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Khadembashiri MM, Mohseni S, Harandi H, Pejman Sani M, Khadembashiri MA, Atlasi R, SeyedAlinaghi S, Mohajeri- Tehrani M, Larijani B. Comparison of adrenalectomy with conservative treatment on mild autonomous cortisol secretion: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1374711. [PMID: 38808111 PMCID: PMC11131104 DOI: 10.3389/fendo.2024.1374711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
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.
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Affiliation(s)
- Mohamad Mehdi Khadembashiri
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Mohseni
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Harandi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Pejman Sani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Amin Khadembashiri
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Rasha Atlasi
- Non-Communicable Diseases Research Center, Endocrine Population Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Mohajeri- Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Carlisle K, Blackburn KW, Japp EA, McArdle PF, Turner DJ, Terhune JH, Englum BR, Smith PW, Hu Y. Laparoscopic surgery for adrenocortical carcinoma: Estimating the risk of margin-positive resection. J Surg Oncol 2024; 129:691-699. [PMID: 38037311 PMCID: PMC10926184 DOI: 10.1002/jso.27544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/05/2023] [Accepted: 11/04/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Over recent years, there has been increasing adoption of minimally invasive surgery (MIS) in the treatment of adrenocortical carcinoma (ACC). However, MIS has been associated with noncurative resection and locoregional recurrence. We aimed to identify risk factors for margin-positivity among patients who undergo MIS resection for ACC. We hypothesized that a simple nomogram can accurately identify patients most suitable for curative MIS resection. METHODS Curative-intent resections for ACC were identified through the National Cancer Database spanning 2010-2018. Trends in MIS utilization were reported using Pearson correlation coefficients. Factors associated with margin-positive resection were identified among preoperatively available variables using multivariable logistic regression, then incorporated into a predictive model. Model quality was cross validated using an 80% training data set and 20% test data set. RESULTS Among 1260 ACC cases, 38.6% (486) underwent MIS resection. MIS utilization increased over time at nonacademic centers (R = 0.818, p = 0.007), but not at academic centers (R = 0.009, p = 0.982). Factors associated with margin-positive MIS resection were increasing age, nonacademic center (odds ratio [OR]: 1.8, p = 0.006), cT3 (OR: 4.7, p < 0.001) or cT4 tumors (OR: 14.6, p < 0.001), and right-sided tumors (OR: 2.0, p = 0.006). A predictive model incorporating these four factors produced favorable c-statistics of 0.75 in the training data set and 0.72 in the test data set. A pragmatic nomogram was created to enable bedside risk stratification. CONCLUSIONS An increasing proportion of ACC are resected via minimally invasive operations, particularly at nonacademic centers. Patient selection based on a few key factors can minimize the risk of noncurative surgery.
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Affiliation(s)
| | | | - Emily A. Japp
- University of Maryland School of Medicine, Department of
Medicine
| | - Patrick F. McArdle
- University of Maryland School of Medicine, Department of
Epidemiology & Public Health
- Maryland Surgery, Pharmacy, and Anesthesiology Research
Collaborative
| | | | | | - Brian R. Englum
- University of Maryland Baltimore, Department of
Surgery
- Maryland Surgery, Pharmacy, and Anesthesiology Research
Collaborative
| | - Philip W. Smith
- University of Virginia School of Medicine, Department of
Surgery
| | - Yinin Hu
- University of Maryland Baltimore, Department of
Surgery
- Maryland Surgery, Pharmacy, and Anesthesiology Research
Collaborative
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3
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van Doesburg JR, Voeten DM, Kalff MC, van Berge Henegouwen MI, Jol S, van den Bergh JE, Engelsman AF, Gisbertz SS, Daams F. Incidence and oncological implication of adrenal incidentalomas in esophageal cancer patients. Dis Esophagus 2023; 36:doad003. [PMID: 36722353 PMCID: PMC10473449 DOI: 10.1093/dote/doad003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/15/2022] [Accepted: 01/01/2023] [Indexed: 02/02/2023]
Abstract
Adrenal incidentalomas are regularly encountered during imaging for esophageal cancer patients, but their oncological significance remains unknown. This study aimed to describe the incidence and etiology of adrenal incidentalomas observed throughout the diagnostic workup. This retrospective cohort study included all esophageal cancer patients referred to or diagnosed in the Amsterdam UMC between January 2012 and December 2016. Radiology and multidisciplinary team meeting reports were reviewed for adrenal incidentalomas. In case of adrenal incidentaloma, the 18FDG-PET/CT was reassessed by a radiologist blinded for the original report. In case of a metachronous incidentaloma during follow-up, visibility on previous imaging was reassessed. Primary outcome was the incidence, etiology and oncological consequence of synchronous adrenal incidentalomas. This study included 1,164 esophageal cancer patients, with a median age of 66 years. Patients were predominantly male (76.1%) and the majority had an adenocarcinoma (69.0%). Adrenal incidentalomas were documented in 138 patients (11.9%) during the diagnostic workup. At primary esophageal cancer workup, 22 incidentalomas proved malignant. However, follow-up showed that four incidentalomas were inaccurately diagnosed as benign and three malignant incidentalomas were visible on staging imaging but initially missed. Stage migration occurred in 15 of 22 (68.2%), but this would have been higher if none were missed or inaccurately diagnosed. The oncological impact of adrenal incidentalomas in patients with esophageal cancer is significant as a considerable part of incidentalomas changed treatment intent from curative to palliative. As stage migration is likely, pathological examination of a synchronous adrenal incidentaloma should be weighted in mind.
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Affiliation(s)
- J R van Doesburg
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - D M Voeten
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - M C Kalff
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S Jol
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - J E van den Bergh
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - A F Engelsman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - F Daams
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Lerario AM, Mohan DR, Hammer GD. Update on Biology and Genomics of Adrenocortical Carcinomas: Rationale for Emerging Therapies. Endocr Rev 2022; 43:1051-1073. [PMID: 35551369 PMCID: PMC9695111 DOI: 10.1210/endrev/bnac012] [Citation(s) in RCA: 6] [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: 12/29/2021] [Indexed: 11/19/2022]
Abstract
The adrenal glands are paired endocrine organs that produce steroid hormones and catecholamines required for life. Adrenocortical carcinoma (ACC) is a rare and often fatal cancer of the peripheral domain of the gland, the adrenal cortex. Recent research in adrenal development, homeostasis, and disease have refined our understanding of the cellular and molecular programs controlling cortical growth and renewal, uncovering crucial clues into how physiologic programs are hijacked in early and late stages of malignant neoplasia. Alongside these studies, genome-wide approaches to examine adrenocortical tumors have transformed our understanding of ACC biology, and revealed that ACC is composed of distinct molecular subtypes associated with favorable, intermediate, and dismal clinical outcomes. The homogeneous transcriptional and epigenetic programs prevailing in each ACC subtype suggest likely susceptibility to any of a plethora of existing and novel targeted agents, with the caveat that therapeutic response may ultimately be limited by cancer cell plasticity. Despite enormous biomedical research advances in the last decade, the only potentially curative therapy for ACC to date is primary surgical resection, and up to 75% of patients will develop metastatic disease refractory to standard-of-care adjuvant mitotane and cytotoxic chemotherapy. A comprehensive, integrated, and current bench-to-bedside understanding of our field's investigations into adrenocortical physiology and neoplasia is crucial to developing novel clinical tools and approaches to equip the one-in-a-million patient fighting this devastating disease.
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Affiliation(s)
- Antonio Marcondes Lerario
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | - Dipika R Mohan
- Medical Scientist Training Program, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | - Gary D Hammer
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
- Department of Cell & Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
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5
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Anyfanti P, Mastrogiannis Κ, Lazaridis Α, Tasios Κ, Vasilakou D, Kyriazidou Α, Aroutsidis F, Pavlidou O, Papoutsopoulou Ε, Tiritidou A, Kotsis V, Triantafyllou Α, Zarifis Ι, Douma S, Gkaliagkousi Ε. Clinical presentation and diagnostic evaluation of pheochromocytoma: case series and literature review. Clin Exp Hypertens 2022; 45:2132012. [PMID: 36218060 DOI: 10.1080/10641963.2022.2132012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Pheochromocytoma is a rare tumor frequently overlooked mainly due to the wide range of its clinical presentation, which may vary from entirely untypical signs and symptoms to life-threatening complications. METHODS The present study aims to present a case series recently treated in our center, with emphasis placed on patients' specific characteristics, clinical presentation and diagnostic evaluation. Relevant literature and current guidelines are being briefly reviewed to summarize screening for pheochromocytoma and appropriate diagnostic procedures. RESULTS While the classic symptoms include headache, palpitations and sweating with permanent or paroxysmal hypertension, a wide range of clinical manifestations may be attributed to pheochromocytoma. The initial screening test is measurement of plasma or 24-hour urine metanephrine levels. Abdominal computerized tomography with intravenous contrast infusion is suggested as the imaging examination of choice, whereas magnetic resonance imaging should be preferred over CT in exceptional cases. 123I-metaiodobenzylguanidine scintigraphy is particularly useful for establishing the diagnosis of pheochromocytoma and should be further applied to detect or exclude possible metastatic lesions. CONCLUSION Early diagnosis of pheochromocytoma is of great significance not only because it represents a curable form of secondary hypertension, but also because it is often related to familial syndromes, malignancy or metastatic disease. Physicians need to be familiar with relevant clinical manifestations and diagnostic steps to raise clinical suspiction of pheochromocytoma and establish a timely diagnosis.
