Adrenal incidentaloma, clinical, metabolic, follow-up aspects: single centre experience

Comparison of adrenalectomy with conservative treatment on mild autonomous cortisol secretion: a systematic review and meta-analysis

Objective

This systematic review and meta-analysis was conducted to compare the benefits of adrenalectomy and conservative treatment for comorbidities associated with mild autonomous cortisol secretion (MACS) in patients diagnosed with MACS.

Background

MACS is the most common benign hormone-secreting functional adrenal incidentaloma. Overproduction of cortisol is observed in MACS patients, resulting in a variety of long-term health issues, including arterial hypertension (HTN), diabetes mellitus (DM), dyslipidemia, obesity, and osteoporosis; however, the classic clinical manifestations of Cushing's syndrome (CS) are not present.

Methods

A systematic search was conducted using MEDLINE, Embase, Web of Sciences, and Scopus databases on December, 2023. Two reviewers independently extracted data and assessed the quality of the included articles. A meta-analysis was performed to compare the beneficial effects of adrenalectomy versus conservative management for MACS-related comorbidities.

Results

Fifteen articles were included in this study, which evaluated 933 MACS patients (384 Adrenalectomy and 501 Conservative treatment, and 48 excluded due to incomplete follow-up duration). MACS diagnosis criteria were different among the included articles. All studies, however, stated that there must be no overt CS symptoms. Meta-analysis demonstrates the overall advantage of adrenalectomy over conservative treatment for MACS-related comorbidities (Cohen's d = -0.49, 95% CI [-0.64, -0.34], p = 0.00). Subgroup analysis indicated that the systolic blood pressure (pooled effect size = -0.81, 95% CI [-1.19, -0.42], p = 0.03), diastolic blood pressure (pooled effect size = -0.63, 95% CI [-1.05, -0.21], p = 0.01), and BMD (pooled effect size = -0.40, 95% CI [-0.73, -0.07], p = 0.02) were significantly in favor of adrenalectomy group rather than conservative treatment but no significant differences between the two treatment groups in other MACS-related comorbidities were reported.

Conclusion

Despite the limited and diverse data, this study demonstrates the advantage of adrenalectomy over conservative treatment for MACS-related comorbidities.

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P < 0.01), along with 7.2 mmHg reduction in SBP (P < 0.01). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2= 28.032, P < 0.01). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

Primary Aldosteronism Prevalence - An Unfolding Story

Primary aldosteronism (PA) is characterized by dysregulated, renin-independent aldosterone excess. Long perceived as rare, PA has emerged as one of the most common causes of secondary hypertension. Failure to recognize and treat PA results in cardiovascular and renal complications, through processes mediated by both direct target tissue insults and indirectly, by hypertension. PA spans a continuum of dysregulated aldosterone secretion, which is typically recognized in late stages after treatment-resistant hypertension and cardiovascular and/or renal complications develop. Determining the precise disease burden remains challenging due to heterogeneity in testing, arbitrary thresholds, and populations studied. This review summarizes the reports on PA prevalence among the general population and in specific high-risk subgroups, highlighting the impact of rigid versus permissive criteria on PA prevalence perception.

Management of Adrenal Cortical Adenomas: Assessment of Bone Status in Patients with (Non-Functioning) Adrenal Incidentalomas

Our aim is to analyse the bone profile in adults with (non-functioning) adrenal incidentalomas (AIs), specifically addressing the impact of autonomous cortisol secretion (ACS). This narrative review, based on a PubMed search from inception to February 2023 (case reports, non-ACS, and other secondary causes of osteoporosis were excluded), included 40 original studies, a total of 3046 patients with female prevalence (female:male ratio of 1921:1125), aged between 20.5 and 95.5 years old. This three decade-based analysis showed that 37 studies provided dual-energy X-ray absorptiometry (DXA) information; another five studies reports results on bone micro-architecture, including trabecular bone score (TBS), spinal deformity index, and high-resolution peripheral quantitative computed tomography; 20 cohorts included data on bone turnover markers (BTMs), while four longitudinal studies followed subjects between 1 and 10.5 years old (surgical versus non-adrenalectomy arms). Post-dexamethasone suppression test (DST) cortisol was inversely associated with bone mineral density (BMD). TBS predicted incidental vertebral fractures (VFx) regardless of BMD, being associated with post-DST cortisol independently of age and BMD. Low BTMs were identified in ACS, but not all studies agreed. An increased prevalence of ACS-related osteoporosis was confirmed in most studies (highest prevalence of 87.5%), as well as of VFx, including in pre-menopause (42.5%), post-menopause (78.6%), and male patients (72.7%) depending on the study, with a 10-fold increased incidental VFx risk up to a 12-fold increased risk after a 2-year follow-up. No specific medication against osteoporosis is indicated in ACS, but adrenalectomy (according to four studies) should be part of the long-term strategy. This bone profile case sample-based study (to our knowledge, one of the largest of its kind) showed that AIs, including the subgroup designated as having ACS, embraces a large panel of osseous complications. The level of evidence remains far from generous; there are still no homogenous results defining ACS and identifying skeletal involvement, which might be a consequence of different investigation clusters underling adrenal and bone assessments over time. However, bone status evaluations and associated therapy decisions remain an essential element of the management of adults with AIs-ACS.

Prevalence of Functioning Adrenal Incidentalomas: A Systematic Review and Meta-analysis

CONTEXT

Adrenal hyperfunction is associated with an increased risk of cardiometabolic complications in subjects with adrenal incidentaloma (AI). Reliable prevalence estimates of functioning AIs are important to direct resources allocations.

OBJECTIVE

To assess the prevalence of autonomous/possible autonomous cortisol secretion (ACS), primary aldosteronism (PA), pheochromocytoma (PHEO), and Cushing syndrome (CS) in patients with AI.

METHODS

We performed a comprehensive search of multiple databases (PubMed, Ovid MEDLINE, Web of Science) for potentially relevant studies without language restriction, up to February 2022. Of the 1661 publications evaluated at title and abstract levels, 161 were examined as full text and 36 were included. Study level clinical data were extracted by 3 independent reviewers.

RESULTS

The overall prevalence of functioning AIs was 27.5% (95% CI 23.0, 32.5). ACS/possible ACS, with a prevalence of 11.7% (95% CI 8.6, 15.7), was the most frequent hormonal alteration, while PA occurred in 4.4% of the patients (95% CI 3.1, 6.2). Subgroup analysis showed that PA was more prevalent in patients from Asia than in patients from Europe/America; in contrast, ACS/possible ACS had a lower prevalence in Asian countries. At meta-regression analysis, the prevalence of ACS/possible ACS was influenced by the proportion of female patients, while the prevalence of PA was positively associated with the proportion of patients with hypertension and the publication year. Finally, PHEO and CS prevalence were 3.8% (95% CI 2.8, 5.0) and 3.1% (95% CI 2.3, 4.3) respectively.

CONCLUSION

This meta-analysis provides extensive data on the prevalence of functioning AIs and the factors affecting heterogeneity in prevalence estimates.

Predicting morphological and functional variations of benign adrenal incidentalomas in relation to initial characteristics

The follow-up strategy for unresected non-functional adrenal tumors (NFAT) is a major controversial issue in endocrinological clinical practice, as the natural history of adrenal incidentalomas (AI) is partially unknown and a consensus on their adequate management is lacking. In a recent longitudinal study by Ceccato et al., a large cohort of patients with conservatively treated AI were evaluated for possible radiological variations over time and their relationship with autonomous cortisol secretion (ACS). Starting from this paper, we performed a literature review of available longitudinal studies focus on the same issue. Notwithstanding the high variability in the duration of follow-up and in the criteria used to define ACS in the included studies, our findings support the idea that there is a not negligible risk of morphological and functional changes, which may have metabolic implications, especially after 5-10 years of follow-up. Unfortunately, these variations seem to be scarcely predictable. Therefore, it may be risky to interrupt the follow-up in patients with NFAT, in particular in the presence of larger diameter of the adenoma and higher cortisol levels at diagnosis. These results should be considered in defining the optimal management of these patients.

