFA, visceral-to-subcutaneous fat ratio (VSR), SMA, skeletal muscle index (SMI), and SMD measured at the third lumbar vertebra (L3). RESULTS At baseline, CS patients had higher VFA, lower SMA, SMI and SMD values, compared to NFAT or MACE patients. Compared to NFAT, significant decreases in VFA and increases in SMA, SMI and SMD was observed in CS 1 year after adrenalectomy. In MACE, adjusted mean changes of SMD but not VFA, SMA or SMI differ significantly compared to NFAT (+8.9% vs -3.4%, P = 0.032). In a multivariate linear regression model, the increase by 1 μg/dL of post-dexamethasone serum cortisol at baseline was independently associated with greater reduction of VFA (-3.95%), VSR (-3.07%), and increase in SMD (+0.92%, P < 0.05 for all) after adrenalectomy. CONCLUSIONS The severity of cortisol excess was associated with greater improvement of L3 VFA, VSR and SMD 1 year after adrenalectomy. These CT-based markers may allow more objective assessment of treatment benefit at earlier stage.
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Affiliation(s)
- Namki Hong
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jooyeon Lee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Cheol Ryong Ku
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kichang Han
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Cho Rok Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Wook Kang
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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91
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Khawandanah D, ElAsmar N, Arafah BM. Alterations in hypothalamic-pituitary-adrenal function immediately after resection of adrenal adenomas in patients with Cushing's syndrome and others with incidentalomas and subclinical hypercortisolism. Endocrine 2019; 63:140-148. [PMID: 30259310 DOI: 10.1007/s12020-018-1769-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with cortisol secreting adrenal adenomas present with Cushing's syndrome (CS), while 5-15% of subjects with adrenal incidentalomas have subclinical hypercortisolism (SH) as they have biochemical abnormalities suggesting autonomous cortisol secretion without associated clinical features of CS. GOALS Examine HPA function immediately after resection of either of these adenomas and utilize the data to decide on initiating glucocorticoid replacement. METHODS ACTH, cortisol, and DHEA-S levels were measured frequently for 8 h after adrenalectomy in 14 patients with CS and 19 others with incidentalomas + SH. Glucocorticoids were withheld before/during surgery and administered 6-8 h postoperatively to those who had cortisol levels of <3 ug/dL (83 nmol/L). RESULTS Preoperatively, incidentalomas + SH patients had larger tumors, higher ACTH, and DHEA-S but lower dexamethasone-suppressed serum cortisol levels than those with CS. Postoperatively, ACTH levels increased in both groups: (90.1 ± 31.6; 24.1 ± 14.4 ng/L, respectively; P < 0.001). Postoperative ACTH levels correlated negatively with preoperative Dexamethasone-suppressed cortisol concentrations in both groups. Patients with CS had steeper decline in cortisol concentrations than those with incidentalomas + SH. All patients with CS had hypocortisolemia requiring glucocorticoid therapy for several months, while only 5/19 with incidentalomas + SH had cortisol levels <3 ug/dL;(83 nmol/L) 6-8 h after adrenalectomy and received hydrocortisone replacement therapy for ≤4 weeks. CONCLUSIONS Surgical stress stimulates HPA function even in patients with hypercortisolemia. Patients with incidentalomas + SH have incomplete HPA suppression that allows more robust response to surgical stress than that observed in patients with CS. HPA assessment immediately after surgical resection of adrenal incidentalomas identified those requiring glucocorticoid replacement before discharge.
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Affiliation(s)
- Dena Khawandanah
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nadine ElAsmar
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Baha M Arafah
- Division of Clinical and Molecular Endocrinology, UH-Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.
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92
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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: 35] [Impact Index Per Article: 5.8] [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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93
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Ribeiro Cavalari EM, de Paula MP, Arruda M, Carraro N, Martins A, de Souza K, Coelho MC, de Oliveira E Silva de Morais NA, Moraes AB, Vieira Neto L. Nonfunctioning adrenal incidentaloma: A novel predictive factor for metabolic syndrome. Clin Endocrinol (Oxf) 2018; 89:586-595. [PMID: 30044007 DOI: 10.1111/cen.13822] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/02/2018] [Accepted: 07/22/2018] [Indexed: 01/06/2023]
Abstract
CONTEXT Although metabolic syndrome has been studied in patients with autonomous cortisol secretion, there are limited data for those with nonfunctioning adrenal incidentaloma (NFAI). OBJECTIVE To assess metabolic syndrome frequency in NFAI patients and controls without adrenal adenoma according to World Health Organization (WHO), National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III), American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) and International Diabetes Federation (IDF) criteria. DESIGN Retrospective and transversal study. PATIENTS Seventy-four NFAI and 90 controls were evaluated. NFAI diagnosis was established according to current guidelines. The control group was selected based on normal adrenal imaging examinations. MEASUREMENTS Subjects were categorized by metabolic syndrome presence according to WHO, NCEP-ATP III, AACE/ACE and IDF. RESULTS Age, gender, ethnicity, body mass index, smoking, menopause, statin and fibrate use were comparable between patients and controls. The frequency of prediabetes, dyslipidaemia and hypertension as well as waist circumference were significantly higher in the NFAI patients compared to the controls. The metabolic syndrome frequency in the NFAI group was significantly higher compared to the normal adrenal group: WHO: 69.2% × 31.0% (P < 0.001); NCEP-ATP III: 81.7% × 44.9% (P < 0.001); AACE/ACE: 77.1% × 31.9% (P < 0.001); IDF: 78.6% × 45.5% (P < 0.001). Logistic regression analysis showed that NFAI was a predictor of metabolic syndrome according to WHO (P = 0.001), NCEP-ATP III (P = 0.005) and AACE/ACE (P = 0.007). CONCLUSIONS Metabolic syndrome is frequently found in patients with NFAI, and this frequency is higher in NFAI patients than in those with normal adrenal imaging.