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Affiliation(s)
- Panagiota Anyfanti
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Κonstantinos Mastrogiannis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Αntonios Lazaridis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Κonstantinos Tasios
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Despoina Vasilakou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Αnastasia Kyriazidou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Aroutsidis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Olga Pavlidou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Εleni Papoutsopoulou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athina Tiritidou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Kotsis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Αreti Triantafyllou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ιoannis Zarifis
- Department of Cardiology, Papanikolaou General Hospital, Thessaloniki, Greece
| | - Stella Douma
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Εugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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6
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Perge P, Nyirő G, Vékony B, Igaz P. Liquid biopsy for the assessment of adrenal cancer heterogeneity: where do we stand? Endocrine 2022; 77:425-431. [PMID: 35552979 PMCID: PMC9385753 DOI: 10.1007/s12020-022-03066-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/27/2022] [Indexed: 02/06/2023]
Abstract
Almost 10 years have passed since the first attempts of liquid biopsy aimed at the characterisation of tumor cells present in the bloodstream from a regular sample of peripheral blood were performed. Liquid biopsy has been used to characterise tumor heterogeneity in various types of solid tumors including adrenocortical carcinoma. The development of molecular biology, genetics, and methodological advances such as digital PCR and next-generation sequencing allowed us to use besides circulating tumor cells a variety of circulating cell-free nucleic acids, DNAs, RNAs and microRNAs secreted by tumors into blood and other body fluids as specific molecular markers. These markers are used for diagnosis, to check tumor development, selecting efficient therapies, therapy monitoring and even possess prognostic power. In adrenocortical carcinoma, there are some studies reporting analysis of circulating tumor cells, circulating cell free DNA and microRNAs for assessing tumor heterogeneity. Among microRNAs, hsa-miR-483-5p seems to be the most important player. Combined with other microRNAs like hsa-miR-195, their expression correlates with recurrence-free survival. Most studies support the applicability of liquid biopsy for assessing temporal tumor heterogeneity (i.e. tumor progression) in adrenocortical cancer. In this mini-review, the available findings of liquid biopsy for assessing tumor heterogeneity in adrenocortical cancer are presented.
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Affiliation(s)
- Pál Perge
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083, Budapest, Hungary
| | - Gábor Nyirő
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083, Budapest, Hungary
- MTA-SE Molecular Medicine Research Group, Eötvös Loránd Research Network, H-1083, Budapest, Hungary
- Institute of Laboratory Medicine, Faculty of Medicine, Semmelweis University, H-1089, Budapest, Hungary
| | - Bálint Vékony
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083, Budapest, Hungary
| | - Peter Igaz
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083, Budapest, Hungary.
- Department of Endocrinology, ENS@T Research Center of Excellence, Faculty of Medicine, Semmelweis University, H-1083, Budapest, Hungary.
- MTA-SE Molecular Medicine Research Group, Eötvös Loránd Research Network, H-1083, Budapest, Hungary.
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7
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Factors predicting prolonged glucocorticoid therapy in patients with adrenal insufficiency after laparoscopic adrenalectomy. Case report. Ann Med Surg (Lond) 2022; 77:103390. [PMID: 35638023 PMCID: PMC9142400 DOI: 10.1016/j.amsu.2022.103390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/07/2022] [Accepted: 02/20/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction and importance Adrenal insufficiency (AI) is common after adrenalectomy for Primary Adrenal Cushing's syndrome (PACS), due to the inhibition of the Hypothalamic-Pituitary-Adrenal Axis (HPAA) by the functioning adrenal mass. The treatment of post-surgical AI is based mainly on glucocorticoid supplementation therapy. To date, however, there is no known predicting factor of the duration of supplementation therapy in patients treated with laparoscopic adrenalectomy for PACS. Case presentation We report the case of a 22-year-old Caucasian female who presented with dyspnea, osteoporosis, vertebral collapses and fractures of the pelvis. The diagnosis of ACTH-independent Cushing's syndrome was provided. Abdominal MRI revealed a left adrenal mass suggestive for adrenal adenoma, highly suggestive for PACS. The patient underwent left laparoscopic adrenalectomy. After surgery, glucorticoid supplementation therapy was started. More than A-year steroid replacement therapy was necessary before the patient completely recovered the function of the HPAA. During this period the patient was strictly followed up in order to adjust pharmacologic treatment, thus allowing to investigate the possible causes of such a slow and hard recover of the contralateral adrenal gland function. Conclusion AI is common after adrenalectomy for PACS due to HPAA suppression. The duration of steroid replacement therapy may be vary depending on patient's characteristics and may be uncommonly long, as in our case. We concluded the not only cortisol and ACTH level, but also radiological findings, such as the size of the mass, its functional activity as well as the hypotrophy or atrophy of the contralateral adrenal gland may be predictive of the duration of the steroid therapy. These factors, if correctly studied before surgery, may be of help in tailoring the postoperative management of the patients after adrenalectomy. Adrenal insufficiency is common after adrenalectomy for secreting masses. In some cases long-lasting glucocorticoid replacement therapy is required before regular function of the contralateral adrenal gland is restored. The high level of cortisol may lead to strong suppression of the Hypothalamic-Pituitary-Adrenal Axis (HPAA), that in turn may lead to hypotrophy of the contralateral adrenal gland. No predictive factor of the need for prolonged steroid therapy has been reported in the literature to date. However, some radiological findings, such as the width of the contralateral adrenal gland is associated to the need of a prolonged glucocorticoid replacement therapy in the post-operative time.
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Abstract
Incidental findings are common in the evaluation of surgical patients. Understanding the appropriate assessment and management of these frequent occurrences is important for the provision of comprehensive quality care. This review details the epidemiology, considerations, and recommendations for management of common incidental manifestations in surgical patients, including Meckel diverticulum, adrenal incidentaloma, thyroid nodule, solitary pulmonary nodule, small bowel intussusception, gallstones, and incidental appendectomy.
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Affiliation(s)
- Keely Reidelberger
- University of Nebraska Medical Center College of Medicine, 986880 Nebraska Medical Center, Omaha, NE 68198-6880, USA
| | - Abbey Fingeret
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE 68198-6880, USA.
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9
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La B, Tung C, Choi EA, Nguyen H. A Gigantic Uterine Leiomyoma and Big Bilateral Adrenal Myelolipomas as a Result of Untreated Congenital Adrenal Hyperplasia. AACE Clin Case Rep 2021; 7:342-345. [PMID: 34765728 PMCID: PMC8573279 DOI: 10.1016/j.aace.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Patients with congenital adrenal hyperplasia (CAH) can present early with salt wasting, adrenal insufficiency, and hyperandrogenism. Late consequences as a result of untreated CAH are now rarely seen. We present a patient with a massive uterine leiomyoma and bilateral adrenal myelolipomas due to longstanding treatment noncompliance. Case Report A female patient with CAH was treated with glucocorticoids until the age of 29 years when they stopped with the intention of identifying as a male. The patient then presented with abdominal pain and distension. Computed tomography images of the abdomen and pelvis revealed a 31 × 35 × 31-cm abdominal mass, a 5.9× 2.4-cm right adrenal mass, and an 11.8 × 8.8-cm left adrenal mass. The patient underwent total hysterectomy and bilateral adrenalectomy. Pathology of the abdominal mass was consistent with uterine leiomyoma, and bilateral adrenal masses were consistent with adrenal myelolipomas. Discussion The goal of CAH therapy is to provide adequate replacement while reducing adrenocorticotropic hormone and adrenal androgens levels. Due to the conversion of androgens to estrogens, untreated females with CAH have elevated androgen and estrogen levels. High levels of these hormones can stimulate the growth of estrogen-dependent organs as exemplified by our patient. Chronic adrenocorticotropic hormone stimulation can not only cause adrenal hyperplasia but has also been associated with the development of adrenal myelolipomas. Conclusion This case demonstrates the significance of CAH treatment compliance as there are several serious sequela outside of the expected adrenal insufficiency and virilization. Even when the desired effect is virilization, other means of hormonal therapy should be considered.
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Affiliation(s)
- Betty La
- Section of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, Texas
- Address correspondence and reprint requests to Dr Betty La, Section of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, 7200 Cambridge St., Houston, TX 77030.
| | - Celestine Tung
- Division of Gynecologic Oncology, Baylor College of Medicine, Houston, Texas
| | - Eugene A. Choi
- Division of Surgical Oncology, Baylor College of Medicine, Houston, Texas
| | - Ha Nguyen
- Section of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, Texas
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10
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Voltan G, Boscaro M, Armanini D, Scaroni C, Ceccato F. A multidisciplinary approach to the management of adrenal incidentaloma. Expert Rev Endocrinol Metab 2021; 16:201-212. [PMID: 34240680 DOI: 10.1080/17446651.2021.1948327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/23/2021] [Indexed: 01/15/2023]
Abstract
An adrenal incidentaloma (AI) is an adrenal neoplasm incidentally discovered during an imaging unrelated to suspected adrenal disease. The aim of the present review is to offer practical guidance on the multidisciplinary approach of AIs.Areas covered:The prevalence of AI is high in the aging population (up to 5-8%); however, hormonally active or malignant conditions are rare. After the discovery of an AI, it is suggested to assess in parallel if the mass is potentially malignant and functionally active. The answer to the former question is mainly based on medical history (extra-adrenal malignancies, new-onset of signs or symptoms) and imaging (conventional radiology and/or nuclear medicine). The answer to the latter question is a complete endocrine evaluation of both cortical (glucocorticoids, mineralocorticoids) and medullary (catecholamines) secretion.Expert opinion:A multidisciplinary discussion is suggested for patients with adrenal disease, after the exclusion of nonfunctioning benign cortical adenoma, in order to plan a close and tailored follow-up for the suspected malignant or functioning forms. Surgery is advised for patients with malignant disease (adrenocortical cancer) or with clinically relevant secreting neoplasm (primary aldosteronism, Cushing's syndrome, and pheochromocytoma).