Prevalence of reported incidental adrenal findings in chest computerized tomography scans performed during the COVID-19 pandemic in a single center in Northeast Brazil

Objective

We investigated the prevalence of adrenal incidentalomas (AIs) in a nonselected Brazilian population in chest computed tomography (CT) performed during the COVID-19 pandemic.

Materials and methods

This was a retrospective cross-sectional observational study using chest CT reports from a tertiary in- and outpatient radiology clinic from March to September 2020. AIs were defined by changes in the shape, size, or density of the gland initially identified in the released report. Individuals with multiple studies were included, and duplicates were removed. Exams with positive findings were reviewed by a single radiologist.

Results

A total of 10,329 chest CTs were reviewed, and after duplicate removal, 8,207 exams were included. The median age was 45 years [IQR 35-59 years], and 4,667 (56.8%) were female. Thirty-eight lesions were identified in 36 patients (prevalence 0.44%). A higher prevalence was observed with age, with 94.4% of the findings in patients aged 40 years and over (RR 9.98 IC 2.39-41.58, p 0.002), but there was no significant difference between the sexes. Seventeen lesions (44.7%) had more than 10 HU, and five lesions (12.1%) were more than 4 cm.

Conclusion

The prevalence of AIs in an unselected and unreviewed population in a Brazilian clinic is low. The impact on the health system caused by AIs discovered during the pandemic should be small regarding the need for specialized follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pathophysiological Link between Insulin Resistance and Adrenal Incidentalomas

Adrenal incidentalomas are incidentally discovered adrenal masses greater than one centimeter in diameter. An association between insulin resistance and adrenal incidentalomas has been established. However, the pathophysiological link between these two conditions remains incompletely characterized. This review examines the literature on the interrelationship between insulin resistance and adrenal masses, their subtypes, and related pathophysiology. Some studies show that functional and non-functional adrenal masses elicit systemic insulin resistance, whereas others conclude the inverse. Insulin resistance, hyperinsulinemia, and the anabolic effects on adrenal gland tissue, which have insulin and insulin-like growth factor-1 receptors, offer possible pathophysiological links. Conversely, autonomous adrenal cortisol secretion generates visceral fat accumulation and insulin resistance. Further investigation into the mechanisms and timing of these two pathologies as they relate to one another is needed and could be valuable in the prevention, detection, and treatment of both conditions.

Sex Differences in Hypercortisolism and Glucose-Metabolism Disturbances in Patients with Mild Autonomous Cortisol Secretion: Findings From a Single Center in China

BACKGROUND AND OBJECTIVE

Mild autonomous cortisol secretion (MACS) presents with a marked female preponderance, but whether the sex difference in its distribution has any relevance to the presentation and outcome of the disease is unknown. The aim of this study was therefore to compare biochemical indices of hypercortisolism and impaired glucose metabolism between male and female patients with MACS.

METHOD

We enrolled a total of 98 patients with autonomous/possible autonomous cortisol secretion in our study, and indices of hypercortisolism and glucose metabolism were collected and compared between the male and female patients. Logistic regression models were used to evaluate the association between sex and cortisol-secretory ability, as well as between the latter and glucose metabolism. In addition, we conducted further stratified analyses according to the degree of autonomous cortisol secretion and menopausal status.

RESULTS

Cortisol levels at 00:00 and 08:00 h after a 1-mg dexamethasone suppression test (DST) and low-dose DST were significantly higher in female than in male MACS patients, and the inhibition rate of 1-mg DST was lower in the women than in the men. This significant difference still remained after adjusting for age, BMI, and the course of the disease. Logistic regression analysis revealed a significant association between autonomous cortisol secretion and fasting C-peptide, as well as with the C-peptide-to-glucose ratio in females relative to male patients. In addition, stratified analyses indicated that this association was observed only among women with autonomous cortisol secretion and who were premenopausal.

CONCLUSION

The level of autonomic cortisol secretion in female patients with MACS was higher than in male patients, and the association between autonomous cortisol secretory ability and glucose homeostasis was only noted in patients with autonomous cortisol secretion and in premenopausal women. This phenomenon will, however, require closer follow-up.

Attenuation Value in Adrenal Incidentalomas: A Longitudinal Study

Context

A tendency to grow has been reported in adrenal incidentalomas. However, long-term data regarding attenuation value, a measure of lipid content, are not available.

Aim

This study aims to collect radiological data (diameter in mm and attenuation value in Hounsfield units, HU) with computed tomography (CT) in adrenal incidentalomas, in order to compare baseline characteristics with the last follow-up imaging.

Design

This is a longitudinal study which included patients with a new diagnosis of adrenal incidentaloma, evaluated from January 2002 to June 2020.

Setting

Referral University-Hospital center.

Patients

Two hundred seventy-seven patients with 355 different cortical adenomas (baseline group) were evaluated at the first outpatient visit; the follow-up cohort consists of 181 patients with 234 adenomas (12-175 months after baseline). Inclusion criteria were conservative management and radiological features able to minimize malignancy or risk of progression.

Main Outcome Measure

CT modification according to endocrine function: autonomous cortisol secretion (ACS) if cortisol >50 nmol/L after 1-mg dexamethasone test (DST).

Results

At baseline CT, mean diameter was 18.7 mm and attenuation value was 0.8 HU (higher in ACS, 66 cases >10 HU), without modification in early imaging (12-36 months). The size increased over time (r = 0.289), achieving the largest differences after at least 60 months of follow-up (mean diameter, +2 mm; attenuation value, -4 HU), combined with a reduction in the attenuation value (r = -0.195, especially in patients with ACS). Lipid-poor adenomas (>10 HU) presented a reduced cortisol suppression after 1-mg DST, an increase in size and the largest decrease in attenuation value during follow-up. Univariate analysis confirmed that larger adenomas presented reduced suppression after DST and increase in size during follow-up.

Conclusions

Growth is clinically modest in adrenal incidentaloma: the first follow-up CT 5 years after baseline is a reasonable choice, especially in ACS. Mean density is increased in patients with ACS and overt hypercortisolism. Mean density reduces during follow-up in all adrenal adenomas, suggesting an increase in lipid content, especially in those with ACS.

Volumetric evaluation of CT images of adrenal glands in primary aldosteronism

OBJECTIVES

To investigate whether adrenal volumetry provides better agreement with adrenal vein sampling (AVS) than conventional CT for subtyping PA. Furthermore, we evaluated whether the size of this contralateral adrenal was a prognostic factor for clinical outcome after unilateral adrenalectomy.

METHODS

We retrospectively analyzed volumes of both adrenal glands of the 180 CT-scans (88/180 with unilateral and 92/180 with bilateral disease) of the patients with PA included in the SPARTACUS trial of which 85 also had undergone an AVS. In addition, we examined CT-scans of 20 healthy individuals to compare adrenal volumes with published normal values.

RESULTS

Adrenal volume was higher for the left than the right adrenal (mean and SD: 6.49 ± 2.77 ml versus 5.25 ± 1.87 ml for the right adrenal; p < 0.001). Concordance between volumetry and AVS in subtyping was 58.8%, versus 51.8% between conventional CT results and AVS (p = NS). The volumes of the contralateral adrenals in the patients with unilateral disease (right 4.78 ± 1.37 ml; left 6.00 ± 2.73 ml) were higher than those of healthy controls reported in the literature (right 3.62 ± 1.23 ml p < 0.001; left 4.84 ± 1.67 ml p = 0.02). In a multivariable analysis the contralateral volume was not associated with biochemical or clinical success, nor with the defined daily doses of antihypertensive agents at 1 year follow-up.