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Affiliation(s)
- Emanuela M Ribeiro Cavalari
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcela P de Paula
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Arruda
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nathália Carraro
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arthur Martins
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kamila de Souza
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria C Coelho
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Endocrine Division, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rio de Janeiro, Brazil
| | - Nathalie Anne de Oliveira E Silva de Morais
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Endocrine Division, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rio de Janeiro, Brazil
| | - Aline B Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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94
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Koracevic G, Stojkovic M, Lovic D, Pavlovic M, Kostic T, Kutlesic M, Micic S, Koracevic M, Djordjevic M. Should Cushing's Syndrome be Considered as a Disease with High Cardiovascular Risk in Relevant Guidelines? Curr Vasc Pharmacol 2018; 18:12-24. [PMID: 30289080 DOI: 10.2174/1570161116666181005122339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/29/2018] [Accepted: 09/29/2018] [Indexed: 12/27/2022]
Abstract
A considerable amount of data supports a 1.8-7.4-fold increased mortality associated with Cushing's syndrome (CS). This is attributed to a high occurrence of several cardiovascular disease (CVD) risk factors in CS [e.g. adiposity, arterial hypertension (AHT), dyslipidaemia and type 2 diabetes mellitus (T2DM)]. Therefore, practically all patients with CS have the metabolic syndrome (MetS), which represents a high CVD risk. Characteristically, despite a relatively young average age, numerous patients with CS display a 'high' or 'very high' CVD risk (i.e. risk of a major CVD event >20% in the following 10 years). Although T2DM is listed as a condition with a high CVD risk, CS is not, despite the fact that a considerable proportion of the CS population will develop T2DM or impaired glucose tolerance. CS is also regarded as a risk factor for aortic dissection in current guidelines. This review considers the evidence supporting listing CS among high CVD risk conditions.
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | - Dragan Lovic
- Clinic for Internal Medicine Intermedica, Nis, Serbia
| | - Milan Pavlovic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | - Tomislav Kostic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | | | | | - Milan Djordjevic
- Health Centre Jagodina, Emergency Medical Service, Jagodina, Serbia
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95
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Affiliation(s)
- Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville
- Knowledge and Evaluation Research Unit (KER-ENDO), Mayo Clinic, Rochester, Minnesota
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hans K Ghayee
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville
- Malcom Randall VA Medical Center, Gainesville, Florida
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96
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Serum Amyloid A, Paraoxonase-1 Activity, and Apolipoprotein Concentrations as Biomarkers of Subclinical Atherosclerosis Risk in Adrenal Incidentaloma Patients. Arch Med Res 2018; 49:182-190. [PMID: 30031631 DOI: 10.1016/j.arcmed.2018.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 07/02/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Adrenal incidentalomas (AIs), particularly subclinical hypercortisolism (SH), are related to an increased risk of atherosclerosis. The anti-oxidative enzyme paraoxonase-1 (PON1) and the acute phase reactant serum amyloid A (SAA) are transported by highdensity lipoprotein and reciprocally regulated in acute inflammatory response. Our aim was to investigate serum SAA, PON1, and apolipoprotein levels as indicators of subclinical atherosclerosis in patients with nonfunctioning AI (NFAI) and SH. METHODS The study group consisted of 60 controls, 14 SH, and 86 NFAI subjects. Serum amyloid A (SAA), PON1 activity, lipid profiles, apoA and B, lipoprotein A (LpA), hsCRP, and HOMA-IR levels were compared in all groups. RESULTS Serum insulin, triglyceride, SAA, SAA/PON1 ratio, LpA, apoB, hsCRP, and morning cortisol levels were found to be higher while PON1 and apoAI levels were lower in the SH and NFAI groups compared with the controls, and these parameters were found to be more impaired in SH group than NFAI group (p <0.001). HOMA-IR was higher and DHEAS was lower in the SH group than in the other groups. The SAA/PON1 ratio was positively correlated with LpA (r = 0.460; p <0.001), apoB (r = 0.515; p <0.001), insulin (r = 0.275; p = 0.026), triglyceride (r = 0.248; p = 0.002), morning cortisol (r = 0.259; p = 0.045), and UFC (r = 0.274; p <0.001) and negatively correlated with apoAI (r = 0.329; p <0.001), ACTH (r = -0.384; p <0.001), and DHEAS (r = -0.521, p <0.001) levels. The cut-off value of the SAA/PON1 ratio for NFAI was >0.23, and for SH it was >1.33. CONCLUSION The serum SAA/PON1 ratio was high in both the NFAI and SH groups and also exhibited higher levels in SH group. An increased SAA/PON1 ratio and low DHEAS could be attributable to subclinical atherosclerosis risk in SH patients.