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Affiliation(s)
- Giacomo Voltan
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Decio Armanini
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
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11
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Lin D, Lin J, Hu X, Liu Y, Zhang J, Zhang L, Jiang J, Li X, Guo J. Preoperative prognostic nomogram for prophylactic steroid treatment of patients with subclinical Cushing's syndrome. Transl Androl Urol 2021; 10:426-437. [PMID: 33532330 PMCID: PMC7844482 DOI: 10.21037/tau-20-1108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Subclinical Cushing’s syndrome (SCS) is incidentally detected in a growing number of patients by advanced imaging technology. However, there is no consensus on the clinical management of SCS, especially in terms of whether prophylactic steroid treatment is necessary following adrenalectomy. In this study we developed a model based on preoperative indices for predicting postoperative adrenal insufficiency (AI) that can guide therapeutic decision-making. Methods A total of 27 patients with SCS who underwent adrenalectomy between August 2016 and August 2019 were enrolled and divided into AI and non-AI groups. Cox proportional hazards regression and least absolute shrinkage and selection operator analyses were performed to select relevant clinical parameters. The predictive performance of our model was evaluated by time-dependent receiver operating characteristic (ROC) curve and calibration curve analyses. Results Five clinical parameters (apolipoprotein A1, neutrophil–lymphocyte ratio, total cholesterol, platelet count, and homocysteine) were identified as the best predictors of replacement therapy (RT). The areas under the ROC curve for our prognostic model were 0.833, 0.945, and 0.967 for 3-, 4-, and 5-day non-(N)RT, respectively. The calibration curve of the 5 independent RT-related markers showed a good fit between nomogram-predicted probability of NRT and actual NRT, suggesting that our model has good predictive value. Conclusions Our prognostic nomogram can help clinicians identify patients with AI who would benefit from RT so that timely treatment can be initiated. Keywords Subclinical Cushing’s syndrome (SCS); Replacement therapy (RT); Adrenal insufficiency (AI); Nomogram; Receiver operating characteristic (ROC)
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Affiliation(s)
- Dengqiang Lin
- Department of Urology, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Jinglai Lin
- Department of Urology, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Xiaoyi Hu
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yujun Liu
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianping Zhang
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Zhang
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingjing Jiang
- Department of Endocrinology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaomu Li
- Department of Endocrinology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianming Guo
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
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Falcetta P, Orsolini F, Benelli E, Agretti P, Vitti P, Di Cosmo C, Tonacchera M. Clinical features, risk of mass enlargement, and development of endocrine hyperfunction in patients with adrenal incidentalomas: a long-term follow-up study. Endocrine 2021; 71:178-188. [PMID: 32915435 PMCID: PMC7835305 DOI: 10.1007/s12020-020-02476-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/23/2020] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Pierpaolo Falcetta
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy.
| | - Francesca Orsolini
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Elena Benelli
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Patrizia Agretti
- Laboratory of Chemistry and Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Paolo Vitti
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Caterina Di Cosmo
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Massimo Tonacchera
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
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Nermoen I, Falhammar H. Prevalence and Characteristics of Adrenal Tumors and Myelolipomas in Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. Endocr Pract 2020; 26:1351-1365. [PMID: 33471666 DOI: 10.4158/ep-2020-0058] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The prevalence of adrenal tumors in congenital adrenal hyperplasia (CAH) is uncertain. Our objective was to estimate the prevalence and characteristics of adrenal tumors and myelolipoma in CAH, and investigate clinical features of this population. METHODS We carried out systematic searches in Medline Ovid and Embase for articles published until January, 2020. Studies with confirmed CAH, biochemically and/or genetically, were included. The two authors independently extracted data from each study. RESULTS Six cohort studies were included in the prevalence calculation. In addition, 32 case reports on adrenal myelolipomas and CAH were included. The prevalence of adrenal tumors in CAH was 29.3%. When only studies with genetically verified cytochrome P450, Family 21, subfamily A, polypeptide 2 gene (CYP21A2) mutations were included the prevalence was 23.6%. The prevalence of myelolipoma in CAH was 7.4% (verified CYP21A2 mutations 8.6%). The proportion of myelolipoma in the adrenal tumors was 25.4% (genetically verified 36.6%). The median (range) age at tumor diagnosis was 36.0 (12 to 60) years and there were more tumors in males than in females (37.9% versus 22.1%; P<.05). In patients with myelolipomas, 93.5% had an undiagnosed or poorly managed CAH. CONCLUSION Patients with CAH had a high prevalence of adrenal tumors, particularly myelolipomas. Those with myelolipomas had a high frequency of late-diagnosed or poorly controlled CAH. Adrenal imaging may be considered in patients with CAH, especially if abdominal pain is present.
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Affiliation(s)
- Ingrid Nermoen
- From the Department of Endocrinology, Akershus University Hospital, Lørenskog, Norway; the Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Henrik Falhammar
- the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden; the Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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14
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AKHANLI P, UCAN B, HASDEMİR A, HEPŞEN S, ÖZTÜRK ÜNSAL İ, FELEKOĞLU MA, ÇAKAL E. Cardiac presentations mimicking acute coronary syndrome of a giant pheochromocytoma case. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2020. [DOI: 10.32322/jhsm.747791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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15
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The Potential of Steroid Profiling by Mass Spectrometry in the Management of Adrenocortical Carcinoma. Biomedicines 2020; 8:biomedicines8090314. [PMID: 32872281 PMCID: PMC7555975 DOI: 10.3390/biomedicines8090314] [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: 08/03/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/23/2022] Open
Abstract
Radiological and endocrinological work up of adrenal neoplasms is aimed at distinguishing between frequent non-functioning adenomas and rare but very aggressive adrenocortical carcinoma (ACC). Relevant research has addressed the identification of molecular, genetic and hormonal markers that could have clinical significance for malignancy, as well as a prognostic value. Regarding endocrine aspects, attention has been paid to the pattern of steroid secretion that can be affected by altered steroidogenic pathway in ACC. The advent of mass spectrometry techniques has overcome many limitations usually associated with immunoassays, allowing the determination of both common and rarely measured steroids in a single analysis with high specificity and sensitivity. Indeed, mass spectrometry strategies may be able to identify an individualized steroid profile of ACC, allowing a rapid diagnosis and a specific follow-up. In this review, insights, strengths and limitations of mass spectrometry-based approaches in steroid profiling, as well as of immunoassay in steroid measurements, will be specifically discussed. Moreover, the latest findings on steroid profiling by mass spectrometry-based techniques, the most promising analytical tool, will be summarized to evaluate if steroid profiling might be the clue for solving the clinical dilemma in differentiating ACC from non-functioning adrenocortical adenomas (ACA).
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16
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Chand R, Tandukar S, Asmil S, Chico M. Primary Hyperaldosteronism in End-Stage Renal Disease: Diagnostic Challenges and Treatment Considerations. Cureus 2020; 12:e9599. [PMID: 32923203 PMCID: PMC7478770 DOI: 10.7759/cureus.9599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
An adrenal incidentaloma is defined as an adrenal mass measuring at least 1 cm that is discovered surreptitiously in an imaging study done for reasons other than the evaluation of adrenal disease. The increase in the prevalence of adrenal incidentalomas has paralleled the increase in diagnostic imaging done for evaluation of other abdominal pathologies. However, most of these adrenal incidentalomas are benign non-hyperfunctioning adenomas. When an adrenal incidentaloma is discovered, the simultaneous presence of hypokalemia, metabolic alkalosis, mild hypernatremia, and mild to severe drug-resistant hypertension may alert a clinician to underlying primary hyperaldosteronism. We present a case of adrenal incidentaloma noted in a patient with end-stage renal disease on hemodialysis which presented a diagnostic challenge due to the correction of metabolic parameters with hemodialysis. The patient was found to have an aldosterone-producing adenoma based on an elevated aldosterone-to-renin ratio and was started on a mineralocorticoid antagonist.
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Abstract
Pheochromocytomas are rare tumors originating in the adrenal medulla. They may be sporadic or in the context of a hereditary syndrome. A considerable number of pheochromocytomas carry germline or somatic gene mutations, which are inherited in the autosomal dominant way. All patients should undergo genetic testing. Symptoms are due to catecholamines over production or to a mass effect. Diagnosis is confirmed by raised plasma or urine metanephrines or normetanephrines. Radiology assists in the tumor location and any local invasion or metastasis. All the patients should have preoperative preparation with α-blockers and/or other medications to control hypertension, arrhythmia, and volume expansion. Surgery is the definitive treatment. Follow up should be life-long.