CONCLUSIONS

Volumetry of the adrenal glands is not superior to current assessment of adrenal size by CT for subtyping patients with PA. Furthermore, in patients with unilateral disease the size of the contralateral adrenal is enlarged but its size is not associated with outcome.

Hormonally Active Adrenal tumors; Challenges and Outcomes for Different Surgical Approaches

Objective:

The aim of this study is to compare the intraoperative and short-term outcomes of different surgical approaches for hormone active and non-functional adrenal masses.

Methods:

The data of 206 patients who underwent adrenal gland surgery in our clinic between 2012 and 2020 were retrospectively analyzed. Pre-operative outpatient clinic records of the patients, imaging methods, laboratory results and surgery records, operation time (OT), amount of bleeding, duration of hospital stay, and complications were evaluated. Patients were divided into two groups as those with non-functional mass (n=80) and those with hormoneactive mass (n=126).

Results:

The median age of the patients was 52 (range 19–83) and 77.2% of them were female. Tumor size was larger in hormone active group (p=0.311), and the difference was more pronounced in the pheochromocytoma subgroup (p=0.088). The rate of transition to open surgery was similar in both groups (0.959), and no conversion to laparoscopy or conventional open surgery was performed in robotic cases. The duration of surgery (p=0.669), mean amount of blood loss (p=0.834), and mean hospital stay (p=0.195) were also similar between the two groups. Intraoperative and post-operative complications were similar between two groups (p=0.573 and p=0.415, respectively). Considering the subgroup analysis of the patients in hormone active group; the duration of hospital stay was longer in patients with Cushing syndrome (p=0.001), while there was no difference in OT and estimated blood loss between patients who were operated for Conn, Cushing, and pheochromocytoma (p=0.086 and p=0.099; respectively).

Conclusion:

Surgical results of hormone active adrenal masses were found to be similar to non-functional masses. Although the hormonal condition of the mass does not change the difficulty level of the surgical procedure, it may be recommended that the robotic approach be preferred to facilitate manipulation in these masses.

CT-based Abdominal Adipose Tissue Area Changes in Patients Undergoing Adrenalectomy Due to Cushing's Syndrome and Non-functioning Adenomas

BACKGROUND

The majority of Cushing's syndrome (CS) cases constitute patients with functional adrenal adenomas. In adrenal CS, visceral adipose tissue (VAT) area, VAT/subcutaneous adipose tissue (SAT), and VAT/total adipose tissue (TAT) ratios are expected to decrease in response to adrenalectomy, although no change is expected in non-functioning adrenal adenomas (NFA).

OBJECTIVE

To evaluate the changes in VAT, SAT, TAT areas and VAT/SAT, VAT/TAT ratios using computed tomography (CT) in patients who underwent adrenalectomy due to adenomas.

METHODS

Preoperative and postoperative CT of 32 patients (16 with CS and 16 with NFA) were retrospectively evaluated. The VAT, SAT, TAT areas were obtained from CT at the level of L1-2 intervertebral disc space, and the VAT/SAT, VAT/TAT ratios were calculated. The postoperative parameter changes in both groups were evaluated compared to the preoperative values. The level of statistical significance was considered as p<0.05.

RESULTS

The time interval between preoperative and postoperative CT measurements were 10.37 months (6-17) in CS and 9.75 months (7-15) in NFA groups (p=073). Preoperative CT indicated that the patients with CS had larger VAT and TAT areas (p=0.03, p=0.02) but SAT remained unchanged (p=0.08). However, postoperative CT revealed that there was no difference between the two groups in terms of VAT, TAT, and SAT areas (p=0.87, p=0.36, p=0.14). Postoperatively, in patients with CS, there was a decrease in VAT and TAT areas (p=0.01 for both) and VAT/SAT and VAT/TAT ratios (p=0.03, p=0.02) but SAT remained unchanged (p=0.10). In patients with NFA, no change was detected in the postoperative SAT, TAT, and VAT areas (p=0.12, p=0.40, p=0.99) or the VAT/SAT and VAT/TAT ratios (p=0.38, p=0.62).

CONCLUSIONS

Adrenalectomy is an effective treatment method leading to a decrease in the VAT, TAT areas, and VAT/SAT and VAT/TAT ratios in patients with cortisol producing adrenocortical adenoma. Thus, CT facilitates quantitative demonstration of the changes while evaluating the response of these patients to treatment.

Adrenalectomy for incidental and symptomatic phaeochromocytoma: retrospective multicentre study based on the Eurocrine® database

BACKGROUND

Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative α-blockade.

METHODS

This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in Eurocrine®, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed.

RESULTS

Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative α-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P = 0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative α-blockade or not.

CONCLUSION

Subclinical phaeochromocytoma detected incidentally is common. A significantproportion of patients with phaeochromocytoma did not have α-blockade before surgery, without an apparent effect on complications.

Cardiovascular and metabolic consequences in patients with asymptomatic adrenal adenomas

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Cortisol level after dexamethasone suppression test in patients with non-functioning adrenal incidentaloma is positively associated with the duration of reactive hyperemia response on microvascular bed

PURPOSE

Data on endothelial derangements in patients with non-functioning adrenal incidentaloma (NFAI) are scarce.

METHODS

We investigated if NFAI patients present clinical, biochemical and endothelial alterations compared to individuals without an adrenal lesion and also the associations among these variables. Forty-two NFAI and 40 controls were evaluated. NFAI diagnosis and controls were defined according to the current guidelines and based on a normal adrenal imaging exam, respectively. Body composition was evaluated by dual emission X-ray absorptiometry. Endothelial reactivity was assessed by two methods: tonometry (Endo-PAT^®) and laser speckle contrast imaging (LSCI).

RESULTS

There were no differences between groups regarding age, gender, ethnicity, smoking status, and statin use. The frequency of metabolic syndrome according to the International Diabetes Federation criteria was 69% and 57.9%, respectively in NFAI and controls (p = 0.36), whereas the atherosclerotic cardiovascular disease (ASCVD) risk was 63.4% and 66.7% (p = 0.81). The clinical, laboratory, and anthropometric characteristics, as well as body composition, were similar between the groups. Additionally, any differences between groups were observed on endothelial reactivity tests. Nevertheless, we noted an association between cortisol levels after 1 mg-dexamethosone suppression test (1 mg-DST) and the duration of post-occlusive reactive hyperemia tested on microcirculation (r = 0.30; p = 0.03). NFAI patients require more antihypertensive drugs to achieve blood pressure control (p = 0.04). The number of antihypertensive drugs used to control blood pressure correlated with cortisol levels after 1 mg-DST (r = 0.29; p = 0.03).

CONCLUSIONS

Since both groups herein investigated had a high frequency of metabolic syndrome and ASCVD risk, it might explain similarities observed on endothelial reactivity. Nevertheless, prolonged reactive hyperemia response on microcirculation was correlated with cortisol levels under suppression.

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P = 0.000), along with 7.2 mmHg reduction in SBP (P = 0.000). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2 = 28.032, P = 0.000). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

Clinical features, risk of mass enlargement, and development of endocrine hyperfunction in patients with adrenal incidentalomas: a long-term follow-up study

PURPOSE

To evaluate the risk of mass enlargement and endocrine function modification in patients with adrenal incidentaloma (AI).