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Eldeiry LS, Alfisher MM, Callahan CF, Hanna NN, Garber JR. The impact of an adrenal incidentaloma algorithm on the evaluation of adrenal nodules. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2018; 13:39-45. [PMID: 29998066 PMCID: PMC6037878 DOI: 10.1016/j.jcte.2018.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/21/2022]
Abstract
Objective To determine the impact of the use of an electronic medical record tool on the evaluation of adrenal incidentalomas. Methods Retrospective chart review was used to compare rates of hormone testing and follow up imaging for adrenal incidentalomas. Patients whose radiology reports contained an algorithm with recommendations, based on our 2013 clinical guideline for the workup of these nodules, were compared to those whose imaging reports did not contain the algorithm. Results For patients whose Radiology reports contained the algorithm, 69% had hormonal testing versus 43% of controls (p < 0.0001). By contrast, 57% of study group patients had a follow up imaging study, compared to 51% of controls (p = 0.1000). However, when the 18% of controls that were given guidance by the radiologist to perform follow-up imaging were excluded from those who received no guidance, there was a statistically significant difference in the rate of follow up imaging (57% vs 48%, p < 0.0001). Conclusion Implementation of a clinical algorithm for the evaluation of adrenal incidentalomas in radiology reports and on the intranet site of a major clinical center led to improved rates of hormone testing. There was also a significant increase in the rate of follow up imaging, compared to when no guidance was given. Additional efforts to further improve performance are needed to increase the detection of clinically significant lesions, particularly hormone secreting tumors that should be removed.
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Affiliation(s)
- Leslie S Eldeiry
- Harvard Vanguard Medical Associates/Atrius Health, Boston, MA, United States
| | - Marina M Alfisher
- Harvard Vanguard Medical Associates/Atrius Health, Boston, MA, United States
| | | | | | - Jeffrey R Garber
- Harvard Vanguard Medical Associates/Atrius Health, Boston, MA, United States
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Endothelial progenitor cells in a patient with Cushing's syndrome before and after adrenal surgery. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.jecr.2018.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
During the last 20 years, a significant body of literature has accumulated regarding subclinical hypercortisolism in patients with adrenal incidentalomas. Retrospective studies have indicated these patients have an increase in cardiovascular events and mortality. Current recommendations for patients with adrenal incidentalomas include an overnight low-dose dexamethasone suppression test and a thorough evaluation of cardiovascular and metabolic risk factors. Further hormonal testing and close monitoring are necessary in patients with incomplete suppression. Unilateral adrenalectomy may be beneficial in cases with abnormal suppression and comorbidities related to hypercortisolemia. Prospective studies are need for a better risk stratification and tailored therapy.
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Affiliation(s)
- Guido Zavatta
- Division of Endocrinology, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy.
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Tabarin A. Do the diagnostic criteria for subclinical hypercortisolism exist? ANNALES D'ENDOCRINOLOGIE 2018; 79:146-148. [PMID: 29661471 DOI: 10.1016/j.ando.2018.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
"Subclinical hypercortisolism" (SH) refers to a condition associated with a mild chronic increase in cortisol secretion. By definition, patients with SH do not exhibit specific symptoms of overt Cushing's syndrome (such as purple striae, easy bruising, proximal muscle weakness), SH has been preferred to "subclinical Cushing's syndrome", a semantic ambiguity since Cushing's syndrome is, by definition, a set of symptoms; and to the term "preclinical Cushing syndrome" because the progression toward overt clinical hypercortisolism is very rare. However, SH still is misnomer as a number of studies suggest that this condition may induce long-term non-specific adverse conditions related to the mild cortisol excess (i.e. diabetes, hypertension, obesity, and osteoporosis). Various attempts have been made to define SH that remains a matter of controversies and uncertainties.
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Affiliation(s)
- Antoine Tabarin
- Department of endocrinology, diabetes and nutrition, CHU de Bordeaux, hopital Haut-Lévêque, 33604 Pessac, France.
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