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18
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Ishii K, Abe I, Kameda W, Sugimoto K, Morinaga Y, Ito M, Takashi Y, Abe M, Hada Y, Takase K, Fujii H, Ohishi H, Ochi K, Yamao Y, Minezaki M, Kudo T, Higashi T, Sonoda Y, Ishizawa K, Kobayashi K. Clinical investigation of pituitary incidentalomas: A two-center study. Intractable Rare Dis Res 2019; 8:239-244. [PMID: 31890450 PMCID: PMC6929595 DOI: 10.5582/irdr.2019.01083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Kota Ishii
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Ichiro Abe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
- Address correspondence to:Dr. Ichiro Abe, Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, 1-1-1, Zokumyoin, Chikushino, Fukuoka 818-8502, Japan. E-mail:
| | - Wataru Kameda
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kaoru Sugimoto
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Yusuke Morinaga
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Miiko Ito
- Department of Neurosurgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Makiko Abe
- Department of Preventive Medicine, Kyushu University Faculty of Medical Sciences, Fukuoka, Japan
| | - Yurika Hada
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kaoru Takase
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Hideyuki Fujii
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Hanako Ohishi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Kentaro Ochi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Yuka Yamao
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Midori Minezaki
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Tadachika Kudo
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Toshio Higashi
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
| | - Yukihiko Sonoda
- Department of Neurosurgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kenichi Ishizawa
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kunihisa Kobayashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikusino, Fukuoka, Japan
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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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Is Prophylactic Steroid Treatment Mandatory for Subclinical Cushing Syndrome After Unilateral Laparoscopic Adrenalectomy? Surg Laparosc Endosc Percutan Tech 2019; 29:31-35. [PMID: 30300254 DOI: 10.1097/sle.0000000000000585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This study aimed to provide rational guidelines for patients with subclinical Cushing syndrome (SCS), who are undergoing laparoscopic adrenalectomy, in order to avoid the risk of overtreatment. METHODS A total of 59 patients diagnosed with SCS caused by unilateral adrenal adenoma, who underwent laparoscopic adrenalectomy from 2010 to 2017, were included into the study. These patients did not receive prophylactic steroid treatment. After discharge, patients with adrenal insufficiency (AI) were treated with glucocorticoid. Then, cortisol levels were reevaluated at three months after surgery by morning serum cortisol. RESULTS No severe perioperative complications occurred. After unilateral laparoscopic adrenalectomy, no patient developed AI and was readmitted. In the first week after surgery, 10 patients (16.9%) received steroid therapy at the clinic because of mild symptoms of AI. The probability of developing AI was greater in patients with 1-mg dexamethasone midnight suppression test (1 mg-DST) >5 μg/dL than patients with mg-DST ranging within 1.8 to 5.0 μg/dL (P=0.042). The initial dose of hydrocortisone was 20.00±6.67 mg/d (range, 10 to 30), and the duration of treatment was 6.90±3.51 weeks (range, 3 to 12 wk). At three months after surgery, morning cortisol was >5 μg/dL in all patients. CONCLUSIONS After laparoscopic adrenalectomy, the probability of AI is small in patients with adrenal SCS, and the symptoms of AI were mild. Meanwhile, the HPA axis rapidly recovered. Therefore, prophylactic steroid treatment is not mandatory. Given that AI is more frequent in patients with higher cut-offs of 1 mg-DST, a more precise definition of SCS is necessary to better manage these patients.
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Malignancy Risk and Hormonal Activity of Adrenal Incidentalomas in a Large Cohort of Patients from a Single Tertiary Reference Center. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16101872. [PMID: 31137898 PMCID: PMC6571894 DOI: 10.3390/ijerph16101872] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 11/17/2022]
Abstract
Background: A rise in adrenal incidentalomas (AIs) detection has been observed recently. Even though AIs are detected in asymptomatic patients, thorough assessment may reveal hormonal and metabolic abnormalities or malignant character. Methods: Medical records of 2005 patients (1301 women, 704 men) with 2498 tumors aged 61 ± 11.3 (18–93) years, who had been hospitalized due to AI diagnosis, were reviewed. Patients underwent clinical examination, adrenal CT and hormonal assessment. In patients subjected to adrenalectomy, histopathological character of AI was confirmed. Results: AIs most frequently occurred in patients in their 7th decade of life. Hypertension was present in 76.6%, glucose metabolism disorders in 41.3%, and hypercholesterolemia in 60.1% of patients. Lipid-rich adenomas (83.2%) and hormonally inactive tumors (83.1%) predominated. Autonomous cortisol secretion was present or suspected in 6.6%, pheochromocytoma in 4.7%, hyperandrogenism in 3.1%, and primary hyperaldosteronism in 2.4% of patients. The risk of malignancy increased in patients with tumors >6 cm was 37.7%. The logistic regression analysis revealed that the strongest predictor of hormonal activity of AIs was lipid-poor picture on CT scan (OR 7.072; CI 5.118–9.771), while the most important factor increasing the risk of malignancy was lipid-poor adenoma or non-adenoma on CT scan (OR 4.843; CI 1.697–13.819). Final histopathology was available for 214 tumors; 106 adrenocortical adenomas, 46 pheochromocytomas, and 18 adrenocortical carcinomas were diagnosed. Conclusion: Most AIs are hormonally inactive adenomas. The most frequent hormonal manifestation of AI is subclinical hypercortisolemia. Presence of AI is often accompanied by features of metabolic syndrome. The tumor density on CT scan picture may be predictive of both hormonal activity and the risk of malignancy. Tumors of all sizes may exhibit hormonal activity, while the risk of malignancy significantly increases with the size above 6 cm.
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Lotfi CFP, Kremer JL, dos Santos Passaia B, Cavalcante IP. The human adrenal cortex: growth control and disorders. Clinics (Sao Paulo) 2018; 73:e473s. [PMID: 30208164 PMCID: PMC6113920 DOI: 10.6061/clinics/2018/e473s] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/26/2018] [Indexed: 12/15/2022] Open
Abstract
This review summarizes key knowledge regarding the development, growth, and growth disorders of the adrenal cortex from a molecular perspective. The adrenal gland consists of two distinct regions: the cortex and the medulla. During embryological development and transition to the adult adrenal gland, the adrenal cortex acquires three different structural and functional zones. Significant progress has been made in understanding the signaling and molecules involved during adrenal cortex zonation. Equally significant is the knowledge obtained regarding the action of peptide factors involved in the maintenance of zonation of the adrenal cortex, such as peptides derived from proopiomelanocortin processing, adrenocorticotropin and N-terminal proopiomelanocortin. Findings regarding the development, maintenance and growth of the adrenal cortex and the molecular factors involved has improved the scientific understanding of disorders that affect adrenal cortex growth. Hypoplasia, hyperplasia and adrenocortical tumors, including adult and pediatric adrenocortical adenomas and carcinomas, are described together with findings regarding molecular and pathway alterations. Comprehensive genomic analyses of adrenocortical tumors have shown gene expression profiles associated with malignancy as well as methylation alterations and the involvement of miRNAs. These findings provide a new perspective on the diagnosis, therapeutic possibilities and prognosis of adrenocortical disorders.
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Affiliation(s)
- Claudimara Ferini Pacicco Lotfi
- Departamento de Anatomia, Instituto de Ciencias Biomedicas, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Jean Lucas Kremer
- Departamento de Anatomia, Instituto de Ciencias Biomedicas, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Barbara dos Santos Passaia
- Departamento de Anatomia, Instituto de Ciencias Biomedicas, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Isadora Pontes Cavalcante
- Departamento de Anatomia, Instituto de Ciencias Biomedicas, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Abe I, Sugimoto K, Miyajima T, Ide T, Minezaki M, Takeshita K, Takahara S, Nakagawa M, Fujimura Y, Kudo T, Miyajima S, Taira H, Ohe K, Ishii T, Yanase T, Kobayashi K. Clinical Investigation of Adrenal Incidentalomas in Japanese Patients of the Fukuoka Region with Updated Diagnostic Criteria for Sub-clinical Cushing's Syndrome. Intern Med 2018; 57:2467-2472. [PMID: 29709936 PMCID: PMC6172556 DOI: 10.2169/internalmedicine.0550-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ichiro Abe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Kaoru Sugimoto
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | | | - Tomoko Ide
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Midori Minezaki
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Kaori Takeshita
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Saori Takahara
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Midori Nakagawa
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Yuki Fujimura
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Tadachika Kudo
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
| | - Shigero Miyajima
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Hiroshi Taira
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Kenji Ohe
- Department of Pharmacotherapeutics, Faculty of Pharmaceutical Sciences, Fukuoka University, Japan
| | - Tatsu Ishii
- Department of Urology, Fukuoka University Chikushi Hospital, Japan
| | - Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Japan
| | - Kunihisa Kobayashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Japan
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Celejewski K, Pogorzelski R, Toutounchi S, Krajewska E, Wołoszko T, Szostek M, Jakuczun W, Fiszer P, Legocka M, Gałązka Z. Adrenal Incidentaloma - Diagnostic and Treating Problem - Own Experience. Open Med (Wars) 2018; 13:281-284. [PMID: 30128359 PMCID: PMC6097090 DOI: 10.1515/med-2018-0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/05/2018] [Indexed: 01/16/2023] Open
Abstract
Introduction Incidentaloma is defined as an tumor diagnosed accidentally using imaging studies performed due to other indications. The aim of this paper was to describe the diagnostic and treatment problems experienced by patients with adrenal incidentaloma in a clinical practice. Material and methods In years 2009-2012 there were 33(16,5%) adrenal tumors diagnosed incidentally out of 200 cases treated due to adrenal pathology. The group consisted of 54 patients aged 27-77. In 15(45,5%) patients the diagnosis was made based on ultrasound examination, while in 18(54,5%) the tumor was visualized in CT/MRI. Results Only after the diagnostics was finalized, in which in all cases no signs of hormonal activity were detected, 26(78,8%) patients were qualified for the surgery. In 7(21,2%) cases no indications for such a management were found. The latter group was followed-up and in all patients the indications for the surgery arose due to enlargement of the tumor or/and the existence of hormonal activity. Our observations suggest that the incident finding of adrenal tumor is an indication of long-term observation. The analysis of our material shows that all patients observed needed surgical treatment. Conclusions The small adrenal tumors under follow-up have a tendency to enlarge and acquire hormonal activity. Long-term observation significantly increases the costs of treatment in that group, which eventually results in surgical management.