METHODS

In this retrospective study, we examined clinical and hormonal characteristics of 310 patients with AI (200 females and 110 males; age: 58.3 ± 12.9 years), followed up for a median (interquartile range) of 31.4 months (13.0-78.6) and evaluated for possible modification in adrenal mass size and hormonal function. The hormonal evaluation included morning serum cortisol and plasma ACTH at 8 a.m., aldosterone, plasma renin activity/direct renin concentration, and 24-h urine metanephrines/normetanephrines. One microgram overnight dexamethasone suppression test (DST) was performed. Autonomous cortisol secretion (ACS) was diagnosed in the presence of cortisol after 1 mg DST > 5 μg/dl (138 nmol/l) or >1.8 and ≤5 μg/dl (50-138 nmol/l) and at least one of the following: (i) low ACTH; (ii) increased 24-h urinary-free cortisol; (iii) absence of cortisol rhythm; and (iv) post-LDDST cortisol level > 1.8 μg/dl (50 nmol/l). When there was no biochemical evidence of adrenal hormonal hyperactivity, AIs were classified as nonfunctioning (NFAIs). The mass was considered significantly enlarged when the size increase was more than 20% and at least 5 mm compared to baseline.

RESULTS

At diagnosis, NFAIs were found in 209 patients, while ACS and overt adrenal hyperfunction were diagnosed in 81 and 20 patients, respectively. During follow-up, 3.3% and 1.5% of patients with NFAI developed subtle and overt endocrine hyperfunction, respectively, while a significant mass enlargement was observed in 17.7% of all AIs. The risk of developing ACS was significantly higher in patients with adenoma >28 mm (hazard ratio [HR] 12.4; 95% confidence interval [CI], 2.33-66.52, P = 0.003), in those with bilateral adrenal tumors (HR: 5.36; 95% CI, 1.17-24.48, P = 0.030), and with low/suppressed ACTH values (HR: 11.2, 95% CI 2.06-60.77; P = 0.005). The risk of mass enlargement was lower for patients in the fourth quartile of body mass index than those in the first quartile (HR 0.33; 95% CI, 0.14-0.78; P = 0.012).

CONCLUSIONS

In patients with AI, the risk of developing hormonal hyperfunction and mass enlargement is overall low, although some tumor characteristics and anthropometric features might increase this risk. Taking account of all these aspects is important for planning a tailored follow-up in AI patients.

Adrenal Incidentaloma

An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup, and clinical symptoms and signs are required in every case. Adrenocortical carcinoma remains a real concern but is restricted to <2% of all cases. Functional adrenal incidentaloma lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.

Comparison between the clinical characteristics of patients with adrenal incidentalomas and those with hypertension-associated adrenal tumors in a single center in Japan

In the largest retrospective study of adrenal incidentalomas (AIs) in Japan between 1999 and 2004, adrenal tumors detected during secondary hypertension (HT) screening were included. The characteristics of patients with adrenal tumors detected during HT screening may differ from those of patients with AIs. This study aimed to compare the characteristics of patients with AIs with those of patients with adrenal tumors detected during HT screening. We retrospectively analyzed patients referred to our division for detailed examination of adrenal tumors between April 2009 and April 2017. When the purposes of imaging tests included HT screening, we defined adrenal tumors as HT associated, otherwise as strictly defined AIs. We reviewed data on age, sex, purpose and modality of imaging, location of tumor, tumor diameter, and hormonal evaluation. We identified 104 patients with HT-associated adrenal tumors and 413 with AIs. Patients with HT-associated adrenal tumors were younger (54.2 years vs. 61.7 years, p < 0.001) and had smaller tumor diameters (1.3 cm vs. 1.9 cm, p < 0.001), lower prevalence of nonfunctioning tumors (24.0% vs. 67.6%, p < 0.001), and higher prevalence of primary aldosteronism (58.7% vs. 4.8%, p < 0.001) than those with AIs. There were no differences in terms of tumor location and prevalence of subclinical Cushing's syndrome, Cushing's syndrome, and pheochromocytoma (18.3% vs. 16.0%, 7.7% vs. 8.0%, and 2.9% vs. 4.6%, respectively). In conclusion, patients with HT-associated tumors were younger and had a smaller tumor with higher prevalence of primary aldosteronism than those with AIs.

Clinical Characteristics and Follow-Up Results of Adrenal Incidentaloma

It is recommended that adrenal incidentaloma patients should be monitored for radiological changes, increase in size and new functionality that may occur in the future, even if they are benign and nonfunctional at the initial evaluation. Our aim is to evaluate the key clinical characteristics of adrenal incidentaloma patients focusing on changes during follow-up and associated clinical outcomes. A total of 755 patients (median age: 56 years), with an adrenal incidentaloma > 1 cm and underwent functionality tests, were included in the study. Clinical characteristics, functionality status and follow-up durations were recorded. During the course of follow-up, any changes in size and development of new functionality, and clinical consequences thereof were evaluated. In 71.8% of patients, incidentalomas were non-functional. Most frequent functionality (15.8%, n=119) was subclinical hypercortisolemia (SH) [10.9% (n=82) possible autonomous cortisol secretion (PACS) and 4.9% (n=37) autonomous cortisol secretion (ACS)] of all incidentalomas. Frequencies of Cushing's syndrome (CS), pheochromacytoma and primary hyperaldosteronism were 4.9% (n=37), 3.8% (n=29) and 3.7% (n=28), respectively. Adrenocortical carcinoma frequency was 1.5% (n=11). Of 755 patients, 43% (n=325) were followed up regularly more than 6 months. Median follow-up duration was 24 months (6-120). A total of 17 (5.2%) patients, which had non-functional incidentalomas at baseline had developed new functionality during follow-up, of which 15 (4.6%) were SH [13 patients (4%) PACS and 2 patients (0.6%) ACS] and 2 (0.6%) were CS. During follow-up, 24% (n=78) of the patients had an increase in mass size between 5-9 mm, while 11.7% (n=38) of the patients had an increase of ≥10 mm. During follow-up, 4% (n=13) of the patients developed a new lesion with a diameter ≥10 mm on the opposite side. In patients with a follow-up duration of more than 2 years, frequencies of size increase and new lesion emerging at the opposite adrenal gland were higher. 14 patients (4.3% of the patients with regular follow-up) underwent surgery due to increase in size or development of new functionality during follow-up. Our study demonstrated that a necessity for surgery may arise due to increase in size and development of functionality during follow-up period in adrenal incidentaloma patients, and thus continuing patient follow-up, even with wider intervals, will be appropriate.

Health-related quality of life in patients undergoing adrenalectomy: report from a Swedish National Audit

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.

Clinical investigation of pituitary incidentalomas: A two-center study

Recent advances in imaging technology resulted in an increase in pituitary incidentalomas (PIs) detection. PIs were reported to be present in 1.6% persons with magnetic resonance imaging of the brain. Whereas, there were few studies about PIs with detailed investigation. We aimed to investigate the clinical and endocrinological characteristics of PIs. We evaluated 65 patients diagnosed with PIs who underwent detailed clinical and endocrinological evaluations. Of the 65 patients, 33 (50.8%) had non-functional pituitary adenomas (NFPAs), 11 (16.9%) had Rathke's cleft cysts (RCCs), 7 (10.8%) had functional pituitary adenomas (FPAs), 6 (9.2%) had benign extra-pituitary tumors (BEPTs), and 8 (12.3%) had malignant tumors (MTs). Compared with patients with NFPAs, those with MTs were significantly younger and had a significantly lower body mass index, lower prevalence of hypertension, and lower prevalence of dyslipidemia. Patients with MTs had significantly higher prevalence of central diabetes insipidus than those with NFPAs. In addition, patients with NFPAs had significantly higher prevalence of pituitary apoplexy than those with FPAs, BEPTs, and MTs. In conclusion, our study demonstrated clinical and endocrinological characteristics of PIs. Highly detailed clinical and endocrinological investigations should be performed for PIs. In addition, MTs should be considered in the differential diagnosis for young and lean patients with central diabetes insipidus.

Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess: A Systematic Review and Meta-analysis

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.