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Affiliation(s)
| | - Ryszard Pogorzelski
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
| | - Sadegh Toutounchi
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
| | - Ewa Krajewska
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Wołoszko
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
| | - Małgorzata Szostek
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
| | - Wawrzyniec Jakuczun
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
| | - Patryk Fiszer
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
| | - Małgorzata Legocka
- Department of General and Endocrine Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gałązka
- General and Endocrine Surgery of Medical University of Warsaw, Warsaw, Poland
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Lavingia K, Torabi R, Kim SW, Hughes MS, Feliberti EC, Perry RR. A Rare Adrenal Incidentaloma That Mimics Adrenocortical Carcinoma. Case Rep Surg 2018; 2018:9607972. [PMID: 29984033 PMCID: PMC6011133 DOI: 10.1155/2018/9607972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We present a case of an adrenal hemangioma, an uncommon cause of an adrenal mass, and review the clinical presentation, work-up, and management of adrenal incidentalomas. BACKGROUND A 64-year-old male was found to have a right adrenal incidentaloma during work-up for elevated liver transaminase levels, later found to be from hepatitis C. The mass was suspicious for adrenocortical carcinoma on CT imaging. Biochemical evaluation revealed no evidence of function. He underwent an open right adrenalectomy. The mass was found to be an adrenal hemangioma on histopathologic analysis. METHODS This is a case report with pertinent review of the diagnosis and management of adrenal incidentalomas. RESULTS Adrenal hemangiomas are rare, benign, nonfunctional tumors typically found during imaging for other reasons. As illustrated by this case, they appear similar to adrenocortical carcinoma on CT imaging. The diagnosis is usually not made prior to surgical resection. CONCLUSION Adrenal hemangioma is a rare nonfunctional adrenal incidentaloma that displays atypical features on CT imaging. The suspicion for adrenocortical carcinoma usually prompts adrenalectomy.
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Affiliation(s)
- Kedar Lavingia
- Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk VA 23507, USA
| | - Ramyar Torabi
- Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk VA 23507, USA
| | - Samuel W. Kim
- Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk VA 23507, USA
| | - Marybeth S. Hughes
- Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk VA 23507, USA
| | - Eric C. Feliberti
- Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk VA 23507, USA
| | - Roger R. Perry
- Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk VA 23507, USA
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26
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Ahn SH, Kim JH, Baek SH, Kim H, Cho YY, Suh S, Kim BJ, Hong S, Koh JM, Lee SH, Song KH. Characteristics of Adrenal Incidentalomas in a Large, Prospective Computed Tomography-Based Multicenter Study: The COAR Study in Korea. Yonsei Med J 2018; 59:501-510. [PMID: 29749133 PMCID: PMC5949292 DOI: 10.3349/ymj.2018.59.4.501] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 02/28/2018] [Accepted: 03/13/2018] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Seong Hee Ahn
- Division of Endocrinology and Metabolism, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hee Baek
- Division of Clinical Epidemiology and Biostatics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeonmok Kim
- Division of Endocrinology and Metabolism, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sunghwan Suh
- Division of Endocrinology and Metabolism, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Beom Jun Kim
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seongbin Hong
- Division of Endocrinology and Metabolism, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jung Min Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Kee Ho Song
- Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.
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van den Broek J, Geenen R, Heijnen L, Kobus C, Schreurs H. Adrenal Incidentalomas During Diagnostic Work-up of Colorectal Cancer Patients: What is the Risk of Metastases? Ann Surg Oncol 2018; 25:1986-1991. [DOI: 10.1245/s10434-018-6501-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Indexed: 12/21/2022]
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Kim BJ, Lee SH, Koh JM. Bone Health in Adrenal Disorders. Endocrinol Metab (Seoul) 2018; 33:1-8. [PMID: 29589383 PMCID: PMC5874185 DOI: 10.3803/enm.2018.33.1.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 01/30/2018] [Accepted: 02/06/2018] [Indexed: 01/07/2023] Open
Abstract
Secondary osteoporosis resulting from specific clinical disorders may be potentially reversible, and thus continuous efforts to find and adequately treat the secondary causes of skeletal fragility are critical to ameliorate fracture risk and to avoid unnecessary treatment with anti-osteoporotic drugs. Among the hyperfunctional adrenal masses, Cushing's syndrome, pheochromocytoma, and primary aldosteronism are receiving particularly great attention due to their high morbidity and mortality mainly by increasing cardiovascular risk. Interestingly, there is accumulating experimental and clinical evidence that adrenal hormones may have direct detrimental effects on bone metabolism as well. Thus, the present review discusses the possibility of adrenal disorders, especially focusing on pheochromocytoma and primary aldosteronism, as secondary causes of osteoporosis.
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Affiliation(s)
- Beom Jun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Min Koh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Nuzzo V, Attardo T, Augello G, Brancato D, Canale C, Camerlingo S, Coretti F, Franco A, Giacometti F, Gambacorta M, Loreno M, Maffettone A, Provenzano V, Zuccoli A. A clinical audit: diagnostic and epidemiological evaluation of the adrenal incidentaloma. MINERVA ENDOCRINOL 2018; 45:18-28. [PMID: 29442478 DOI: 10.23736/s0391-1977.18.02780-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Audit is a clinical instrument of government characterized by a whole process of evaluation inter pares to improve medical behaviors in the clinical practice. Different endocrinopathies are underestimated in the clinical and diagnostics practice but they can be a real problem in patients admitted in the departments of Internal Medicine. The adrenal incidentaloma is an accidental discovery with an incidence equal to 4% in radiologic studies but it's rarely considereted in the internal disorders. In the departments of Internal Medicine are hospitalized each year approximately 1450,000 patients and 58,000 about them show a surrenalic lesion identified with CT or MRI as Adrenal Incidentaloma. METHODS Through a search in the radiological archives, were reviewed all abdominal CT performed in the year 2012 in 8 departments of Internal Medicine of 8 Italian public hospitals. They also examined all medical records of these patients to value clinical management of the adrenal masses and the real incidence of the adrenal incidentaloma. RESULTS Distribution of pathological results show an important incidence about adrenal incidentaloma in Italian patients although this pathology is represented as a rare disease and its clinical and economic burden are significant. Many questions remain unanswered as the association between duration and severity of the disease, morbidity and how the dimensions affecting it. These results need to be supported by important studies with long follow-up to realize an easy diagnosis. CONCLUSIONS The results of this audit confirm the real incidence of this pathology in the internistic patients and the final target is to implement changes about therapeutic diagnostic pathway of the hospital patients in the internal medicine departments.
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Affiliation(s)
- Vincenzo Nuzzo
- Unit of Endocrinology and Human Nutrition, Ospedale del Mare, Naples, Italy -
| | | | | | | | - Clelia Canale
- Bianchi Melacrino Morelli Hospital, Reggio Calabria, Italy
| | | | - Federica Coretti
- Unit of Endocrinology and Human Nutrition, Ospedale del Mare, Naples, Italy
| | | | | | | | | | | | | | - Alfonso Zuccoli
- Unit of Endocrinology and Human Nutrition, Ospedale del Mare, Naples, Italy
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Haan RRD, Visser JB, Pons E, Feelders RA, Kaymak U, Hunink MM, Visser JJ. Patient-specific workup of adrenal incidentalomas. Eur J Radiol Open 2017; 4:108-114. [PMID: 28932767 PMCID: PMC5596359 DOI: 10.1016/j.ejro.2017.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 08/10/2017] [Accepted: 08/29/2017] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Romy R. de Haan
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes B.R. Visser
- Industrial Engineering & Innovation Sciences (IE&IS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Ewoud Pons
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Uzay Kaymak
- Industrial Engineering & Innovation Sciences (IE&IS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - M.G. Myriam Hunink
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Jacob J. Visser
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Evaluation and diagnostic potential of circulating extracellular vesicle-associated microRNAs in adrenocortical tumors. Sci Rep 2017; 7:5474. [PMID: 28710381 PMCID: PMC5511159 DOI: 10.1038/s41598-017-05777-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/14/2017] [Indexed: 02/07/2023] Open
Abstract
There is no available blood marker for the preoperative diagnosis of adrenocortical malignancy. The objective of this study was to investigate the expression of extracellular vesicle-associated microRNAs and their diagnostic potential in plasma samples of patients suffering from adrenocortical tumors. Extracellular vesicles were isolated either by using Total Exosome Isolation Kit or by differential centrifugation/ultracentrifugation. Preoperative plasma extracellular vesicle samples of 6 adrenocortical adenomas (ACA) and 6 histologically verified adrenocortical cancer (ACC) were first screened by Taqman Human Microarray A-cards. Based on the results of screening, two miRNAs were selected and validated by targeted quantitative real-time PCR. The validation cohort included 18 ACAs and 16 ACCs. Beside RNA analysis, extracellular vesicle preparations were also assessed by transmission electron microscopy, flow cytometry and dynamic light scattering. Significant overexpression of hsa-miR-101 and hsa-miR-483-5p in ACC relative to ACA samples has been validated. Receiver operator characteristics of data revealed dCT hsa-miR-483-5p normalized to cel-miR-39 to have the highest diagnostic accuracy (area under curve 0.965), the sensitivity and the specifity were 87.5 and 94.44, respectively. Extracellular vesicle-associated hsa-miR-483-5p thus appears to be a promising minimally invasive biomarker in the preoperative diagnosis of ACC but needs further validation in larger cohorts of patients.
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Ceccato F, Antonelli G, Frigo AC, Regazzo D, Plebani M, Boscaro M, Scaroni C. First-line screening tests for Cushing's syndrome in patients with adrenal incidentaloma: the role of urinary free cortisol measured by LC-MS/MS. J Endocrinol Invest 2017; 40:753-760. [PMID: 28247215 DOI: 10.1007/s40618-017-0644-8] [Citation(s) in RCA: 18] [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: 11/30/2016] [Accepted: 02/16/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND AIM Patients with adrenal incidentaloma present a wide range of cortisol secretion, which is not always properly defined by first-line screening tests recommended to rule out Cushing's syndrome (CS), such as 1-mg dexamethasone suppression test (1-mg DST), late night salivary cortisol (LNSC), or 24-h urinary free cortisol (UFC). Therefore, we examined the diagnostic performance of each screening test in patients with adrenal incidentaloma. MATERIALS AND METHODS In a series of 164 consecutive patients with adrenal incidentaloma, we measured serum cortisol after 1-mg DST, LNSC, and UFC (with LC-MS/MS). Medical history was investigated for cardiovascular events (CVE) in a subgroup of 93 patients with at least 2 years of follow-up. RESULTS Serum cortisol <50 nmol/L after 1-mg DST presented the highest sensitivity (100%) to rule out CS, despite a low specificity (62%). UFC > 170 nmol/24 h achieved the highest diagnostic accuracy (sensitivity 98%, specificity 91%, and negative/positive likelihood ratios of 0.02/10.83, respectively). The prevalence of CVE was higher in patients with non-suppressed cortisol after 1-mg DST and high UFC levels (p = 0.018). Traditional cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidemia, BMI > 30 kg/m2, smoke or high gender-based waist circumference) were not associated with CVE. CONCLUSIONS The 1-mg DST at its lowest threshold presented high sensitivity in identifying CS, but its low specificity encourages us to consider UFC levels, measured with LC-MS/MS, to reduce false-positive test results. High UFC levels could also be considered as markers to stratify cardiovascular risk in patients with adrenal incidentaloma.
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Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, Padova University Hospital, Via Ospedale Civile, 105-35128, Padova, Italy.
| | - G Antonelli
- Laboratory Medicine Unit, Department of Medicine DIMED, Padova University Hospital, Padova, Italy
| | - A C Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - D Regazzo
- Endocrinology Unit, Department of Medicine DIMED, Padova University Hospital, Via Ospedale Civile, 105-35128, Padova, Italy
| | - M Plebani
- Laboratory Medicine Unit, Department of Medicine DIMED, Padova University Hospital, Padova, Italy
| | - M Boscaro
- Endocrinology Unit, Department of Medicine DIMED, Padova University Hospital, Via Ospedale Civile, 105-35128, Padova, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, Padova University Hospital, Via Ospedale Civile, 105-35128, Padova, Italy
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Can Imaging Predict Subclinical Cortisol Secretion in Patients With Adrenal Adenomas? A CT Predictive Score. AJR Am J Roentgenol 2017; 209:122-129. [DOI: 10.2214/ajr.16.16965] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Adrenal Ganglioneuroblastoma in Adults: A Case Report and Review of the Literature. Case Rep Endocrinol 2017; 2017:5796236. [PMID: 28713603 PMCID: PMC5497652 DOI: 10.1155/2017/5796236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/19/2017] [Accepted: 05/24/2017] [Indexed: 11/24/2022] Open
Abstract
Incidentally discovered adrenal masses are very common given the increased number of imaging studies performed in recent years. We here report a clinical case of a 20-year-old woman who presented with left flank pain. Ultrasound examination revealed a contralateral adrenal mass, which was confirmed at computed tomography (CT) scan. Hormonal hypersecretion was excluded. Given the size (11 × 10 × 7 cm) and the uncertain nature of the mass, it was surgically removed and sent for pathological analyses. Conclusive diagnosis was ganglioneuroblastoma. Ganglioneuroblastoma is an uncommon malignant tumor, extremely rare in adults, particularly in females. This neoplasm is frequently localized in adrenal gland.
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Li L, Yang G, Zhao L, Dou J, Gu W, Lv Z, Lu J, Mu Y. Baseline Demographic and Clinical Characteristics of Patients with Adrenal Incidentaloma from a Single Center in China: A Survey. Int J Endocrinol 2017; 2017:3093290. [PMID: 28848603 PMCID: PMC5564109 DOI: 10.1155/2017/3093290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/14/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022] Open
Abstract
AIM To investigate the clinical and endocrinological characteristics of patients with adrenal incidentaloma (AI). MATERIALS AND METHODS This retrospective study enrolled 1941 AI patients hospitalized at the Department of Endocrinology, Chinese PLA General Hospital, Beijing, China, between January 1997 and December 2016. The patient gender, age at visits, imaging features, functional status, and histological results were analyzed. RESULTS Of the 1941 patients, 984 (50.70%) were men. The median age was 52 years (interquartile range: 44-69 years). 140 cases had bilateral AI. Endocrine evaluation showed that 1411 (72.69%) patients had nonfunctional tumor, 152 (7.83%) had subclinical Cushing syndrome (SCS), and 82 (4.33%) had primary hyperaldosteronism. A total of 925 patients underwent operation for removal of 496 cortical adenomas (53.62%), 15 adrenal cortical carcinomas (1.62%), and 172 pheochromocytomas (18.59%). The bilateral group had a higher proportion of SCS (18.57% versus 7.10%, P < 0.001, P = 0.006). A mass size of 46 mm was of great value in distinguishing malignant tumors from the benign tumors, with sensitivity of 88.2% and specificity of 95.5%. CONCLUSIONS We reported the baseline demographic and clinical characteristics of patients with AI in a large series from a single center in China.
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Affiliation(s)
- Lele Li
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Guoqing Yang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Ling Zhao
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
- *Jingtao Dou:
| | - Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Juming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
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Lee SH, Song KH, Kim J, Park S, Ahn SH, Kim H, Cho YY, Suh S, Kim BJ, Kim JH, Koh JM. New diagnostic criteria for subclinical hypercortisolism using postsurgical hypocortisolism: the Co-work of Adrenal Research study. Clin Endocrinol (Oxf) 2017; 86:10-18. [PMID: 27341314 DOI: 10.1111/cen.13145] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/23/2016] [Accepted: 06/20/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There is no consensus on the biochemical diagnostic criteria for subclinical hypercortisolism (SH). Using parameters related to the hypothalamic-pituitary-adrenal axis, we aimed to develop a diagnostic model of SH for predicting postsurgical hypocortisolism and metabolic complications. DESIGN Prospective and cross-sectional, observational, multicentre study in Korea. METHODS After exclusion of overt Cushing's syndrome, adrenal incidentaloma (AI) patients who underwent unilateral adrenalectomy (n = 99) and AI patients (n = 843) were included. Primary outcome was defined as the presence of postsurgical hypocortisolism; secondary outcome was the presence of ≥4 complications (components of the metabolic syndrome and low bone mass). Postsurgical hypocortisolism was determined on the fifth postsurgery day using the ACTH stimulation test. RESULTS Thirty-three of the 99 patients developed postsurgical hypocortisolism. Analysis of the presurgery overnight 1-mg dexamethasone suppression test (1-mg DST) showed that all patients with cortisol levels of >138 nmol/l experienced postsurgical hypocortisolism, whereas those with levels of ≤61 nmol/l did not. The models of (i) 1-mg DST >138 nmol/l or (ii) >61 nmol/l with the presence of one among low levels of ACTH and dehydroepiandrosterone-sulphate had the highest accuracy (89·9%, P < 0·001) and odds ratio [OR 111·62, 95% confidence interval (CI) 21·98-566·74, P < 0·001] for predicting postsurgical hypocortisolism. Finally, patients with the same criteria in the 843 AI patients showed the highest risk for having ≥4 complications (OR 3·51, 95% CI 1·84-6·69, P < 0·001), regardless of gender, age, body mass index and bilaterality. CONCLUSIONS Our proposed model is able to accurately predict subtle cortisol excess and its chronic manifestations in AI patients.
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Affiliation(s)
- Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee-Ho Song
- Division of Endocrinology and Metabolism, Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jinju Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sooyoun Park
- Division of Endocrinology and Metabolism, Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Seong Hee Ahn
- Department of Endocrinology, Inha University School of Medicine, Incheon, Korea
| | - Hyeonmok Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Department of Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sunghwan Suh
- Division of Endocrinology and Metabolism, Department of Medicine, Dong-A University Medical Center, Dong-A University School of Medicine, Busan, Korea
| | - Beom-Jun Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Raffaelli M, De Crea C, D'Amato G, Gallucci P, Lombardi CP, Bellantone R. Outcome of adrenalectomy for subclinical hypercortisolism and Cushing syndrome. Surgery 2016; 161:264-271. [PMID: 27865591 DOI: 10.1016/j.surg.2016.07.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND We compared operative and metabolic outcomes in patients with subclinical Cushing syndrome and Cushing syndrome caused by unilateral adrenal lesion, aiming to clarify the role of glucocorticoid replacement treatment in patients with subclinical Cushing syndrome after adrenalectomy. METHODS The medical records of all the patients who underwent unilateral adrenalectomy for subclinical Cushing syndrome or Cushing syndrome were reviewed. Diagnostic criteria for subclinical Cushing syndrome were a pathologic dexamethasone suppression test plus 2 additional criteria. RESULTS Twenty-nine patients with subclinical Cushing syndrome and 50 with Cushing syndrome were identified. No significant difference was found between patients with subclinical Cushing syndrome and Cushing syndrome regarding lesion size, operative time, and hospital stay. Two patients out of 29 with subclinical Cushing syndrome and 3 out of 50 patients with Cushing syndrome experienced Clavien-Dindo grade II complications (P = .87). All the patients required postoperative glucocorticoid replacement that was discontinued within 6 months in 28 of the 29 patients with subclinical Cushing syndrome and in 3 out of 50 Cushing syndrome patients (P < .005). At long-term follow-up, adrenalectomy significantly improved hypertension and diabetes in affected patients, with no differences between subclinical Cushing syndrome and Cushing syndrome. Hypercortisolism was resolved in all the cases. CONCLUSION Operative and metabolic outcomes of adrenalectomy are similar in subclinical Cushing syndrome and Cushing syndrome. Postoperative glucocorticoid replacement treatment is advisable in all patients with subclinical Cushing syndrome. Prolonged adrenal insufficiency is more frequent in Cushing syndrome patients.