Assessment of Subclinical Cardiac Alterations and Atrial Electromechanical Delay by Tissue Doppler Echocardiography in Patients with Nonfunctioning Adrenal Incidentaloma

Background

Majority of the incidentally discovered adrenal masses, called adrenal incidentaloma (AI), are nonfunctioning adrenal adenomas. The appropriate management of AI is still a matter debate, so it is necessary to investigate their associated morbidity. However, data regarding morphological and functional cardiac alterations are limited in this group.

Objective

In this study, we aimed to assess cardiac structural and functional characteristics and atrial conduction properties in patients with nonfunctioning AI.

Methods

Thirty patients with nonfunctioning AI and 46 properly matched control subjects were included in the study. After hormonal and biochemical analysis, all participants underwent transthoracic echocardiography to obtain systolic and diastolic parameters of both ventricles, in addition to atrial conduction times by tissue Doppler echocardiography. Data were analyzed with Statistical Package for the Social Sciences (SPSS, Chicago, IL, United States) statistics, version 17.0 for Windows. P < 0.05 was considered statistically significant.

Results

Left ventricular (LV) mass index and LV myocardial performance index were significantly increased in AI group. Among atrial conduction times, both intra- and interatrial electromechanical delays were significantly prolonged in patients with nonfunctioning AI. Other laboratory and echocardiographic findings were similar between groups.

Conclusion

Our study revealed that intra- and inter-atrial conduction times were prolonged, and LV mass index was increased in patients with nonfunctioning AI. These findings may be markers of subclinical cardiac involvement and tendency to cardiovascular complications. Close follow-up is necessary for individuals with nonfunctioning AI for their increased cardiovascular risk.

Clinical Investigation of Adrenal Incidentalomas in Japanese Patients of the Fukuoka Region with Updated Diagnostic Criteria for Sub-clinical Cushing's Syndrome

Objectives We retrospectively investigated the clinical and endocrinological characteristics of adrenal incidentalomas. Methods We studied 61 patients who had been diagnosed with adrenal incidentalomas and had undergone detailed clinical and endocrinological evaluations while hospitalized. We used common criteria to diagnose the functional tumors, but for sub-clinical Cushing's syndrome, we used an updated set of diagnosis criteria: serum cortisol ≥1.8 μg/dL after a positive response to a 1-mg dexamethasone suppression test if the patient has a low morning adrenocorticotropic hormone (ACTH) level (<10 pg/mL) and a loss of the diurnal serum cortisol rhythm. Results Of the 61 patients, none (0%) had malignant tumors, 8 (13.1%) had pheochromocytoma, and 15 (24.6%) had primary aldosteronism; when diagnosed by our revised criteria, 13 (21.3%) had cortisol-secreting adenomas (Cushing's syndrome and sub-clinical Cushing's syndrome), and 25 (41.0%) had non-functional tumors. Compared with the non-functional tumor group, the primary aldosteronism group and the cortisol-secreting adenoma group were significantly younger and had significantly higher rates of hypokalemia, whereas the pheochromocytoma group had significantly larger tumors and a significantly lower body mass index. Conclusion Our study found a larger percentage of functional tumors among adrenal incidentalomas than past reports, partly because we used a lower serum cortisol level after a dexamethasone suppression test to diagnose sub-clinical Cushing's syndrome and because all of the patients were hospitalized and could therefore receive more detailed examinations. Young patients with hypokalemia or lean patients with large adrenal tumors warrant particularly careful investigation.

Characteristics of Adrenal Incidentalomas in a Large, Prospective Computed Tomography-Based Multicenter Study: The COAR Study in Korea

PURPOSE

Previous studies on adrenal incidentalomas (AIs) are limited by their retrospective design, small numbers of patients, Western populations, or use of an outdated imaging technique. We investigated the characteristics of AIs in Korean patients and compared them with those reported in the largest retrospective study in Italy to discover the effects of improved imaging techniques and ethnicity differences.

MATERIALS AND METHODS

This was a prospective, multicenter, cross-sectional observational study including 1005 Korean patients. Levels of plasma adrenocorticotrophic hormone, 24-h urinary free cortisol (UFC), serum cortisol after a 1 mg-dexamethasone suppression test, 24-h urinary fractionated metanephrine, and plasma aldosterone and plasma renin activity were measured. All AIs were characterized using computed tomography (CT).

RESULTS

Compared with the results of the Italian study, AIs in Korean patients were observed more frequently in men and predominantly on the left side. Korean patients with AIs were slightly younger, and fewer patients underwent surgery. Most AIs were nonfunctional in both studies, while fewer subclinical hypercortisolism and more primary aldosteronism (PA) cases were detected in Korean patients. In our study, high UFC levels showed very low sensitivity, compared to those in the Italian study. In pheochromocytoma or PA cases, there were no hormonal differences between the studies. AIs in Korean patients were smaller, such that a lower cutoff size for detecting adrenocortical carcinoma (ACC) could be warranted.

CONCLUSION

Recent advances in CT technology were leveraged to provide accurate characteristics of AIs and to detect smaller ACCs.

Comprehensive analysis on 559 cases of adrenal incidentalomas in the elderly Chinese

OBJECTIVE

This study was conducted to describe the incidence, classifications and characteristics of adrenal incidentalomas (AIs) in the elderly Chinese.

METHODS

Primary clinical records in Shanghai Changzheng Hospital (n = 559) were collected for incident cases of AI between January 1, 2002 and December 1, 2016. We examined demographics, endocrine functions, treatment, etiology, and prognoses.

RESULTS

We identified 559 new diagnoses of elderly onset AIs, of which 41.25% were male and were diagnosed at a mean age of 74.39 ± 9.03 years. About 61% showed no typical symptoms. Upon systematic review, 41.34% showed dysglycemia, high blood pressure, kaliopenia, and so on. 24.15% (n = 135) received complete or partial endocrine function assessments. A total of 281 cases underwent surgical treatment, and 278 cases went through regular follow-ups without any operation. Preoperative evaluation was basically consistent with postoperative pathology (P > .05). During the follow-up, the presence of new subclinical hypercortisolism was 8.99%, and the tumor grew up 3.92% per year (1.96 ± 0.09 mm). 51 cases (9.12%) eventually received further invasive examinations or surgical treatments.

CONCLUSION

The detection of AI in the elderly Chinese is increasing annually. The imaging method and endocrine function tests have great roles in distinguishing between benignancy and malignancy. The diagnosis and treatment of the elderly Chinese with AI should receive multidisciplinary assessment. Biochemical and morphological follow-up of aged patients with AI should be conducted every 5 years at least.

Nonfunctioning adrenal incidentaloma affecting central blood pressure and arterial stiffness parameters

PURPOSE

Recently, cardiovascular risk is thought to be increased in patients with nonfunctioning adrenal incidentaloma (NFAI). There are no sufficient studies in the literature to evaluate this situation in NFAI patients without cardiovascular risk. The objective of this study is to compare peripheral and central blood pressure and arterial stiffness between patients with NFAI and healthy volunteers (of a similar age, gender and body mass index as the NFAI group) who have no traditional cardiovascular risk factors and autonomous cortisol secretion, with pulse wave analysis (PWA).

METHODS

In this cross-sectional study, we evaluated 35 NFAI patients who have no traditional cardiovascular risk factors and 35 healthy volunteers. PWA was performed in the participants of similar gender, age and body mass index, with a Mobil-O-Graph PWA/ABPM (I.E.M. GmBH, Stolberg, Germany) device. Radiological and biochemical data were obtained retrospectively in the NFAI group.

RESULTS

In our study, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), central SBP, central DBP, peripheral vascular resistance, augmentation pressure (AP), heart rate-corrected augmentation index (Aix@75) and pulse wave velocity (PWV) values were significantly higher in the NFAI group compared to the control group. In addition, peripheral and central blood pressure and arterial stiffness parameters were correlated with age and duration of NFAI diagnosis of more than 1 year.

CONCLUSIONS

NFAIs are known as cardiometabolically innocent, but in our study, both peripheral and central blood pressure values and arterial stiffness parameters were negatively affected in patients diagnosed with NFAI who have no traditional cardiovascular risk factors. These patients are at risk of cardiovascular diseases.

Is there a role for epithelial-mesenchymal transition in adrenocortical tumors?

PURPOSE

Epithelial-mesenchymal transition (EMT) is a biological dynamic process by which epithelial cells lose their epithelial phenotype and acquire mesenchymal invasive and migratory characteristics. This has been postulated as an essential step during cancer progression and metastasis. Although this is well described in other tumors, the role of EMT in adrenocortical tumors (ACT) has yet to be addressed.

METHODS

The aim of this study was to evaluate the expression of EMT markers e-cadherin, vimentin, and fibronectin, along with EMT-transcription factors (EMT-TFs), TWIST1, SIP1, and SNAIL in 24 adrenocortical carcinoma (ACC), 19 adrenocortical adenomas (ACA), 27 childhood-onset adrenocortical tumors (CAT), and 12 normal adrenal glands. The association of EMT and EMT-TFs with clinical outcomes and pathology features were also evaluated.

RESULTS

Cytoplasmic vimentin expression was increased among CAT samples when compared to ACC, ACA, and normal adrenal samples (p < 0.001). There was no difference in e-cadherin and fibronectin expression observed between groups. Nuclear and cytoplasmic expression of TWIST1 and SIP1 was stronger in CAT and ACC vs. ACA and normal tissue samples (all, p < 0.05). ACT, regardless of classification, exhibited increased SNAIL expression when compared to normal tissue (p < 0.05). A significant correlation was observed between vimentin and TWIST1 (r _s = 0.44, p < 0.001); SIP1 (r _s = 0.51, p < 0.001); and SNAIL (r _s = 0.23, p < 0.05). TWIST1 and SIP1 expressions demonstrated a significant correlation (r _s = 0.56, p < 0.001). High SIP1 expression was associated with a lower survival rate among ACC cases (p < 0.05).

CONCLUSIONS

Vimentin, TWIST1, and SIP1 expressions are increased in aggressive ACT. Therefore, EMT may play a relevant role in adrenal tumorigenesis.

Patient-specific workup of adrenal incidentalomas

PURPOSE

: To develop a clinical prediction model to predict a clinically relevant adrenal disorder for patients with adrenal incidentaloma.

MATERIALS AND METHODS

: This retrospective study is approved by the institutional review board, with waiver of informed consent. Natural language processing is used for filtering of adrenal incidentaloma cases in all thoracic and abdominal CT reports from 2010 till 2012. A total of 635 patients are identified. Stepwise logistic regression is used to construct the prediction model. The model predicts if a patient is at risk for malignancy or hormonal hyperfunction of the adrenal gland at the moment of initial presentation, thus generates a predicted probability for every individual patient. The prediction model is evaluated on its usefulness in clinical practice using decision curve analysis (DCA) based on different threshold probabilities. For patients whose predicted probability is lower than the predetermined threshold probability, further workup could be omitted.

RESULTS

: A prediction model is successfully developed, with an area under the curve (AUC) of 0.78. Results of the DCA indicate that up to 11% of patients with an adrenal incidentaloma can be avoided from unnecessary workup, with a sensitivity of 100% and specificity of 11%.

CONCLUSION

: A prediction model can accurately predict if an adrenal incidentaloma patient is at risk for malignancy or hormonal hyperfunction of the adrenal gland based on initial imaging features and patient demographics. However, with most adrenal incidentalomas labeled as nonfunctional adrenocortical adenomas requiring no further treatment, it is likely that more patients could be omitting from unnecessary diagnostics.

Glucose Metabolism Abnormalities in Cushing Syndrome: From Molecular Basis to Clinical Management

An impaired glucose metabolism, which often leads to the onset of diabetes mellitus (DM), is a common complication of chronic exposure to exogenous and endogenous glucocorticoid (GC) excess and plays an important part in contributing to morbidity and mortality in patients with Cushing syndrome (CS). This article reviews the pathogenesis, epidemiology, diagnosis, and management of changes in glucose metabolism associated with hypercortisolism, addressing both the pathophysiological aspects and the clinical and therapeutic implications. Chronic hypercortisolism may have pleiotropic effects on all major peripheral tissues governing glucose homeostasis. Adding further complexity, both genomic and nongenomic mechanisms are directly induced by GCs in a context-specific and cell-/organ-dependent manner. In this paper, the discussion focuses on established and potential pathologic molecular mechanisms that are induced by chronically excessive circulating levels of GCs and affect glucose homeostasis in various tissues. The management of patients with CS and DM includes treating their hyperglycemia and correcting their GC excess. The effects on glycemic control of various medical therapies for CS are reviewed in this paper. The association between DM and subclinical CS and the role of screening for CS in diabetic patients are also discussed.

Concomitant alterations of metabolic parameters, cardiovascular risk factors and altered cortisol secretion in patients with adrenal incidentalomas during prolonged follow-up

OBJECTIVE

Adrenal incidentalomas (AI) are associated with metabolic and hormonal abnormalities, most commonly autonomous cortisol secretion (ACS). Data regarding alterations of insulin resistance (IR) and ACS after prolonged follow-up are limited. We investigated the evolution of IR, cortisol secretion and ACS development in patients with AI during prolonged follow-up.

DESIGN

Prospective study in a tertiary hospital.

PATIENTS AND MEASUREMENTS

Seventy-one patients with AI [51 nonfunctioning (NFAI) and 20 ACS] and 5·54 ± 1·7 years follow-up underwent testing for ACS and oral glucose tolerance test to determine IR indices and adrenal imaging.

RESULTS

At follow-up, 16/51 (31%) NFAI patients converted to ACS, while two with previous ACS reverted to NFAI; 21% (7/33) of patients who did not covert to ACS exhibited high urinary-free cortisol (H-UFC) levels. All AI patients developed deterioration of IR irrespective of their cortisol secretory status. Eight patients developed newly diagnosed type 2 diabetes (9·8% NFAI and 15% ACS, respectively) and 14 IR (17·6% NFAI and 25% ACS, respectively). Adenoma size increased from 2·1 ± 0·8 to 2·3 ± 0·8 cm, whereas IR correlated with postdexamethasone cortisol level and adenoma size increase. IR showed an incremental continuum trend from normal UFC (Ν-UFC), to H-UFC, C-ACS and ACS patients.

CONCLUSIONS

New-onset ACS developed in 31% patients with NFAI, whereas 21% of NFAI patients had H-UFC levels. All AI patients as a group and the subgroups of N-UFC, H-UFC, C-ACS and ACS patients developed deterioration of metabolic parameters during follow-up that was more prominent in ACS patients.

Follow-up of patients with adrenal incidentaloma, in accordance with the European society of endocrinology guidelines: Could we be safe?

Recently, the European Society of Endocrinology (ESE) published new guidelines on the management of adrenal incidentalomas. At the same time Lopez and coworkers published on the Annals of Internal Medicine an important study showing that even patients with non-functioning adrenal tumors have an increased risk of incident diabetes. In consideration of previous data and of the results of the study of Lopez and coworkers, some points emerge from the ESE Guidelines that deserve attention. Firstly, it must be observed that the term "autonomous cortisol secretion," introduced by the ESE Panel in the place of the commonly used "subclinical hypercortisolism," seems questionable, since the guidelines do not suggest determining the adrenocorticotroph hormone levels that could give the certain proof of a truly autonomous cortisol secretion. Secondly, the ESE Guidelines suggest against repeated hormonal workup in AI patients with a normal hormonal secretion at initial evaluation, but also in those with a "possible autonomous cortisol secretion," if in the absence of comorbidities potentially related to hypercortisolism. Thirdly, the ESE Guidelines suggest against further imaging during follow-up in patients with an adrenal mass below 4 cm in size with clear benign features on imaging studies. Considering the available literature data that are briefly summarized in this comment, we believe that no sufficient evidence is available to date for giving sharp-cutting recommendations about the uselessness of a biochemical and morphological follow-up in AI patients, even in those with initially benign and not hypersecreting adrenal adenomas. However, if a recommendation has to be given on the basis of the present evidences, we should suggest to biochemically and morphologically follow-up AI patients for at least 5 years.