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Affiliation(s)
- Marco Raffaelli
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Carmela De Crea
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gerardo D'Amato
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pierpaolo Gallucci
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Celestino P Lombardi
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rocco Bellantone
- UO Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Rome, Italy
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Falhammar H, Torpy DJ. A 42-year-old man presented with adrenal incidentaloma due to non-classic congenital adrenal hyperplasia with a novel CYP21A2
mutation. Intern Med J 2016; 46:1115-6. [DOI: 10.1111/imj.13177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- H. Falhammar
- Menzies School of Health Research, Royal Darwin Hospital; Darwin Northern Territory Australia
- Department of Endocrinology, Metabolism and Diabetes; Karolinska University Hospital; Stockholm Sweden
- Department of Molecular Medicine and Surgery; Guidlelines of Karolinska Institutet; Stockholm Sweden
| | - D. J. Torpy
- Endocrine and Metabolic Unit; Royal Adelaide Hospital and University of Adelaide; Adelaide South Australia Australia
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Rubin B, Regazzo D, Redaelli M, Mucignat C, Citton M, Iacobone M, Scaroni C, Betterle C, Mantero F, Fassina A, Pezzani R, Boscaro M. Investigation of N-cadherin/β-catenin expression in adrenocortical tumors. Tumour Biol 2016; 37:13545-13555. [PMID: 27468715 DOI: 10.1007/s13277-016-5257-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/15/2016] [Indexed: 02/07/2023] Open
Abstract
β-catenin is a multifunctional protein; it is a key component of the Wnt signaling, and it plays a central role in cadherin-based adhesions. Cadherin loss promotes tumorigenesis by releasing membrane-bound β-catenin, hence stimulating Wnt signaling. Cadherins seem to be involved in tumor development, but these findings are limited in adrenocortical tumors (ACTs). The objective of this study was to evaluate alterations in key components of cadherin/catenin adhesion system and of Wnt pathway. This study included eight normal adrenal samples (NA) and 95 ACT: 24 adrenocortical carcinomas (ACCs) and 71 adrenocortical adenomas (ACAs). β-catenin mutations were evaluated by sequencing, and β-catenin and cadherin (E-cadherin and N-cadherin) expression was analyzed by quantitative reverse transcription PCR (qRT-PCR) and by immunohistochemistry (IHC). We identified 18 genetic alterations in β-catenin gene. qRT-PCR showed overexpression of β-catenin in 50 % of ACC (12/24) and in 48 % of ACA (21/44). IHC data were in accordance with qRT-PCR results: 47 % of ACC (7/15) and 33 % of ACA (11/33) showed increased cytoplasmic or nuclear β-catenin accumulation. N-cadherin downregulation has been found in 83 % of ACC (20/24) and in 59 % of ACA (26/44). Similar results were obtained by IHC: N-cadherin downregulation was observed in 100 % (15/15) of ACC and in 55 % (18/33) of ACA. β-catenin overexpression together with the aberrant expression of N-cadherin may play important role in ACT tumorigenesis. The study of differentially expressed genes (such as N-cadherin and β-catenin) may enhance our understanding of the biology of ACT and may contribute to the discovery of new diagnostic and prognostic tools.
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Affiliation(s)
- Beatrice Rubin
- Division of Endocrinology, Department of Medicine (DIMED), University of Padua, via Ospedale Civile, 105, 35128, Padua, Italy.
| | - Daniela Regazzo
- Division of Endocrinology, Department of Medicine (DIMED), University of Padua, via Ospedale Civile, 105, 35128, Padua, Italy
| | - Marco Redaelli
- Department of Molecular Medicine, University of Padova, via Marzolo 3, 35131, Padova, Italy
| | - Carla Mucignat
- Department of Molecular Medicine, University of Padova, via Marzolo 3, 35131, Padova, Italy
| | - Marilisa Citton
- Division of Minimally Invasive Endocrine Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Maurizio Iacobone
- Division of Minimally Invasive Endocrine Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Carla Scaroni
- Division of Endocrinology, Department of Medicine (DIMED), University of Padua, via Ospedale Civile, 105, 35128, Padua, Italy
| | - Corrado Betterle
- Division of Endocrinology, Department of Medicine (DIMED), University of Padua, via Ospedale Civile, 105, 35128, Padua, Italy
| | - Franco Mantero
- Division of Endocrinology, Department of Medicine (DIMED), University of Padua, via Ospedale Civile, 105, 35128, Padua, Italy
| | - Ambrogio Fassina
- Division of Pathology and Cytopathology, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Raffaele Pezzani
- Division of Endocrinology, Department of Medicine (DIMED), University of Padua, via Ospedale Civile, 105, 35128, Padua, Italy
| | - Marco Boscaro
- Division of Endocrinology, Department of Medicine (DIMED), University of Padua, via Ospedale Civile, 105, 35128, Padua, Italy
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Falhammar H, Torpy DJ. Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency Presenting as Adrenal Incidentaloma: A Systematic Review and Meta-Analysis. Endocr Pract 2016; 22:736-752. [DOI: 10.4158/ep151085.ra] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Brossaud J, Ducint D, Corcuff JB. Urinary glucocorticoid metabolites: biomarkers to classify adrenal incidentalomas? Clin Endocrinol (Oxf) 2016; 84:236-243. [PMID: 25571968 DOI: 10.1111/cen.12717] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 12/10/2014] [Accepted: 01/05/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Total urinary cortisol metabolites represent cortisol production and metabolism. We hypothesized that to assay metabolites could add some information to the one provided by a sole cortisol assay. DESIGN AND PATIENTS We set up an inexpensive multiplex mass spectrometry assay to quantify cortisol metabolites. We investigated 43 patients with benign secreting (AT+) or silent (AT-) adrenal tumours compared to 48 lean (Nl) or 143 obese (Ob) subjects, and to 26 patients with a Cushing's disease (CD). The initial investigation included immunoreactive quantification of urinary free cortisol (UFC). RESULTS Cortisol metabolites were overexcreted in CD but not in Ob subjects. Nl and Ob were thus pooled in a control population (Ctl). Cortisol, tetrahydrocortisol (THF) and tetrahydrocortisone (THE) excretions were significantly increased in AT compared to Ctl subjects, whereas immunoreactive UFC was similar. A logistic regression retaining cortisol, THF, and α- and β-cortolone as significant analytes allowed the construction of a receiver-operating characteristics (ROC) curve significantly better than the curve generated by cortisol alone (area under the curve (AUC) 0·927 vs 0·729, respectively; P < 0·0001). More importantly, although there was no significant difference between Ctl vs AT- subjects for cortisol metabolites, a logistic regression retaining cortisol, allo-THF, and α- and β-cortolone as significant analytes generated a ROC curve performing significantly better than cortisol alone (AUC 0·910 vs 0·635, respectively; P < 0·0001). CONCLUSION Cortisol metabolite excretion is modified in AT, including AT-, patients even without modification of UFC. Clinical usefulness of these biomarkers has to be investigated in prospective studies following up patients with AT.
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Affiliation(s)
- Julie Brossaud
- Department of Nuclear Medicine, CHU de Bordeaux, Pessac, France
- Nutrition et Neurobiologie intégrée, UMR 1286, University of Bordeaux, Pessac, France
| | - Dominique Ducint
- Department of Physical Measurements, CHU de Bordeaux, Bordeaux, France
| | - Jean-Benoît Corcuff
- Department of Nuclear Medicine, CHU de Bordeaux, Pessac, France
- Nutrition et Neurobiologie intégrée, UMR 1286, University of Bordeaux, Pessac, France
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Daniel G, Mahony OM, Markovich JE, Appleman E, Monaghan KN, Lawrence YA, Fiocchi EH, Weaver K, Johnston A, Barton B. Clinical findings, diagnostics and outcome in 33 cats with adrenal neoplasia (2002-2013). J Feline Med Surg 2016; 18:77-84. [PMID: 25714105 PMCID: PMC11149020 DOI: 10.1177/1098612x15572035] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES The objective of this retrospective study was to describe the clinical signs and diagnostic findings in cats with histopathologically confirmed adrenal neoplasms, and to assess correlations with survival data. METHODS Study data were acquired by reviewing medical records for all cats diagnosed with adrenal neoplasms at seven referral institutions between 2002 and 2013. Inclusion criteria required a histopathologic diagnosis of an adrenal neoplasm (ante-mortem or on necropsy). RESULTS Thirty-three cats met the inclusion criteria for the study. The most common presenting complaints included weakness (n = 12), respiratory signs (n = 4), blindness (n = 4) or gastrointestinal signs (n = 3). Laboratory abnormalities included hypokalemia (n = 18), alkalemia (n = 12), elevated creatine kinase (>3000, n = 5) and azotemia (n = 4). In addition, hypertension was noted in 13 cats. Thirty cats were diagnosed with cortical tumors (17 carcinomas, 13 adenomas) and three cats were diagnosed with pheochromocytomas. Twenty-five cats underwent tests to evaluate the function of the adrenal tumors; 19/25 cats had functional tumors (hyperaldosteronism [n = 16], hypercortisolemia [n = 1], high estradiol [n = 1], and hypersecretion of aldosterone, estradiol and progesterone [n = 1]). Twenty-six cats underwent adrenalectomy, one cat was medically managed and six were euthanized without treatment. Long-term survival postoperatively ranged from 4-540 weeks, with 20 (77%) cats surviving the perioperative period of 2 weeks. The only variable that was found to be negatively associated with survival was female sex. The most common complications noted during the perioperative period were hemorrhage and progressive lethargy and anorexia. CONCLUSIONS AND RELEVANCE Surgical treatment for feline adrenal tumors (regardless of tumor type) resulted in good long-term survival. Given that pre- and postoperative hypocortisolemia was identified in this study, and, in addition, hypersecretion of more than one adrenal hormone occurred in one cat, adrenal panels prior to surgery may be beneficial as part of the preoperative work-up.