Advances in our understanding of the prognosis of adrenal incidentaloma

As cross-sectional abdominal imaging is used increasingly, adrenal incidentaloma (AI) are being found frequently and present a clinical dilemma. The vast majority are benign and non-functioning, but a minority represent incidentally found functional or malignant tumours. In this review we summarise the current clinical, biochemical and radiological investigation of AI and discuss recent advances that differentiate clinically inconsequential lesions from functional and/or malignant AI. Areas covered: Prevalence, natural history, biochemical and radiological assessment, indications for surgery and surgical provision. Expert commentary: Well established work-up of AI usually enables benign, non-functioning lesions to be differentiated from functioning and/or malignant AI. In indeterminate lesions recent advances in work-up such as urine steroid profiles measured by gas chromatography /mass spectrometry and functional imaging with 18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) in addition to standard investigations have improved characterisation of these lesions. The management of AI showing mild autonomous hypercortisolism without overt features of Cushing's syndrome remains controversial and is discussed in this review.

Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors

: By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? SELECTED RECOMMENDATIONS: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.

Prevalence and clinical characteristics of adrenal incidentalomas in potential kidney donors

BACKGROUND

The prevalence of adrenal incidentalomas (AIs) in asymptomatic individuals is unknown. This study evaluated the prevalence of AIs in healthy kidney donors in whom pre-operative computed tomography (CT) is performed routinely.

METHODS

All potential kidney donors evaluated at the Rabin Medical Center who had routine abdominal CT were identified and their medical records were retrospectively reviewed. Subjects who had normal CT scans were compared with those with a finding of an AI, evaluating demographic (age, body mass index, systolic and diastolic blood pressure) and laboratory variables (glucose, sodium, potassium, calcium, phosphorus, albumin and creatinine). In addition, prevalence of hypertension, rate of donation and surgical mortality were compared between the two groups.

RESULTS

CT was performed in 673 potential kidney donors. Of these, 645 had a normal CT and 28 (4.2%) had evidence of an AI. Those with AIs had a similar prevalence of hypertension, kidney donation and surgical mortality as those with a normal CT. Those with AIs were older (50.93 ± 11.1 versus 43.76 ± 11.1 years) but other demographic variables were similar; laboratory variables were also similar except for slightly lower albumin and creatinine in those with AIs.

CONCLUSIONS

The prevalence of AIs is high even in healthy asymptomatic individuals.

Clinical and endocrinological characteristics of adrenal incidentaloma in Osaka region, Japan

The aim of this study was to investigate the clinical and endocrinological characteristics of adrenal incidentalomas in Osaka region, Japan. The study was a multicenter retrospective analysis of 150 patients with adrenal incidentalomas who underwent radiographic and endocrine evaluations between 2005 and 2013. Most adrenal incidentalomas were discovered by computed tomography (77.0%) and the rest were identified by abdominal ultrasonography (14.6%), magnetic resonance imaging (4.2%), or positron emission tomography (4.2%). Adrenal incidentalomas were more frequently localized on the left side than on the right. The average diameter of tumors was 21 ± 11 mm. On endocrinological evaluation, 14 patients were diagnosed with primary aldosteronism (9.3%), 10 with subclinical Cushing's syndrome (6.7%), 7 with pheochromocytoma (4.7%), 7 with Cushing's syndrome (4.7%), 2 with both subclinical Cushing's syndrome and primary aldosteronism (1.3%), and 110 with non-functioning tumors (73.3%). Patients with functioning tumors were significantly younger and had larger tumor diameters than those with non-functioning tumors. Except for hypertension, complications were comparable between patients with functioning and non-functioning tumors, including the presence of glucose intolerance, cardiovascular disease, and dyslipidemia. In conclusion, a higher prevalence of primary aldosteronism was observed compared with a previous report. Complications were comparable between patients with functioning and non-functioning tumors, including the frequencies of glucose intolerance, cardiovascular disease, and dyslipidemia. Long-term follow-up is required in patients with non-functioning tumors because the frequency of complications, such as glucose intolerance, cardiovascular disease, and dyslipidemia, was equal to that in patients with functioning tumors.

Clinical significance of screening for subclinical Cushing's disease in patients with pituitary tumors

Cushing's syndrome (CS) is a clinical state caused by chronic excess of glucocorticoid, and results in hypertension, impaired glucose tolerance, and dyslipidemia. Recently, a mild state of pituitary CS without typical Cushingoid appearance (subclinical Cushing's disease; SCD) has been identified. However, the true prevalence of SCD and its effect on metabolic disorders remain obscure. The aim of this prospective study was to determine the prevalence of SCD according to the guideline proposed by the working group of the Japanese Ministry of Health, Welfare and Labor, and to assess the outcome of surgery on metabolic disorders. The prevalence of SCD was investigated in 105 consecutive patients diagnosed with pituitary adenomas by MRI. ACTH-dependent hypercortisolism was diagnosed based on the results of the 0.5 mg dexamethasone suppression test (serum cortisol >3.0 μg/dL) plus one positive finding of the following two tests: midnight serum cortisol level >5.0 μg/dL or ACTH increase >50% after 1-deamino-5-D-arginine vasopressin (DDAVP) challenge. The final diagnosis of SCD was established by positive staining for ACTH in surgically-excised pituitary adenoma. Three patients (4.8%) were diagnosed with SCD among 62 patients with pituitary adenoma. Transsphenoidal adenomectomy partially resulted in improvement of blood pressure and glucose metabolism in SCD patients. Our results emphasize the importance of SCD screening in patients with pituitary tumors, especially in those patients with metabolic disorders.

The clinical course of patients with adrenal incidentaloma: is it time to reconsider the current recommendations?

OBJECTIVE

The current guidelines for the management of adrenal incidentaloma advise hormonal and radiological follow-up of patients for 2-5 years after the initial diagnosis. However, the vast majority of adrenal incidentaloma are non-functional benign cortical adenomas that require no treatment, so the routine application of the current strategies often results in a number of unnecessary biochemical and radiological investigations. The aim of this study was to analyse the clinical course of patients with adrenal incidentaloma and to provide a critical review of the current management strategy of the disease.

DESIGN AND METHODS

This was a retrospective study performed in the Croatian Referral Center for adrenal gland disorders. The study included 319 consecutive patients with adrenal incidentaloma, 174 of which were followed for at least 24 months.

RESULTS

The vast majority of patients were diagnosed with benign adrenal masses, whereas in about 5% of them adrenal tumor corresponded to adrenal carcinoma or metastasis. Tumor density was found to be superior to tumor size in distinguishing benign adrenal masses from malignant tumors and pheochromocytomas. During the follow-up, no patient demonstrated a clinically significant increase in tumor size. In addition, no changes, either in metanephrines and normetanephrines or in the activity of renin-aldosterone axis, were observed during the follow-up. Six patients developed subclinical Cushing's syndrome (SCS) whereas eight patients with SCS showed biochemical remission during follow-up.

CONCLUSION

The study suggests that the risk of an adrenal mass initially diagnosed as benign and non-functional becoming malignant or hormonally active is extremely low. Therefore, the clinical management of those patients should be tailored on an individual basis in order to avoid unnecessary procedures.

CLINICAL OUTCOMES IN ADRENAL INCIDENTALOMA: EXPERIENCE FROM ONE CENTER

OBJECTIVE

To investigate the outcome in patients with adrenal incidentaloma (AI).

METHODS

A retrospective evaluation of 637 patients with AI referred to a tertiary center over 8 years. Radiologic and hormonal evaluations were performed at baseline. Follow-up imaging was carried out if necessary, and hormonal evaluation was performed at 24 months according to national guidelines.

RESULTS

The mean age was 62.7 ± 11.6 years, and the mean AI size was 25.3 ± 17.0 mm at presentation. Hormonal evaluation revealed that 85.4% of all tumors were nonfunctioning adenomas, 4.1% subclinical Cushing syndrome (SCS), 1.4% pheochromocytoma, 1.4% primary hyperaldosteronism, 0.8% Cushing syndrome, 0.6% adrenocortical carcinoma, 0.3% congenital adrenal hyperplasia, 2.2% metastasis to adrenals, and 3.8% other lesions of benign origin. Bilateral tumors were found in 11%, and compared to unilateral tumors, SCS was more prevalent. Only 2 cases were reclassified during follow-up, both as SCS, but neither had had a dexamethasone suppression test performed at initial work-up. In patients diagnosed with an adrenal metastasis, 92.9% were deceased within 2 years. Excluding those with malignant tumors, 12.9% of patients died during the study period of up to 11 years due to other causes than adrenal.

CONCLUSION

Most AIs were benign, but a small fraction of tumors were functional and malignant. The prognosis of patients with adrenal metastasis was extremely poor, but otherwise, the mortality rate was similar to that for the general population. Follow-up of AIs <4 cm with an initial nonfunctional profile and benign radiologic appearance appears unwarranted, but screening for congenital adrenal hyperplasia should be considered.

Adrenal Mass in Patients who Underwent Abdominal Computed Tomography Examination

BACKGROUND

Adrenal masses are usually discovered incidentally (IAM) during abdominal computed tomography (CT).

AIMS

We aimed to describe the prevalence, management, and outcome of incidentally discovered adrenal mass on radiological investigation.

MATERIALS AND METHODS

A retrospective analysis was conducted to look for IAM identified by abdominal CT performed for other reasons between 2004 and 2008 and were followed for 4 years. IAM patients with known malignancy or clinically evident adrenal disease or overt disease originally missed due to insufficient clinical examination were excluded.

RESULTS

A total of 13,115 patients underwent abdominal CT, of which 136 were identified with adrenal mass (69 males and 67 females). Overall, 84 patients had benign IAM and six had primary adrenal carcinoma (all had tumor size ≥4 cm and five were males). Hormonal evaluation was performed in 80 cases, which revealed hypersecretion in 10 cases (six had Conn's syndrome and four had pheochromocytoma). Males had higher frequency of right-sided IAMs; whereas, left-sided IAM swere more common among females (P = 0.02). Seven patients underwent surgery and all were males (one Conn's syndrome, one pheochromocytoma, three primary adrenal adenocarcinoma, one benign nonfunctional adenoma, and one metastatic tumor). Only one patient died due to brain metastasis.

CONCLUSION

The overall prevalence of adrenal incidentaloma is 1% in Qatar. Unfortunately, hormonal evaluation, surgical referral, and follow-up are not appropriate in this study. Moreover, screening of IAM warrants more attention to rule out malignancy. This work could be of value as a local auditing for the current management.

Screening for Cushing's syndrome: is it worthwhile?

INTRODUCTION

Cushing's syndrome (CS) is a rare disease characterized by a collection of signs and symptoms, also common in the general population without elevated cortisol secretion. During the last years more patients with CS are identified earlier and with milder disease. Many of these patients are diagnosed during screening efforts performed for certain or isolated complaints like weight gain, diabetes mellitus (DM), hypertension, osteoporosis, elevated white blood cell counts and more.

METHODS

In this review article the most popular screening test performed in the studies cited was the 1-mg dexamethasone suppression test.

CONCLUSIONS

Cushing is not frequent enough to support the use of routine screening in patients with morbid obesity and type 2 DM. Also only 1% of hypertensive patients have secondary hypertension due to CS. However, screening should be considered in young patients with resistant DM and/or hypertension. Among patients with osteoporosis and vertebral fractures up to 5% were diagnosed with subclinical hypercortisolism; most of these had adrenal adenoma. Screening for CS is important in subjects with adrenal incidentaloma, and many studies show a high prevalence (~10%) of Cushing or subclinical CS in these patients.

Clinical Characteristics and Metabolic Features of Patients with Adrenal Incidentalomas with or without Subclinical Cushing's Syndrome

BACKGROUND

The aim of this study was to examine the clinical characteristics of adrenal incidentalomas discovered by computed tomography (CT) and to investigate metabolic features of subclinical Cushing's syndrome (SCS) in patients with adrenal incidentalomas in a tertiary hospital in Korea.

METHODS

This retrospective study examined the clinical aspects of 268 patients with adrenal incidentalomas discovered by CT at Soonchunhyang University Bucheon Hospital. Clinical data and endocrine function of the patients as well as histological findings were obtained from medical records, while anatomic characteristics were analyzed by reviewing imaging studies. Hormonal tests for pheochromocytoma, Cushing's syndrome, and aldosterone-secreting adenoma were performed.

RESULTS

Most (n=218, 81.3%) cases were nonfunctioning tumors. Of the 50 patients with functioning tumors (18.7%), 19 (7.1%) were diagnosed with SCS, nine (3.4%) with overt Cushing's syndrome, 12 (4.5%) with primary aldosteronism, and 10 (3.7%) with pheochromocytoma. Malignant tumors (both primary and metastatic) were rare (n=2, 0.7%). Body mass index, fasting glucose, hemoglobin A1c, and total cholesterol were significantly higher in patients with SCS in comparison with those with nonfunctioning tumors. The prevalence of type 2 diabetes mellitus and hypertension were significantly higher in patients with SCS compared with those with nonfunctioning tumors.

CONCLUSION

Functioning tumors, especially those with subclinical cortisol excess, are commonly found in patients with adrenal incidentalomas, although malignancy is rare. In addition, patients with SCS in adrenal incidentalomas have adverse metabolic and cardiovascular profiles.

Effectiveness of partial adrenalectomy for concomitant hypertension in patients with nonfunctional adrenal adenoma

OBJECTIVE

To evaluate the effect of adrenal surgery on blood pressure (BP) in patients with both nonfunctional adrenal adenoma (NFA) and hypertension and to assess factors affecting hypertension outcomes after surgery.

METHODS

Nonfunctional adrenal adenoma patients with hypertension who were treated with or without adrenal surgery at our center during 2005-2011 were retrospectively studied. Clinical characteristics were collected, and changes in BP were evaluated and compared at 2 year after discharge. Factors predicting favorable hypertension outcomes after surgery were determined using logistic regression.

RESULTS

A total of 186 patients, including 77 surgically treated cases, were eligible for this study. Retroperitoneoscopic procedure was mostly adopted, and partial adrenalectomy was performed in 69 patients. At 2 year postoperatively, both systolic and diastolic pressure levels of the surgery group decreased significantly (162.9/97.6 vs. 146.9/88.2 mmHg), with 27 (35%) patients cured and 26 (31%) improved. In contrast, BP levels of conservatively treated patients remained relatively stable (159.9/96.8 vs. 161.9/97.4 mmHg) after 2 years. Multivariate logistic regression analyses showed hypertension duration<6 years was the only independent factor associated with favorable hypertension outcomes after surgery, which predicted complete cure as well as response to surgical intervention.

CONCLUSION

Early partial adrenalectomy substantially cures or improves concomitant hypertension in most patients with NFA. Prospective studies should be performed of large cohorts to construct ideal clinical guidelines for NFA patients at cardiometabolic risk.