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Affiliation(s)
- Gideon Daniel
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA, USA
| | - Orla M Mahony
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA, USA
| | - Jessica E Markovich
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA, USA
| | - Elizabeth Appleman
- Department of Internal Medicine, Animal Medical Center, USA; VCA Fifth Avenue Veterinary Specialists, USA
| | - Kelly N Monaghan
- Department of Medical Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Yuri A Lawrence
- Department of Clinical Sciences, Oregon State University, Corvallis, OR, USA
| | | | - Kelli Weaver
- Tampa Bay Veterinary Specialists, Largo, FL, USA
| | - Andrea Johnston
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine Companion Animal Hospital, NY, USA
| | - Bruce Barton
- Department of Quantitative Health Sciences, University of Massachusetts, Worcester, MA, USA
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Tabuchi Y, Otsuki M, Kasayama S, Kosugi K, Hashimoto K, Yamamoto T, Tsugawa M, Mineo I, Yamada Y, Kurebayashi S, Ohashi M, Umayahara Y, Kouhara H, Nakamura T, Taki H, Matsuoka TA, Imagawa A, Funahashi T, Shimomura I. Clinical and endocrinological characteristics of adrenal incidentaloma in Osaka region, Japan. Endocr J 2016; 63:29-35. [PMID: 26490049 DOI: 10.1507/endocrj.ej15-0404] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Yukiko Tabuchi
- Departments of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Angelousi A, Zilbermint M, Berthon A, Espiard S, Stratakis CA. Diagnosis and Management of Hereditary Adrenal Cancer. Recent Results Cancer Res 2016; 205:125-47. [PMID: 27075352 DOI: 10.1007/978-3-319-29998-3_8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Benign adrenocortical tumours (ACT) are relatively frequent lesions; on the contrary, adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with unfavourable prognosis. Recent advances in the molecular understanding of adrenal cancer offer promise for better therapies in the future. Many of these advances stem from the molecular elucidation of genetic conditions predisposing to the development of ACC. Six main clinical syndromes have been described to be associated with hereditary adrenal cancer. In these conditions, genetic counselling plays an important role for the early detection and follow-up of the patients and the affected family members.
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Affiliation(s)
- Anna Angelousi
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
| | - Mihail Zilbermint
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Annabel Berthon
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Stéphanie Espiard
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
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Schalin-Jäntti C, Raade M, Hämäläinen E, Sane T. A 5-Year Prospective Follow-Up Study of Lipid-Rich Adrenal Incidentalomas: No Tumor Growth or Development of Hormonal Hypersecretion. Endocrinol Metab (Seoul) 2015; 30:481-7. [PMID: 26354488 PMCID: PMC4722402 DOI: 10.3803/enm.2015.30.4.481] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/24/2015] [Accepted: 08/14/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Current guidelines for follow-up of adrenal incidentalomas are extensive and hampered by lack of follow-up studies. We tested the hypothesis that small lipid-rich adrenal incidentalomas, initially characterized by tumor size <40 mm and <10 Hounsfield units (HUs) on unenhanced computed tomography (CT) may not demonstrate excessive growth/hormonal hypersecretion on follow-up. METHODS Sixty-nine incidentalomas in 56 patients were restudied with unenhanced CT and screening for hypercortisolism (dexamethasone suppression test [DST], plasma adrenocorticotropic hormone) and pheochromocytoma (24-hour urinary metanephrines and normetanephrines) 5 years later. Primary hyperaldosteronism was excluded at base-line. RESULTS Tumor (n=69) size was similar before and after 5 years follow-up (19±6 mm vs. 20±7 mm). Mean tumor growth was 1±2 mm. Largest increase in tumor size was 8 mm, this tumor was surgically removed and histopathology confirmed cortical adenoma. DST was normal in 54 patients and two patients (3.6%) were still characterized by subclinical hypercortisolism. Initial tumor size was >20 mm for the patient with largest tumor growth and those with subclinical hypercortisolism. All patients had normal 24-hour urinary metanephrines and normetanephrines. Low attenuation (<10 HU) was demonstrated in 97% of 67 masses re-evaluated with unenhanced CT. CONCLUSION None of the patients developed clinically relevant tumor growth or new subclinical hypercortisolism. Biochemical screening for pheochromocytoma in incidentalomas demonstrating <10 HU on unenhanced CT is not needed. For such incidentalomas <40 mm, it seems sufficient to perform control CT and screen for hypercortisolism after 5 years.
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Affiliation(s)
- Camilla Schalin-Jäntti
- Department of Endocrinology, Abdominal Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland.
| | - Merja Raade
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Esa Hämäläinen
- HUSLAB, Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland
| | - Timo Sane
- Department of Endocrinology, Abdominal Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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Babinska A, Peksa R, Sworczak K. Primary malignant lymphoma combined with clinically "silent" pheochromocytoma in the same adrenal gland. World J Surg Oncol 2015; 13:289. [PMID: 26419235 PMCID: PMC4588683 DOI: 10.1186/s12957-015-0711-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/22/2015] [Indexed: 02/25/2023] Open
Abstract
An increased number of adrenal tumors are now diagnosed due to the increased number of abdominal CT scans being performed. We present the first case of malignant lymphoma combined with clinically “silent” pheochromocytoma in the same adrenal gland. An abdominal CT scan demonstrates unilateral adrenal lesion which suggests pheochromocytoma or adrenal carcinoma. Laboratory examinations revealed a slight increase of 24-h urine vanillylmandelic acid and 24-h urinary methanephrine excretion. Histological examination revealed two intermingled tumor cell proliferations—diffuse B cell lymphoma and pheochromocytoma. Unexpected coexistence of catecholamine-producing tumor with the other adrenal lesion can lead to serious complications of diagnosis and treatment. The adequate preparation for surgery can protect patient from threatening catecholamine crisis.
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Affiliation(s)
- Anna Babinska
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, ul. Dębinki 7, 80-288, Gdańsk, Poland.
| | - Rafał Peksa
- Department of Pathology, Medical University of Gdansk, ul. Dębinki 7, 80-288, Gdańsk, Poland.
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, ul. Dębinki 7, 80-288, Gdańsk, Poland.
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Abstract
Endogenous Cushing's syndrome is a rare endocrine disorder that incurs significant cardiovascular morbidity and mortality, due to glucocorticoid excess. It comprises adrenal (20%) and non-adrenal (80%) aetiologies. While the majority of cases are attributed to pituitary or ectopic corticotropin (ACTH) overproduction, primary cortisol-producing adrenal cortical lesions are increasingly recognised in the pathophysiology of Cushing's syndrome. Our understanding of this disease has progressed substantially over the past decade. Recently, important mechanisms underlying the pathogenesis of adrenal hypercortisolism have been elucidated with the discovery of mutations in cyclic AMP signalling (PRKACA, PRKAR1A, GNAS, PDE11A, PDE8B), armadillo repeat containing 5 gene (ARMC5) a putative tumour suppressor gene, aberrant G-protein-coupled receptors, and intra-adrenal secretion of ACTH. Accurate subtyping of Cushing's syndrome is crucial for treatment decision-making and requires a complete integration of clinical, biochemical, imaging and pathology findings. Pathological correlates in the adrenal glands include hyperplasia, adenoma and carcinoma. While the most common presentation is diffuse adrenocortical hyperplasia secondary to excess ACTH production, this entity is usually treated with pituitary or ectopic tumour resection. Therefore, when confronted with adrenalectomy specimens in the setting of Cushing's syndrome, surgical pathologists are most commonly exposed to adrenocortical adenomas, carcinomas and primary macronodular or micronodular hyperplasia. This review provides an update on the rapidly evolving knowledge of adrenal Cushing's syndrome and discusses the clinicopathological correlations of this important disease.
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Affiliation(s)
- Kai Duan
- Department of Pathology, University Health Network, Toronto, Ontario, Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
| | - Karen Gomez Hernandez
- Department of Medicine, University Health Network, Toronto, Ontario, Canada Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, Ontario, Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Kastelan D, Kraljevic I, Dusek T, Knezevic N, Solak M, Gardijan B, Kralik M, Poljicanin T, Skoric-Polovina T, Kastelan Z. The clinical course of patients with adrenal incidentaloma: is it time to reconsider the current recommendations? Eur J Endocrinol 2015; 173:275-82. [PMID: 26024670 DOI: 10.1530/eje-15-0199] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/29/2015] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Darko Kastelan
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Ivana Kraljevic
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Tina Dusek
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Nikola Knezevic
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Mirsala Solak
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Bojana Gardijan
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Marko Kralik
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Tamara Poljicanin
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Tanja Skoric-Polovina
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Zeljko Kastelan
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
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Patrova J, Jarocka I, Wahrenberg H, Falhammar H. CLINICAL OUTCOMES IN ADRENAL INCIDENTALOMA: EXPERIENCE FROM ONE CENTER. Endocr Pract 2015; 21:870-7. [PMID: 26121453 DOI: 10.4158/ep15618.or] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Ioachimescu AG, Remer EM, Hamrahian AH. Adrenal incidentalomas: a disease of modern technology offering opportunities for improved patient care. Endocrinol Metab Clin North Am 2015; 44:335-54. [PMID: 26038204 DOI: 10.1016/j.ecl.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Adrenal incidentalomas (AIs) are found in approximately 4% of patients undergoing abdominal imaging, with peak prevalence in the sixth and seventh decades of life. Detection of AI warrants clinical, biochemical, and radiological evaluation to establish its secretory status and risk of malignancy. Careful review of the lipid content, size, and imaging phenotype of an adrenal mass is needed to evaluate the risk for malignancy. Identification of an AI may be an opportunity to identify an underlying secretory tumor that may have been otherwise unrecognized. A practical approach to investigation and follow-up of AIs is presented in this article.
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Affiliation(s)
- Adriana G Ioachimescu
- Emory University School of Medicine, 1365 B Clifton Road, Northeast, B6209, Atlanta, GA 30322, USA
| | - Erick M Remer
- Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, A21, Cleveland, OH 44195, USA
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